ICSC 03 Sports Imaging

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1.1_Spinal - ICSC05_ Biomechanics Spinal

Section 01_ICSC05
English PDF direct download ICSC05_1.1 VIEW_Biomechanics Spinal

ICSC Lower Extremity Module 5
Section 1.1_ICSC05 Spinal Biomechanics
Instructor Steven Smilkstein
Video Lesson: 21:12

Welcome to the basics of biomechanics. This is a simple guide to pick up on Normal and Abnormal biomechanical behavior of the spine. In this short lesson, we will be looking at basic concepts in joint anatomy and the types of diarthrodial joints, joint function in the form of kinematic chains, and alter kinematics. We will also be looking at muscle and tendon physiology, muscle physiology and biomechanics, common injuries in muscle, injury grading of muscle, and related sports and rehabilitation. We will also be looking at ligament physiology, common injuries, and ligaments, injury grading of the ligament injuries, and related sports and rehabilitation.

General Spinal Biomechanics.

The vertebral column resembles a curved rod composed of 33 vertebrae and 23 intervertebral disks. They are divided into the following five regions: the cervical region consisting of 7 vertebrae, the thoracic or dorsal region consisting of 12 vertebrae, the lumbar region consisting of five vertebrae, the sacral region consisting of five fused vertebrae, the coccygeal region consisting of four fused vertebrae. The vertebrae adhere to a common basic structural design but show regional variations in size and configuration that reflect the functional demands of a particular region.

General spinal characteristics can be seen as follows: There is an increase in size from the cervical spine to the lumbar spine region. In fetal life, the spine exhibits one long curve that is convex posteriorly as a c-shaped primary curve. The secondary curves that we see in the lumbar and cervical regions develop secondarily in infancy.

In an adult, there are four distinct anteroposterior curves. There are two in the thoracic and sacral regions which are primary curves, they are convex posteriorly. Two in the cervical and lumbar region which are secondary curves which are convex anteriorly. These developers are a result of their accommodation of forces on the skeleton to the upright posture. A curved vertebral column provides significant advantage to that of a straight rod, and that it is able to resist much higher compressive loads up to four times our own body weight. The image below represents the basic anatomical structure of the vertebrae, the supporting ligamentous structures, and the small anatomical differences between the different regions. Bare these in mind as we move further forward.

General Vertebral Anatomy. The vertebra consists of two major divisions. The anterior virtual body portion or the posterior vertebral or neural arch division. The vertebral body is designed to be the weight bearing structure of the spinal column. It is suitably designed for this task given its block like shape with a generally flat superior and inferior surface. The vertebral body is not a solid block of bone but a shell of cortical bone reinforced by trabeculae which provide resistance to compressive forces. They also disperse the forces through into the intervertebral discs which are found between two adjacent vertebral bodies.

The posterior or vertebral on neural arch is consisted of pedicles, lemony, articular processes, spinous process, and transverse processes. The posterior arch is designed to serve more as a bony protection of the neural arch from compression and torsion more than bearing weight. The intervertebral discs. This is a collection of fibrocartilage rings, which surround an amorphous nucleus pulposus. It has two principal functions: number one, to separate two vertebral bodies, thereby increasing available motion and to two, transmit the load from one virtual body to the next.

The size of the intervertebral disk is related to both the amount motion and the magnitude of the loads that must be transmitted. As said before, it is composed of an annulus fibrosus and a nucleus pulposus. Its main design focuses on both stability yet not sacrificing flexibility. The function of the spine, as a whole. The motions available to the spinal column are seen as flexion and extension in the sagittal plane, lateral flexion through the coronal plane, and rotation about the Y axis. These motions appear to occur independently of each other. However, at the level of the individual motion segment, these motions are often coupled motions.

Spinal Segmental Flexion. At the segment, we see interior tilting and gliding of the superior vertebra on the vertebra below. This causes a widening of the intervertebral foramen and separation of the spinous processes. Tension in the supraspinous and interspinous ligaments resists separation of the spinous processes and thus limits the extent of flexion. Passive tension in the zygapophyseal joints, and ligamentum flavum, posterior longitudinal ligament, posterior annulus fibrosus, and the back extensors also imposes controls on excess of flexion.

Spinal segmental extension. This is seen as posterior tilting and gliding of the superior vertebra over the vertebra below and causes narrowing of the intervertebral foramen. This is also seen as approximation of the spinous processes. The amount of motion available in extension is limited by bony contact of the spinous processes and passive tension zygapophyseal joint capsules anterior fibers of the annulus fibrosus, anterior trunk muscles, and the anterior longitudinal ligament. The only ligament that limits extension is the anterior longitudinal ligament

Spinal Segmental Lateral Flexion. This is seen where the superior vertebral laterally tilts over the vertebra below. There is some degree of rotation and translation over there dries in vertebra below. The annulus fibrosus is compressed on the concavity of the curve and stretched on the convexity of the curve. Passive tension in the annulus fibers intertranverse ligaments, and anterior and posterior trunk muscles on the convexity of the curve limits lateral flexion. The direction of rotation that accompanies lateral flexion differs slightly from region to region because of the orientation of the facets.

Spinal segmental rotation. The superior vertebra rotates axially over the vertebra below. It rotates and translates less than what is seen in lateral flexion. The annulus fibrosus fibers are slightly angulated and alternating direction in each layer. This creates a central compressive force as the disc is twisted. Passive tension in the annulus fibers intertransverse ligaments and anterior and posterior trunk muscles on the convexity of the curve limits rotation. Regional variances of the spine. Facet Joint orientation.  Each virtual section has small differences to accommodate force. The vertebrae are depicted as follows and have favorable functions to deal with varying loads and shift of center of gravity through each region. The angulation of the spinal facets vary between segments. In the cervical region, you see the facets facing coronally with a 45° superior to inferior tilt. The thoracic spine region, you see a 40 to 60 degree lateral from coronal plane, and a 30° superior to inferior tilt. In the lumbar spine region is a 45-degree lateral and a sagittal orientation of the facets. The changing orientation of facets is suspected due to the change from mobility in the cervical spine to anchoring in the thoracic spine for the vital organs and weight and load bearing in the lumbar spine.

Posture: The key concepts of posture are as follows: Postural Control, which is the ability to maintain stability of the body and body segments in response to forces applied on the body in any direction. The Base of Support, which is the area bounded posteriorly by the heels and anteriorly by a line joining, the tips of the toes. The Centre of Gravity, this is the line of gravitational force as it transmits down the spine to the base of support. Perturbation, any sudden change in conditions that displaces the body posture away from equilibrium. The basic elements of postural control. These control the body’s orientation in space. They maintain the body’s center of gravity over the base of support and stabilize the head with respect to the vertical so that eye gaze is appropriately orientated. This requires optimal function of an intact central nervous system, visual system, and musculoskeletal system.  Control depends on correct information from proprioceptors in the joint capsule, tendons, ligaments, and the soles of feet. A completely healthy vestibular system and a balanced visual system.

Posture Analysis. For the anterior view, there is quite a list of key landmarks to identify on the anterior view. We always look at the level of the eyes, the level of the ears at the external auditory meatus, the facial features in case of any hemiplegia ptosis or Bell’s Palsy, the AC joints to see if they are level and orientated correctly, the manubrium sterni, the antecubital fossae, the ASIS or anterior superior iliac spine, the knee joint line for any deviations of genu valgus or genu varum. The patellae for any patella alta or baja, squinting or divergent patellae. Medial arch of the foot for any arch collapse or pronation of the foot. And angulation of the first rays to see any spreading or foot leg length deformities,

On Posterior View. Key landmarks to identify on the posterior view are as follows: the External Occipital Protuberance, the External Auditory Meatus, the AC joint/spine of scapula on Ectomorphic patient body types, the Inferior Angle of the Scapula to see for any winging or protrusion of the scapulae, any Elbow Joint lines or carrying angles, the Posterior Superior Iliac Spine, notified by dimples above the buttock area, the gluteal folds, the Popliteal Fossa, the Achilles Tendons, for any calcaneus vulgus or virus,

On Lateral View. Key landmarks to identify lateral view are as follows: an Anterior or Posterior Head Carriage, the CT Junction for Dowager’s hump or Pottenger’s Saucers, the Thoracic Profile or for Hyper or Hypo-Kyphosis, the Chest Profile for Pectus Cavus or Pectus Carinatum, Anterior or Posterior pelvic tilt on the line between the Anterior Superior Iliac Spine, and the Posterior Superior Iliac Spine levels, the Gluteal Profile, the Knees whether they are in semi flexed position for a posterior pelvic tilt, or hyperextended/genu recurvatum position for a severe anterior pelvic tilt, and the Foot Profile for plantar flexion or heel lift.

General Postural Syndromes. Kyphosis, this refers to an abnormal increase in the normal posterior convexity of the thoracic spine. It may be a compensation for an increase in lumbar spine lordosis, or as a result of poor postural habits, or developmental, such as Sherman’s disease, or in secondary infections such as TB, or secondary developmental disorders or autoimmune disorders such Ankylosing Spondylitis. A gibbus or humpback deformity can result due to vertebral fractures. These are significantly different with a sharp angulation in the thoracic curvature compared to a general thoracic convexity. A Dowager’s hump is a common recognizable condition often found in postmenopausal women, especially if they have osteoporosis. It is a common postural problem that is developed from prolonged anterior head carriage and results in the collapse of the vertebral bodies anteriorly, increasing compression due to the lack of interior support resulting in the hump.

Here are some simple diagrams on General Postural Syndromes, especially around kyphosis. Scoliosis, this is a condition which involves lateral flexion and rotation of the vertebrae in a coupled motion the adolescent form or idiopathic type makes up 80% of all scoliosis cases. These curves are defined as structural curves. They are named according to the direction of the convexity and the location of the curve. It is due to asymmetrical growth and development, which causes wedging of the vertebral bodies. These commonly needs surgical intervention or bracing.

The second type of scoliosis is known as functional or non-structural scoliosis, which can be reversed if the cause of the curve is corrected, and structural changes are not present. The examples for non-structural scoliosis are leg length inequality and or muscle spasm. The following pictures depict the types of scoliosis that can be seen such as a single thoracic curve, a single lumbar curve, a single thoracolumbar curve, and a double lumbar and thoracic curve.

Postural Syndromes to consider in the athlete. Upper Crossed Syndrome. This is signified by tightness of the upper trapezius and Levator scapulae on the dorsal side which crosses with tightness of the pectoral muscles. Weakness of the deep cervical flexes ventrally crosses with weakness of the middle and lower trapezius.  This pattern of imbalance creates joint dysfunction at the atlanto-occipital joint or C4-C5 segment, also cervical thoracic joint, glenohumeral joint, and the T4 T5, segment. Specific postural changes are seen in Upper Cross syndrome, including forward head posture, increased cervical lordosis and thoracic kyphosis, elevated and protracted shoulders, and rotation or abduction and winging of the scapula.

Lower Crossed Syndrome. This is signified by tightness of the thoracolumbar extensors on the dorsal side, which crosses with the hip flexor muscles, and weakness of the deep abdominal muscles ventrally, which crosses with the weakness of the gluteal muscles. This pattern of imbalance creates joint dysfunction particularly at The L4 and L5 segments. L5 and S1, the sacroiliac joint, and the hip joint. Specific postural changes are seen in lower crossed syndrome which include anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension or genu recurvatum. If the lordosis is deep and short, then imbalance is predominantly in the pelvic muscles; every lordosis is shallow and extends into the thoracic area, then imbalance predominates in the trunk muscles.

Thank you for taking the time to refresher your knowledge about the basics of biomechanics.  [End]

1.1 Lower - ICSC05_Biomechanics Lower Extremity

Section 1 – 1.1 Lower_ICSC05
English Direct Download PDF
ICSC05-1.1 VIEW Biomechanics Lower Limb Dr S Smilkstein 41.18.mp4

ICSC Lower Extremity Module 5
Section 1.1_ICSC05 Lower Limb
Instructor Steven Smilkstein
Video Lesson: 41:18

This is a guide to pick up on normal and abnormal biomechanical limb behaviour of the lower limb. In this section, we will be looking at the hip, the knee, the ankle and foot complex, the general injuries, and Gait Analysis.

The Hip Complex. The hip joint is a very unique joint to the body, even though it has similarities to that of the shoulder joint, it also has its characteristic differences. We will be investigating the anatomy, structure, and function of the Coxafemoral Joint; the angles of importance; the hip joint pathology that we see in young athletes and hip joint degeneration in senior athletes; and possible ideas for rehabilitation.

The Anatomy of the Hip. The Hip joint or Coxafemoral joint is a diarthrodial ball and socket joint with three degrees of freedom, allowing flexion and extension in the sagittal plane; abduction and adduction in frontal plane motion; and medial or internal rotation and lateral or external rotation in the transverse plane.

The Anatomy of the Hip. The ilium, ischium, and pubis bones fuse to form the pelvis. They contribute to the structure of the acetabulum or cup-like socket that articulates with the head of the femur. The cup-like girdle is referred to as the innominate or Os Coxa. Ossification of the pelvis occurs at approximately 20 to 25 years of age. The lunate surface of the acetabulum is covered with hyaline cartilage and is the articulating surface with contact to the head of the femur. The base of the horse-shoe or the lunate surface is interrupted by the acetabular notch. The acetabular fossa is a non-articular portion and the femoral head does not contact this area.

Comparison of the Hip to the Shoulder Joint. There are quite a few similarities and differences between the shoulder and hip joints. The shoulder provides a stable base for hand mobility against gravity with precedence for open chain functions, and has a relatively weak capsule. The hip has a primary function to support the weight of the head, arms, and trunk. The capsule is strong and dense and contributes to joint stability. In this diagram, you can see the vast differences between the glenohumeral joint and the hip joint, where the anatomy provides the ability for the shoulder to have more flexibility with less stability and the hip to have more stability with slightly less flexibility. The Angles of Importance of the Hip Joint. The Center Edge Angle of Acetabulum. The Center Edge Angle is the measurement of inferior angulation of the acetabulum. It is measured by a line connecting the lateral room of the acetabulum and the center of the femoral head. This line forms an angle with the true vertical. The average measurements are 38 degrees in males and 35 degrees in females. A smaller center edge angle makes the acetabulum more vertically orientated and results in less coverage of the femoral head resulting in less joint stability.

The Angle of Acetabular Anteversion. The acetabulum faces laterally, inferiorly, and anteriorly. The magnitude of the anterior orientation is called the angle of acetabular anteversion. Pathological increase in angle of anteversion causes a decreased joint stability and an increased tendency for anterior dislocation of the head of the femur.

Femoral Angulations. The first of the femoral angulations we look at is the Angle of Femoral Inclination or Angle of Inclination. It occurs in the frontal plane between an axis through the femoral head and neck and the longitudinal axis of the femoral shaft. In early infancy, it is approximately 150 degrees and decreases to average of 125 degrees in the normal adult, and to approximately 120 degrees in the elderly. Normally, the greater trochanter lies at the level of the center of the femoral head. In pathological increase in angle, it is called coxa valga; and a pathological decrease in the angle is called coxa vara. The second of femoral angulations is the Angle of Femoral Torsion or Anteversion. The Angle of Torsion also known as the Angle of Anteversion occurs in the transverse plane between an axis through the femoral head and neck, and the axis through the distal femoral condyles which creates a twist in the femoral shaft. The angle decreases with age: in the newborn, it is approximately 40 degrees and it decreases to approximately 10 to 15 degrees in adults, with a range between seven degrees and 30 degrees. A pathological increase in the angle is called femoral anteversion; and a pathological decrease is called femoral retroversion.

Hip Joint Pathologies in the Young Athlete. Age is an important factor in the diagnosis of athletic injuries. Athletes are more susceptible to certain problems at certain ages. Young athletes with hip pain must be checked for: Leg-Calve-Perthe’s Disease, Slipped Femoral Capital Epiphysis, Hip Dysplasia, and Juvenile Rheumatoid Arthritis. Most of these pathologies can be picked up on normal X-rays. So, therefore, think clearly and send your patients for an assessment using X-rays. Simple measurement tools such as the sentence line at the hip might give you an indication of possible problems.

Hip Joint Pathologies in the Senior Athlete. Peripheral Degenerative Joint Disease is most commonly found at the hip joint in the seasoned or senior athletes. The most common symptoms are groin pain on activity or chronic gluteal pain and spasm. It’s usually picked up on Passive Range of Motion assessment with the patient experiencing pain or crepitus. Most commonly it is found in runners and lunging sports.

The Knee Joint. In these slides, we will be looking at the anatomy, structure, and function of the knee; the Tibiofemoral Joint Anatomy; the menisci; the ligaments of the knee; the important mechanisms of the knee; and the Patellofemoral joint.

The Anatomy of the Knee. It is one of the largest joints in the body, and the most complex. It is a double condyloid joint, with two degrees of freedom, allowing flexion and extension in the sagittal plane around the transverse axis; and medial and lateral rotation in the transverse plane around a vertical axis. The complexity of the knee joint comes from the fact that it has ligamentous support both extra-articularly and intra-articularly. The ligaments themselves are restraints both on the outside of the knee and inside retaining forces of translation and shifting.

The Distal Femur. The medial and lateral condyles on the distal femur form the proximal part of the knee joint. They are large and have an obvious curvature anteroposteriorly and convex in the frontal plane. The condyles are separated by the intercondylar notch or fossa and joined anteriorly by the patella groove. The femoral shaft is not aligned in a true vertical position and it is angled so that the femoral head is medial to the femoral condyles. The lateral articular surface is not as large as the medial surface. Therefore, the medial condyle extends further distally than the lateral, so that the distal end of the femur is essentially level in anatomical position.

The Tibia. The distal knee joint is composed of two concave, asymmetrical tibial condyles. The articular surface of the medial condyle is approximately 50% larger than the lateral condyle, which corresponds with the femoral condyles. The articular cartilage of the medial tibial condyle is approximately three times thicker than the lateral. The two articular condyles are separated by the intercondylar tubercles.

The Function of the Knee. In a closed kinematic chain, the knee works with the hip and ankle to support the body weight in the static erect posture. It works dynamically to move and support the body in setting and squatting, as well as when supporting the transfer of weight during ambulation. In an open kinematic chain, the knee provides mobility for a foot in space. The incongruence in the knee joint structure is accompanied by an accessory joint structure that enhances congruence and assists in the balance between mobility and stability.

The Menisci. They are two asymmetrical fibrocartilaginous joint discs, which are located between the condyles of the femur and the tibia. The medial meniscus is semicircular in presentation, and the lateral meniscus is a 4/5th ring in presentation. Both are wedge-shaped which are thick peripherally and thin centrally. They open towards the intercondylar area. They increase the radius of curvature of the tibia condyles and therefore, generate congruence in the knee joint. They distribute weight-bearing forces. They reduce friction between the segments and there are shock absorbers.

The Ligaments of the Knee. The Anterior Cruciate Ligament or ACL. The ACL runs from the anterior tibia, superiorly and posteriorly, and attaches to the posterior inner aspect of the lateral femoral condyle. It is comprised of two subdivisions of the ligament: your Anterior Medial Band or AMB, and the Posterior Lateral Band or PMB. With valgus loading, both ACL bands increased tautness with increased flexion. The ACL is the primary restraint to anterior displacement of the tibia on the femoral condyles. It has a minor role to play in restraining medial and lateral forces to the knee. Injury to the ACL can result in: increased anterior tibial translation, especially between zero degrees and 90 degrees of flexion; increase in valgus tibia rotation, between 30 degrees and 90 degrees of flexion; increase in lateral tilt of the patella with flexion; increase in lateral shift of the patella with flexion. The Quadriceps are antagonistic to the ACL, but if the hamstrings are co-contracting, it will reduce the forces through the ACL. Therefore, the hamstring complex decreases anterolateral tibial translation independent of the ACL.  In this diagram, you can see the difference between a normal ACL and an injured ACL. With regards to the injury, try to picture, how the knee would shift or deviate without the restraint of the ACL ligament.

The Posterior Cruciate or PCL. The PCL runs superiorly and anteriorly to the inner aspect of the medial femoral condyle. It is the primary restraint to posterior displacement to the tibia beneath the femur. If a posterior directed force is applied, the tibia will also rotate laterally, i.e., the PCL plays a role in locking the knee which is critical for stabilization. Maximum loading occurs in the PCL with the knee fully extended and a posterior translatory force applied to the tibia. It also restrains varus and valgus forces. The hamstrings and gastrocnemius muscles are antagonistic, whereas the quadriceps and popliteus muscles are synergistic to the actions of the PCL. The restraining system for knee extension includes: the PCL, the posterior joint capsule, the LCL, the posterior oblique ligament, the MCL with the meniscus attached, the posterior medial and posterior lateral menisco-tibial bands, and the posterior menisco-fibular ligament.

This diagram depicts the anatomical location of the PCL when the knee is flexed. It is very difficult to see in the neutral position. Try to imagine where the tibia would drift to if the PCL was injured.

The Colateral Ligaments of the Knee. The lateral Collateral Ligament or LCL. It attaches between the lateral femoral epicondyle and posteriorly to the head of the fibula. It resists varus forces and adduction stresses on the knee. It also limits lateral rotation of the tibia in conjunction with the posterior lateral capsule and popliteus muscles. It has the most substantial effect of restraint at 35 degrees of knee flexion.

The Medial Collateral Ligament or MCL. It attaches between the medial femoral epicondyle and inserts into the medial aspect of the tibial condyle. It slants slightly anteriorly. It resists valgus forces or stresses on the knee. It especially works when the knee is slightly flexed and the other structures make a lesser contribution to resistance of valgus stress. The MCL checks the lateral rotation of the tibia. It acts as a backup restraint to pure anterior displacement of the tibia when the ACL is insufficient or absent. Here is a diagram depicting the collateral ligaments in anatomical position. Try to Vision the forces or the translation of the knee joint with the absence or weakness of these ligaments.

Important Mechanisms of the Knee. Tib-Fem alignment. The long axis of the femur is oblique directed inferiorly and medially. The axis of the tibia is almost vertical. This creates an angle, at the knee medially between 185 degrees and 190 degrees and creates a normal physiological valgus at the knee joint. Therefore, there is a balance of weight distribution on lateral and medial condyles as might be expected in bilateral static stance.

Important Mechanisms of the Knee. Genu Valgus or Genu Varus. If the tib-fem angle is greater than 195 degrees, it is called the genu valgum or knock knees position. This will increase compressive forces laterally and increase tensile forces medially. If the tib-fem angle is less than 180 degrees. it is considered genu varum or bow leg position. This increases compressive forces medially and tensile forces laterally. Even a mild genu varum can increase compression on the medial meniscus by at least 25%.

The Q-angle. This is the net effect of the pull of the quads and the patellar ligament on the patella. This is the angle formed between a line connecting the ASIS to the midpoint of the patella and a line connecting the tibial tuberosity and the midpoint of the patella. It usually measures 10 to 15 degrees with the leg in extension. In females, they may have a greater angle due to the wider pelvic anatomy. A Q-angle of 20 degrees or more is considered abnormal and creates excessive lateral forces on the patella which can lead to pathological changes and suggest patellar instability.

The Patellofemoral Joint. The patella is the largest sesamoid bone in the body and forms the least congruent joint in the body. The posterior surface of the patella can be divided into two separate facets: the medial and lateral articular facets. The medial facet may be further divided into a larger medial and much smaller most medial odd facet. The patella is seemed to slide distally on the femur during flexion and proximally on the female during knee extension. In patellar tilt, the patella seems to rotate around the vertical axis. The patella also rotates around an anterior-posterior axis but the apex of the patella is attached to the tibial tuberosity via a tendon, and therefore medial rotation that the patella causes the inferior pole of the patella to follow the medial tibial rotation. In lateral rotation, the patella causes the inferior pole of the patella to remain lateral with the tibia. This diagram is a longitudinal section of the knee joint. You can see the intercommunicating into joint spaces and you can see the articulations between the tibia femoral joint and the patellofemoral joint.

Important Mechanisms of the Knee. The Screw Home Mechanism. When the femur extends from full flexion back to approximately 30 degrees of flexion, the smaller lateral femoral condyle is at complete range of motion. The extension continues in order to return the need to zero degrees flexion because the larger medial condyle continues to roll or glide posteriorly, although the lateral side has halted. This results in the lateral rotation of the tibia on the femur, when non-weight-bearing, and medial rotation of the femur on the tibia whhen in weight-bearing position. This pivots the femur about the fixed lateral condyle of the tibia when weight bearing, and this is most evident in the last five degrees of extension. the mechanism may be assisted by increased tension in the ligaments as the knee reaches full extension. This medial rotation is not voluntary and not produced by muscle action. It is this rotation that accompanies the end of extension and brings the knee joint into the close-packed position. It is also known as the locking mechanism or screw home mechanism. This mechanism is an important pointer when dealing with a patient who has no signs of knee instability, but chronic knee pain.

The Ankle and Foot Complex. In these slides, we will be looking at the anatomy, structure, and function of the ankle and foot complex; the Mortise joint; the Subtalar joint; Forefoot and Hindfoot behavior with pronation and supination and the compensating mechanisms in pronation and supination twist; and the Plantar Fascia.

The Anatomy of the Mortise Joint or Talocrural Joint. The ankle is the most congruent joint in the body and therefore, can withstand compression forces during gait up to 450% of body weight with little incidents of primary degenerative arthritis. The Mortise or talocrural joint is made up of the tibiotalar and the talofibular surfaces of the joints. It is a synovial hinge joint with a capsule and associated ligaments. It has a single oblique axis with one degree of freedom in dorsiflexion and plantarflexion.

The Anatomy of the Subtalar Joint. The Subtalar joint or Talocalcaneal Composite Joint is formed by three separate plane articulations between the talus superiorly and the calcaneus inferiorly. It also provides triplanar movement around a single joint axis in the form of pronation or supination. The function is to balance between dampening rotational forces imposed by the body weight and maintaining contact with the foot of the supporting surface. The three articulations on the superior surface of the talus are the posterior talocalcaneal articulation, which is the largest; and the medial and anterior articulations which are smaller. Between the posterior medial and anterior articulations is a bony tunnel formed by a sulcus or concave groove known as the tarsal canal.

The Essence of Forefoot and Hindfoot Behavior. How do you get triplanar movement at the Subtalar Joint? When the talus moves on the posterior facets of the calcaneus, the articular surface of the talus moves in the same direction as the bone moves; but at the medial and anterior facets, the talus surface moves opposite to the movement of the bone, therefore motion of the talus is a complex twisting or screw-like motion. Triplanar movement to the talus is then considered to be around a single oblique joint axis. Therefore, the subtalar joint is essentially a uniaxial joint with one degree of freedom, in the sense of supination and pronation.

Forefoot and Hindfoot Behavior. In pronation in non-weight-bearing, pronation is composed of the component of calcaneal motions of adduction, eversion and dorsiflexion. In weight-bearing, pronation consists of calcaneal eversion, talar adduction, and plantar flexion, not calcaneal adduction and dorsiflexion. Supination in non-weight bearing is composed of component calcaneal motions of adduction, inversion, and plantar flexion. In weight-bearing, supination consists of calcaneal inversion, talar abduction, and dorsiflexion, not calcaneal adduction and plantar flexion.

Pronation Twist. This is a mechanism to compensate for hindfoot supination in weight-bearing and maintaining contact with the foot with the ground. The hindfoot and Transverse Tarsal joints are both locked into supination. Adjustment to the forefoot position must be left entirely to Tarso-Metatarsal joints. The four foot tends to lift medially and press into the ground laterally. The first and second rays will plantar flex and the fourth and fifth will dorsiflex.

Supination Twist. This occurs as compensation for substantial hindfoot pronation in weight bearing, and thus, to maintain contact of the foot with the ground. The Transverse Tarsal Joint will generally supinate to counter-rotate the forefoot but it can only supinate to a limited degree. If range of the Transverse Tarsal Joint supination is not sufficient to meet the demands of pronating force, the medial forefoot will press into the ground and the lateral side will tend to lift. The 1st and 2nd rays up pushed into dorsiflexion, while the 4th and 5h rays will plantarflex in order to keep contact with the ground. This results in forefoot inversion. The whole foot undergoes an inversion rotation about a hypothetical axis at the 2nd ray as a supination twist of the tarso-metatarsal joints.

Gait Analysis. A simple understanding of Gait is important. We will be looking at normal gait, gait initiation, determinant factors of gait, gait diagrams, and the Running Gait.


Normal gait is rhythmic and characterized by alternating propulsive and retropulsive motions of the lower extremities. The lower extremities essentially support and carry the heads, arms, and trunk, i.e. 75% of your body weight. In gait, the head, arms, and trunk must not only be balanced over one extremity but must also be transferred from one extremity to the other. These activities require coordination, balance, intact kinesthetic and proprioceptive senses, and the Integrity of the joints and muscles.

Three main tasks are involved in walking: weight acceptance, single limb support, and swing limb advancement. It is needed to support the weight of the body on one lower extremity and to swing one extremity forward in order to progress. These tasks thus include the following tasks: maintenance of support of the head, arms, and trunk against gravity; maintenance of upright posture and balance; and the control of foot trajectory to achieve safe ground clearance and gentle heel contact.

The Gait cycle can be divided into two separate main phases: one, the stance phase, and two, the swing phase. The stance phase is divided further into: heel strike, the flat foot, midstance, terminal stance, and the toe off or pre-swing phase. The swing phase can be subdivided into three main points: acceleration or initial swing, the midswing, and the deceleration or terminal swing phases. In this diagram, you can see the merge between the stance phases and the swing phases, and the sub-phases. Also the shifting weight and balance across the body. We also have a diagram from the top of the head where you can see how the limb is swung forward while stance is maintained.

Gait Initiation. This begins in the erect standing posture with an activation of the tibialis anterior muscle and the vastus lateralis muscle. in conjunction with an inhibition of the gastrocnemius muscles. Bilateral concentric contractions of the tibialis anterior result in a sagittal torque that inclines the body anteriorly from the ankles. The Center of Pressure is now described as shifting either posteriorly and laterally towards the swing foot or posteriorly and medially towards the supporting limb. Abduction of the swing hip occurs simultaneously with contractions by the tibialis anterior and the vastus lateralis and produces a coronal torque that propels the body towards the support limb. The support limb hip and knee flex a few degrees. This causes an anterior movement of the body and medially towards the support limb. This anterior medial shift frees the swing limb so that it can leave the ground. The end of the gate initiation activity ends when either the stepping or swing extremity lifts off the ground or when the heel strikes the ground.

Determinant Factors of Gait. Distance and Time Variables. Stance time is the amount of time that elapses during the stance phase of one extremity in a gait cycle. Single-support time is the time that elapses during the period when only one extremity is on the supporting surface in a gait cycle. Double-limb support time is the amount of time that a person spends with both feet on the ground during one gait cycle. Stride time or duration is the amount of time it takes to accomplish one stride. Step time is the amount of time spent during a single step measured in seconds per step. Cadence is the number of steps taken by a person per unit of time, measured as the number of steps per second or per minute. Speed or Walking Velocity is the rate of linear forward motion of the body. Acceleration is the rate of change of velocity with respect to time. Speed is usually referred to as slow or fast stepping.

Distance Variables. Stride length is the linear distance between two successive events that are accomplished by the same lower extremity during gait. It’s measured from the point of heel strike of one lower extremity to the next heel strike of the same extremity. Step length is the linear distance between two successive points of contact of opposite extremities. This is where it’s measured from heel strike of one extremity to the heel strike of the opposite extremity. Width of walking base is found by measuring the linear distance between the midpoint of the heel of one foot in the same point on the other foot. Degree of toe out represents the angle of foot placement and may be found by measuring the angle formed by each foot’s line of progression and a line intersecting the center of the heel and the second toe. The angle measured is approximately seven degrees.

Phases of the Gait Cycle. The gait cycle includes the activities that occur from the point of initial contact of one lower extremity to the point at which the same extremity contacts the ground again. During one gait cycle, each extremity passes through two phases: one, a single stance phase, and two, a single swing phase. The stance phase begins at the instance that one extremity contacts the ground and continues only as long as some portion of the foot is in contact with the ground. This makes up 60% of the gait cycle. The swing phase begins as soon as the toe of one extremity leaves the ground and ceases just before heel strike or contact of the same extremity on the ground. This makes up 40% of the gait cycle. A period of double-limb support occurs when the lower extremity of one side of the body is beginning at stance phase and the other extremity on the opposite side is ending its stance phase. There are two periods of double support in a single gait cycle. During double support, both lower extremities are in contact with the ground at the same time.

In the diagram below, we have broken down the stance and swing phases of both limbs. As you can see, they run synchronously and timelessly. Note that the initiation of the left-sided stance phase starts roughly at 75% of the right-sided stance phase completion. Therefore, when there is swing phase there Is no interruption of the stance phase of the opposite side. It is always important to note and take good care in watching the pattern of gait when assessing a patient. This can give you pointers of where the problem is located that is disturbing the gait cycle, the structures that are not performing in the correct manner, and also the ease of movement in both your injured patients and your performance athletes. This does occur in marathon walkers, runners, and sprinting athletes.

The Running Gait. In the running gait cycle, maximum power is achieved with minimum contact and resistance from the ground. This is achieved by explosive contractions from the hamstrings and triceps suri muscle groups, and the quadriceps, glutei and ankle dorsiflexors alternating between the roles of synergists and antagonists, in order to spring load the lower limbs for propulsion. Minimum resistance is achieved by bringing both limbs into the air as a double float phase instead of the double stance phase seen in the conventional walking gait cycle.

You can see in the diagrams below the difference of the running gait compared to that of the walking gait. Also, take note that your swing phase now becomes 60% of your running gait cycle compared to its 40% contribution in walking gait cycle, and your stance phase goes into 40% in your running gait cycle compared to its 60% contribution in the walking gait cycle. Also, take note, the double float or the floating position that occurs instead of the double stance phase in walking gait cycle.

Thank you for your time in today’s lesson. All the best for the rest of the modules.



1.2 - ICSC05-1.2_Hip

English Direct Download PDF ICSC05-1.2 VIEW Hip C Foss.1.32.42.mp4

ICSC Lower Extremity Module 5
Section 1.2_ICSC05
Instructor Christine Foss
Video Lesson: 1:32:42

Welcome to the Hip Module Part 1. I thought I would start by just telling you a little bit about myself. I am a Chiropractor in the USA, in New Jersey specifically. I have my Master’s Degree in Sports Medicine and a certified athletic trainer. I have my diplomate from the American Chiropractic Board of Sports Physicians, and I am internationally certified as a Chiropractic Sports Physician. I have worked with athletes for many years, and this is my passion and education really are my passion. I am the current Education Chair for FICS and looking forward to taking you on this journey of Education, as you go through these ICSC modules and really embed yourself in the culture of being a Chiropractic Sports physician. It is a lifetime of learning so, thank you for taking part in not only today’s lectures but all the programs. This is really a very exciting time to be a Sports Chiropractor as we are really welcomed and invited by athletes and sporting federations to participate in helping athletes achieve their optimal performance. It is really a great thing for the athletes and the sporting federations to notice that we are an integral part of that important team, that health care team, or that medical team in helping achieve one’s goals.

We are going to move through this module and start learning a lot about the hip. Before I move forward, I just wanted to talk about the objectives. This is the first part of the hip module and we are going to be talking about the assessment of the hip. How am I going to look and explore the diagnosis of the hip?  When I teach evaluation and diagnosis, I want you to consider the idea of laser focus, first on the diagnosis, so you get very good at making the accurate diagnosis, then come backwards and look at the functional components that might have predisposed the athlete to that injury. We are going to talk a lot about that as we go through todays lesson.

I want you to think about that though and understand that getting a diagnosis is not the last step in figuring out what is wrong with that athlete or patient. That is the first step in opening the doors to figure out the why or what is going on with that patient. Why are they predisposed to that injury? Because it is really about preventing injuries and not so much about just figuring out what is wrong because we are going on a journey with an athlete. We want to see them reach success and sometimes that comes with the injury but if we could jump over some of those puddles and help these athletes attain their goals without sustaining an injury that is where we need to be focused on. As I said at the start of this lesson, this is the first part, the assessment portion then your next portion of the hip will be the functional assessment and then the rehabilitation.

You have three parts in going through the hip and then the same with the whole lower extremity, the knee, and then the ankle. You are looking at assessment, at functional assessment, then looking at rehabilitation.

Let us talk about our course outline for today. We will be looking at the anatomical features of the hip and just going to refresh your memory on the muscles that are called to action as we go through different sports. We must attain an assessment skill of the hip, and be able to have in your brain the order of events you need to do to get a good hip evaluation. As you are starting out, I would like for you to do the hip evaluation in the same order each time and you know, honestly, when I evaluate the hip doing it this many years, I still do it in the same order. This way I am sure that I am not forgetting anything or leaving some nuance out that might predispose the athlete to injury. We are going to work on developing treatment plans and strategies for the acute, subacute, and chronic phases of hip injury, and then we will talk about sports return strategies post hip injury. When is the athlete ready to get on the field? When are they not ready? When do I start functional sport-specific training? When do I not start sport-specific training? We need to think about all these things as you are walking somebody through those cycles of injury.

The first thing we need to think about with hip injuries are muscular considerations. We have learned the anatomy in school but going back and understanding the anatomy sometimes is not the anatomy. If we look at these two different athletes here on the right side of your screen, we can really appreciate and understand that there are different things going on with each of them. Certain muscles are activated. Certain muscles are inhibited. We have different structural confirmations. We might have femoral anteversion or femoral retroversion.

What are we talking about with overall tone and body confirmation postural biomechanics that might be predisposing to injury? Again, we are going to laser focus on that diagnosis. We need to be able to pan out and say all hips are not created equal. We need to be able to see there are different muscular considerations for different patients. For example, the patient on the left here, her QL on the right side looks like it is turned off to me. Why are her hips uneven? Would that predispose her to a left IT band syndrome? Possibly. Then let us look at the athlete on the right. This is a high-level gymnast. We can see a number of things going on here, but we can again, focus on that right thoracolumbar angle. That looks different. Why is her right shoulder activated different than her left? And how is that going to make her more predisposed to certain injuries in the hip? As we start panning back and talking about the why is later on in this lecture, these are the things I want you to think about. Not just keeping somebody on the table and evaluating them laying down.

Let us take a moment and just refresh ourselves with the anatomy. I am kind of an anatomy nerd and love going back over anatomy and actually, I really enjoy New York Chiropractic Colleges letting me go in annually and take a look at the cadavers and work through some of how we evaluate these sports injuries on cadavers. I wanted to really see when We are doing certain orthopedic tests, how are those structures affected and what other structures are called into play. So just entertain me for a minute and just refresh your memory on the anatomy as we go through muscle testing and diagnosis. You need to imagine these structures as you are evaluating. When students come to my office and I work with them, I say, “Listen. As you are palpating, as you are muscle testing, when you are going for orthopedic tests, I want you to picture that anatomy as you are doing it. It really helps to make sure you are testing the right structure. You feel that the right position is making sense to test that structure.

Let us look at the picture here on the left and we can see the psoas and the iliac coming down to attach here onto the lesser trochanter of the femur. I want you to appreciate here the breadth of this adductor group. It is not as often discussed as we would like to see in the literature. There are some articles on adductor injury but, however, it is not really like one of those very commonly talked about things in sports injuries. But if we look at it, how can we not? How can we overlook this very vast structure, group of muscles, this adductor group that is actually helping to align the hip with every step? We need all these muscles to be working in concert, or in synergy to allow a normal street gait of the hip. For that femoral acetabular joint to move straight forward, I need all those muscles working as well as working agonistically and antagonistically with the lateral structures, the abductors.  Of course, we have that adductor group and then here we have your pectineus which plays a large role in the position of the hip. We can see if that is injured. What is going to happen to this femoral acetabular joint and the sartorius here?

Looking at the right side of your screen, we are going to go into this gluteus medius a lot later, but the gluteus minimus here and its insertion understanding where they insert on the femur will really help you nail down a diagnosis as you later understand. I have some mnemonics to help you out with that later on so that you can kind of remember when you are evaluating your patients and your athletes, what is injured, and why would it be important to know that. Why would I need to know if it is a gluteus medius versus a gluteus minimus injury? That tells us what action is causing the injury. Then we can take that one step further and think about which biomechanical fault might be overusing or underusing that muscle to cause the injury. Understanding the anatomy is just really the very small first step in evaluating the injury and figuring out how to prevent re-injury or new injury.

Looking at the external rotators on the posterior aspect of the hip would be your gluteus minimus, your piriformis, superior gemellus, obturatorius internus and externus, and that is separated by the inferior gemellus and quadratus femoris. Then here’s your obturatorius internus here. We all know and are very familiar with the sciatic nerve and its course either under, through, or around the piriformis muscle in certain athletes and in patients as well.

As we move forward, we have to understand that we are going to look at the biomechanical considerations and hip injury. We need to know the anatomy, understand the anatomy function and structure as well as the biomechanical considerations with that anatomy. How might that change my diagnosis or my treatment regime, more importantly? Just watching an athlete like this, this is that gymnast we saw earlier, do a simple squat on a TRX, I need to see how her hips move with function. I am not just evaluating patients laying down or athletes laying down. I want to see them, do what they need to do. I want them up and moving. For her, I am going to have her do a squat for me. I am going to have her do TRX moves and I am going to really look at what faults crop up or biomechanical faults crop up that might be hindering her ability to use a muscle efficiently or overuse a muscle. I really want you to understand that. I would just take our time with that early on in the lecture.

Getting into the bony considerations in Biomechanics 2. Let us just look at the basic hip structure here and understand this femoral acetabular joint here the labrum which is the cartilage and its function really is to deepen the cup of the femoral acetabular joints. We are going to call this the cup here. Can you see how this labrum crops out making this cup a little deeper, which speaks to the stability of the hip? When that femoral acetabular joint in the femur is snugged up into the acetabulum, we have greater stability and more acetabular coverage to stabilize that joint. Without the labrum, we’d have a little less coverage on the femoral head and more femoral acetabular instability. That is one of the functions of the labrum. Then, really understand the position of the acetabulum, the femoral head, femoral neck, and greater and lesser trochanters. That actual biomechanical position plays a huge role in our ability to recruit muscles. Let us just take a look at the multi-directional articulation of the hip as well and understand that this is the ball and socket. It needs to move in many different planes, unlike the knee. Understanding the blood flow and conditions such as osteonecrosis of the hip where we have a decrease in blood flow of the femoral head here and we get necrosis. That becomes a surgical intervention pretty quickly. How do muscular actions play a huge role in the function of this hip joint? How did the two come together? Understanding when we are looking at an injury of any body part, it is very rare that somebody has one pure injury. We are not going to just have a labral tear and nothing else has happened to the whole hip. Understand that we are going to have layers of injury. Maybe we have a labral tear and possibly, we have some rectus femoris irritation too because the rectus femoris originates up at the AIIS. Maybe we have a combination of things. You need to do your job and your evaluation to tease apart which structures are injured and don’t always be satisfied with just one finding, one finding. Keep looking until you are sure that there’s nothing else going on there.

Talking about the structure of that joint, look at the bony anatomy, I want you to understand that we are all not created equal. We are all structurally developed differently. A lot of these structural developments are derived from the way you were sleeping when you were a baby. Did you sleep on your belly? Were your knees bent, were your knees out, were your feet tucked under? Then we develop structurally as a result of this. As part of this module, you’ll see an article from the Pediatric Association that talks about these structural developments and how the ramifications of, when you get older, how our bodies develop. We are just going to take a quick peek at that here in these next couple of slides and understand the term femoral anteversion. This is a really important term when We are looking at hip injuries and predisposition and guiding athletes towards optimal performance. I am going to tell you why.

If we look at the normal femoral anteversion position here, between that 15 and 20 degrees, this of course here is your tibia. This is the posterior condyle of your tibia, this is the acetabulum, and your femoral head and neck. We can see if we draw a line straight across horizontal in line with the tibial posterior condyles, and then we draw another line in the center between the femoral head and neck, and we take a measurement of that angle and that angle. That angle in the adult is about 15 to 20 degrees. That ankle actually decreases with age. When you were a newborn, that angle is very large. It is a 40-degree angle approximately and it decreases down as we get a little older. Let us look at this larger angle, this increased femoral neck anteversion. This would be more when you were younger, this larger angle, and understanding why it takes a little while for us to learn how to walk and balance. We don’t really have good control but what I want you to take away from this slide here on the bottom left corner is to imagine the lack of stability in the joint with this femoral neck anteversion because the femoral neck has come forward here. Can you see? I don’t have that femoral head snugged into this acetabular notch and therefore have greater instability. This would be somebody that would be more prone, with a greater femoral neck anteversion, more prone to an anterior dislocation of the hip.

Conversely, we can look at a femoral neck retroversion. When it is retroverted it is deeper in there. What is going to happen with that? What are the ramifications of somebody maybe that structurally anteverted versus retroverted? Somebody that is more anteverted will have a different range of motion than somebody retroverted normally. We need to consider that in understanding how somebody performs and trying to get, let us say a rhythmic gymnast to do a certain maneuver with her hips, let us call it a split and maybe she can’t do that because structurally, she is unable. Understanding the anatomy and how these positions of the femur and how they were formed when we were younger plays a huge role. As chiropractors, we always want to straighten everybody out. Everybody should be straight. But guess what? We can’t straighten everybody out because our normal homeostasis is not always straight. We need to understand what is normal for that patient or athlete. We need to have them function in their normal playground and not in what we think is normal. A great example of this is this graphic right here that We are looking at and here would be our normal 15 to 20-degree femoral anteversion, that is with skeletal maturity. Notice the toe is straightforward. Here’s the knee right here. Here’s the patella. Then, here would be a pre-schooler aged 4 to 6 and we talked about how they have that femoral anteversion. The toe is still straightforward, but they have that larger degree up to 40 degrees. Then we talked about this femoral anteversion with in toeing. We see these patients walking around and we always trying to correct this in toeing, but understand, we can’t always make that correction if we have a structural problem. We are trying to fix things sometimes that maybe can’t be fixed. With this, we notice that this alignment is very different than this alignment. This would result in our in toeing.

Another thing to consider in evaluating athletes with hip injuries, is the center edge of the angle of the acetabulum. Again, it speaks to the stability of that femoral acetabular joint. When we take first, our first line is a straight vertical line here right to the center of the head of the femur and our second line is a line, if we look here, that comes just [inaudible] at the edge of the acetabulum and into the center of the femoral head. One of these two lines bisects here. We grab this center edge from an angle here. That should be around 35 degrees in females, and 38 degrees in males. A smaller angle means that the acetabulum is more vertically sitting and that means less coverage of the femoral head. That means more instability of that joint. All right? Let’s just look at that. This angle was smaller. It would mean that my femoral head is not sunk into the acetabulum. It is out further here and that would speak to more instability as We are moving the hip as opposed to the stability you get being inside that acetabulum. That is how I want you to think about that. If we have an athlete that has a lot of instability in the hip you might want to take a radiograph and take a look and see if they have the center edge angle greater than 35 degrees. Then we might want to consider more stability exercises in the recovery process to build the muscle around the joint to help stabilize, and not necessarily more stretching exercises to make them looser because that would feed into the problem. Sometimes, as We are bringing somebody back to sport, we don’t want to do things that we call cement in the problem, or make the problem stay there longer. We want things that get rid of the problem. Someone with a large or small or center edge angle would be somebody that is more of a perturbation-type recovery where We are doing lots of things for stability of the joint.

Then looking one more time at this angle of anteversion it is something that interests me because I see it so commonly with athletes that struggle with, not only technique but low back pain and hip pain. Low back and hip pain kind of go hand-in-hand. They have very intimately related. As I am evaluating my low back patients, every time I evaluate the hips of several athletes, I find the hip is the cause of the low back pain. So, you know, we want to talk about this acetabular anteversion because if somebody’s acetabulum is slightly introverted, let us look down at this picture right here, this bone scan, we can understand here’s an anteverted acetabulum. You see the angle that this is sitting a little more forward than its other side? So can you understand as we get this increased angle of introversion, we are going to have a different amount of stability. When we have an increased angle of anteversion we actually have decreased joint stability because now that acetabulum is rolled forward and now, I have more motion of that femoral head. Again, this speaks to recovery if somebody has chronic tendinopathy around the hip joint, maybe they have a slight increase in the angle of anteversion and maybe they would need more stability exercises.

Going back and looking at some of these angles just on a simple radiograph is very easy. It will really help us get that athlete further. We are reaching for optimal performance without injury. That is always our goal. One of the last lines that were looking at when we talk about the structure of the hip is this angle of femoral inclination. It is super important when We are talking about biomechanical efficiency of muscle. We know that muscle is stronger or weaker on different levers. We learned about levers, third class lever, first class lever, and we understand that when a muscle fiber is shortened origin to insertion, it has a greater ability to produce power. When the muscle origin insertion is wider, it has a decreased ability to produce power. Let’s just take a journey and put those two together and understand our normal angle of femoral inclination is 125, and that is this angle right here. Can you understand that if I have this C right here, coxa valga, and I have an increased angle of my femoral inclination, my femoral head is going to be further away from my ileum? What does that mean when We are talking about biomechanics? What that really means is let’s just talk about the gluteus medius. The gluteus medius begins up on your acetabulum, I am sorry, your ilium up here and attaches onto the greater trochanter of the femoral head, femoral neck– greater trochanter, I am sorry. It is going to be a long class, guys. So now we have that gluteus medius going from an optimal 125-degree angle of inclination where we can produce the most power or a good amount of power, now I have an increased coxa valga with 140 degrees of an angle of inclination. Now, my gluteus medius muscle becomes inefficient.

Why is that important for athletes? Let us talk about a basketball player. They need to get a good vertical jump, but if they have a large angle of inclination, their gluteus medius is not going to be performing well. We are going to be missing a little bit of abduction there. Therefore, a little bit of power. What can I do for that athlete that has a coxa valga that has an inefficient gluteus medius? We will cover that in the rehab section.

Taking it one step further, do I develop other muscles in the area that make up for the loss of the gluteus medius? Or do I have chronic gluteus medius tendinopathy because of this and maybe I need to change the technique or talk to the coach about how a technique change might constitute a more biomechanically efficient gluteus medius? So, we side step injury there.

As we move into our hip evaluation, we are going to go nice and slow. We will talk about our best way to get that hip eval in a step-by-step progression so that you can really digest and process what is going on. Remember that your hip eval is the first step and you have laser focusing your diagnosis, then we are going to ask the whys. We have got to get a good diagnosis first, which is your first step in everything. Let us take a moment and get really proficient at this hip exam. We are going to take our time as we work through here because I want everybody to really understand the hip is one of the most important joints to own this evaluation particularly as chiropractors because of that hip and low back relationship that we see so commonly.

We talked about all hips not being created equal. These are those same two athletes. I gave the command of simply, before I took this picture, simply jump up. I am going to take a picture. Well, look at these two different jumps, and this is just, again, my command was just jump. This tells me a lot about these two athletes, hip motion and hip mobility, and things that might be a problem. The athlete on the left, I am going to look at her hip flexors. I am going to look at why she is kind of just flexing her knee so much and not her hips. What is going on there versus the athlete on the right, who’s a gymnast. We got a gymnast on the right and a weightlifter on the left. Notice how sports play a huge role in mobility or maybe the athlete chooses a sport because they have that mobility or don’t have that mobility. It could go either way but understand that we need to really grasp male and female hips are not created equal. The age of the athlete plays a huge role in what injury you are looking for or not looking for. The sport, the mechanism of injury, what muscles is that athlete using in their sport most commonly? Because sometimes they get injuries of other muscles, but we need to go to the major muscles that they need to call to action as they are performing their sport. Then, what is the past medical history? The greatest predictor of injury is the history of past injury. Understanding that history will also lead you in the direction of that accurate diagnosis.

Let us go on a journey here, and put you out on a hockey game, and you are the covering doctor for the day. They have asked you to come out and travel with the team and we have got somebody down with an injury. What do you need to think about? We think a little bit differently when we are treating on the field or in this case, on the ice versus in your office. But we always need to consider some things. Can the athlete bear weight on that body part? Can they walk, is there gait alterations? Is this an old injury with a new injury? We call that acute on chronic, old on new. What was the mechanism? Did he just get checked? Did he get hit really hard and fall? Did he hit the wall? Did he just step funny? Did he hear anything? Or what did it feel like? We typically talk about the athletes that ruptured a tendon or muscle. They all described it very similarly, kind of like that velcro, that tear. They know when something’s torn because they feel that feeling and that is something that tends to stay with somebody once they’ve had a significant rupture, they understand what that feels like. Listen to the words they are using when they describe what is going on. Did it happen on the field or field of play or ice or mat or when they were walking in the parking lot or playing catch with a friend? So really getting that mechanism of injury. What muscles were being used during the activity of the injury?

So, we left the ice rink and now we are working here with this athlete. This is a track and field athlete. What are you thinking about here? As you become a sports chiropractor, you will be asked to cover events, if that is what you want to do. You need to be ready to handle situations like this. You need to have in your mind, what am I going to do first, second, and third. What do I do when I am asked to go out on the field of play in this situation? What do I do on the sidelines and what is appropriate in my office? Of course, we’ve got a meet going on and we can’t spend an hour doing a wonderful examination with functional evaluation while everybody’s waiting to continue the meet. As we have a situation like this, we need to understand what is appropriate for me to do on the field of play. That would be ruling out fracture or dislocation, making sure the person is good neurological and blood flow to the area, and making sure we have stability to transfer. First, calming down the person would be the first order of business, talking to them, and making them feel a little bit confident as you assess them that you are able to safely get them onto the side of the sidelines, that you can do a better evaluation, more full evaluation. Your on-the-field exam is really to rule out any major structures that you would need to transport to the hospital immediately. Nothing is dislocated, nothing is fractured, and there is no bleeding anywhere that I can’t control. The patient is of good mental status. We don’t have a concussion.  She is able to talk, can calm down, and could tell me what the problem is. She has good blood flow to the area, good circulation, can wiggle her toes, and can wiggle her fingers. Great. How about we help you see if you can sit up? Let us see if we can carry you off the mat or the field or see if you can walk off to the sidelines where I can do a more thorough evaluation. So just making sure that we are competent in each stage that we are asked to perform as sports chiropractors because it is important that we put our best foot forward when we are working in events and we show our competency, and that we are not running out here and adjusting her neck. Point proven.

Now we have that athlete to the sideline, we are moving from an ice hockey game through the track game, now you are working a football sideline. We have the injured athlete off the field. He was able to walk off and now I am going to begin my more thorough evaluation. This is when we kind of get in the habit of doing the evaluation in the same order every time. In this way, we don’t miss anything but, on the field, or sidelines just take your time making sure you are doing a nice thorough evaluation taking the shoe off.

Notice, if this athlete is getting their ankle looked at, the shoe is off. The other shoe is off too so I can compare side to side. Big, bilateral comparison is critical if you are going to get a good diagnosis that you are comparing bilaterally. Listen to the patient. Listen to what he or she tells you. “I injured this last year. It felt exactly the same. I injured the other side last year, felt exactly the same. That was broken. You need to understand, listen to what they’re saying, and listen to how they’re describing it. An old proverb says talk to an athlete long enough they’ll tell you what is wrong with them. That is true for all our patients. We really need to take our time in that evaluation because in this scenario here on the screen, you are going to decide if that athlete can go back into the field of play or not. The athlete is looking to you for the right decision. The coach is looking to you for the right decision. You, morally and ethically, need to make the right decision so as to prevent further injury to that athlete. Keep them safe but allow them to do what they’ve trained to do. That is a very large role and that doesn’t come without practice, and that does not come without proficiency. Really understand that this decision is a very big decision.

When I first started doing this years ago, I worked in an event with a chiropractor. At that time, I was an athletic trainer, and I was asked to work a football game. The chiropractor was a benefactor of the school. In other words, he donated money to the school, and the patient the athlete football player ran off the field and said that he couldn’t feel his arms at all. They were tingling and numb on both sides. Well, for an athletic trainer, that is a lot of red flags. For everybody, that is a lot of red flags. The chiropractor, not having any training in how to take care of athletes at all, just basically said to him, “Listen. Out between every play, run back down the field and I’ll push down on your arms really quick, and then you can go in for the next play.”

This is unacceptable. This is an unacceptable standard of care. I expressed this and I would no longer work with that particular person because I feel like that liability exposes all of us. We need to really know what We are doing, not to pretend what we are doing. Again, thank you for taking the time to continue to learn and be the best you because it is all of us that strive to be the best version of chiropractic that we can that elevates our profession.

Where do we begin with this hip evaluation? Let’s jump back into that. What is our first plan of attack? What is our second? How do I know what I am looking at? I am going to organize it all for you and that is how I want you to practice it. I want you to get a friend, a spouse, a family member, or a small pet, and I want you to practice this evaluation repeatedly until you can do it in your sleep in this order because this will allow you to be super proficient and win, and you’ll gain your confidence in getting a good diagnosis.

We are going to organize our exam and do all the tests in one position and then have the patient change position. Taking into consideration if the athlete is injured, if they are in pain, we might have to alter this a little bit. If they are not in pain and they can kind of move the way I want them to move, fine. But just really, always consider patient comfort. Stop, put a pillow under their head or something under their knees if they need to alter that position as you are doing your evaluation. Change the position as infrequently as possible. Because the hip is multi-directional, we need to look at the hip from the anterior aspect, the lateral aspect, from the posterior aspect, and we can’t forget about the medial aspect. We need to move the patient in three positions to do a really good hip-on-the-table evaluation, and that is even before we get them up to do a functional evaluation.

Let us talk about our first order of business. Don’t forget the obvious stuff that we are there for. Don’t forget to look at leg length differences, tibial torsion, or angle of the tibia, we talked about that a little bit looking at the structure of their bodies, bruises, and scars. Have they had surgery here before? Did this person have osteonecrosis of the femoral head? I need to know that. As you are evaluating an injury, please make sure you are looking in a discreet and appropriate way at the area and the skins. You can look for scars or bruises. Maybe they had some Kinesio tape on there because there was an old injury and they forgot to tell you. How about the shoes? What does the footwear tell you? Is it worn on one side versus the other side? What is the patient position of comfort? I want to talk about how shoes play such a huge role in Hip assessment. Actually, just last week, I had a patient come in with lateral hip pain and he was with his mom. And he’s about 15 or 16 years old, very tall, basketball player male. They had been to physical therapy. They had been to an orthopedist. They had X-rays of the hip and he had right lateral hip pain and just could not get rid of it. I did a whole evaluation on him, the mom happened to be sitting down by his feet. I said, “Well, what do you think about the shoes he is wearing?” As she looked down at the shoe, she could see that the one hole outside of the shoe is completely worn down. Now the athlete was walking on two issues, one like this and one tilted sideways on the side of injury. Most times I see with this particular condition that it is more footwear related than hip related. He promised to throw his shoes away when he got home and put on new shoes. The next time he came in later in the week, he had little to no hip pain. If We are not really looking at everything, sometimes, we are missing the causative agent. We are so focused on looking at the body, don’t forget to step back and look at the environment and this picture is a great example of that. What does that athlete need to do with their hip? What is the action that I need to get this hip to do to get them better? That is different from a runner different from a gymnast. This martial artist would again have something very different that I need to be acquainted with to get him better.

I like to start the exam in 3 ways. I do a supine exam first, then a sideline exam, and then a prone exam. We are going to go through each step. We are going to talk about what structures we evaluate in each position, then I am going to show you videos of the whole evaluation. You are welcome to play them repeatedly. Please practice them that way. You get very proficient at the hip exam. Think about the anatomy that we reviewed in the beginning. Which structures do you think we look at in the supine position? Let’s put your brain on that for a second. Think about, kind of in your mind, think about what would be most efficient to look at as they are laying face-up, on their side, and as they are laying prone.

 Okay. Let’s see if you are right.

Again, I talked about that I love anatomy so much and so that does not go unnoticed in this particular graphic right here that I made. This is an app that I keep on my iPad, great for patient education. It is called Clinical Anatomy. You can put layers of the muscle on, you can tease it down to Bone. You can put nerves on it. You can turn and rotate the specimen. I like to use it when I am talking to patients about what is going on in their body and I like to show them the injury and actually show them the muscle. When We are looking at this hip right here, we need to really understand that We are looking at the sartorius origin here and rectus femoris origin here. We talked about the iliopsoas and psoas muscles, really appreciating your gluteus minimus insertion point, vastus lateralis. Look at how high up those inserts. Then intermedius and vastus medialis, and psoas. Then this is pectineus, adductor longus, and gracilis. I use LIMP, lateralis, intermedius, medialis, and psoas as my cascade down the superior aspect, looking at that patient anteriorly for evaluation. These are our anterior evaluations. Some of the muscular structures, again, we are looking at muscle. Then We are going to look at structure, we are looking at bone, and then we can’t forget about tendon and functionality.

When they are supine, begin your valuation with the log roll every time. It gives you so much information. It is a very, very simplistic orthopedic test but you really can see intra-articular pathologies or lesions. You just place your hand just where I have it, one on the thigh, one on the tibia, passively have the patient relax, and just gently roll the femur on the acetabulum in and out, just nice, and slow. What you are looking for is that the femoral acetabular joint is gliding smoothly through the joint. You are going to kind of roll and just appreciate. Does it feel like it gets stuck? Does it feel like it is moving slowly, or does it move nice and easy? And the key, this is compared to the other side because we want to see what one side does versus the other. Take your time in practicing this because I’ve picked up so many labral tears just by doing this, and it is pretty amazing. You also can notice any intra-articular edema or inflammation in the joint, things that are causing irritation to the joint itself. So, the log roll is your first order of business in the supine evaluation.

Then we are going to palpate the area of pain. I like to look at the bony landmarks as we talked about before. In understanding that, we have to know the gender and the age because if it is a youth athlete, they have growth plates that are open. They’ve got a lot of growth centers in the hip that you really need to be acquainted with. Understanding that sometimes their pain location might be a growth center and if it is somebody that is in that adolescent stage that is still growing well, then I can consider a possibly a Salter-Harris fracture, or an avulsion-type injury.

Here is a really terrific picture for you to call to memory on the growth centers of the hip as you palpate the hip in your youth athletes, really understanding that here is your iliac crest and these are your abdominal aponeurosis attaches here. Your ASIS or anterior superior iliac spine. Your sartorius origin here. Your AIIS is your rectus femoris, very commonly injured in sport, one of the quadriceps muscles, very commonly injured. Whenever a muscle crosses two joints, it is more prone to injury. When you are really trying to figure out which muscle is injured, go for the ones that cross two joints in evaluation, and really take your time with those because again, there’s more biomechanical area for them to injure. More than likely, they’re injured first. Then we had your gluteus medius and minimus on the greater trochanter. Your lesser trochanter. Here’s your iliopsoas, psoas. Hamstrings, of course, huge injury in the growing athlete, hamstring avulsion up on the ischial tuberosity, and your adductors in your symphysis, your pubic symphysis. My mnemonic for this is A Sargeant in his Army – ASRGIHA. That is the way I memorize my order of events that happen for the growth centers in the hip in your youth athletes. Again, you are going to cascade the pelvis during palpation and you are going to touch either of these structures. It is pretty amazing how quickly we pick up an injury when we know what We are looking for. Take your time. Palpate and look at these growth centers in your youth athletes and see if they have pain and tenderness there. Can we see how a rectus femoris injury would be mistaken for a labral tear? Very commonly. So, making sure that We are coupling, if they have pain here, We are coupling that with the muscle test of the rectus femoris and then comparing that to testing the labrum. If I have all muscle injury positives and no labral positives, then I have a rectus femoris injury and not a labral tear.

Then we talk about the range of motion at the hip. What is the normal range of motion? They should be able to get to flexion 140 degrees and here’s a good example here, and they should be able to get extension, 10 degrees of extension, abduction 45 degrees. That is pretty minimal. Remember, these are for normal people. We really want athletes to express more motion than this. We want the athlete to have a greater range of motion than just normal. Normal is our normal homo sapien walking around the planet earth. But if We are going to run and jump, we need more range of motion. Like 10, 15, 20 degrees more for my athletes, depending on the sport, of course. For example, 45 degrees of abduction is not going to fly for a gymnast or rhythmic gymnast, or ice skater. Then, of course, for adduction 30 degrees, internal and external rotation, 40 and 50 degrees. We can see that they’re prone to internal and external. We are going to talk a lot about this a little while. I do my internal external exam of the hips supine in prone, but just understand that we get different degrees a little bit. But if you just put in your mind that you want about 40 degrees in each direction, that just makes it easy to remember.

As you are going through range of motion, you need to feel what we call the end feel. That means where it stops. It is that the brakes are going on slow, and when you get to that end feel, it kind of feels mushy or soft, that is called a soft end feel or a tissue end feel, which sometimes means we can get them further. If we get them into flexion of their hips, and I am hitting up against a brick wall, that is called a hard end feel. A hard end feel might indicate something like a bony issue. Like a femoral acetabular impingement. When you are testing internal and external rotation of the hip, and this is me here, checking a supine internal rotation of the hip, make sure you take it to the point that you feel the end feel, not that We are causing pain, but We are noticing if it is soft like the brakes are getting put on slowly or they’re hitting up against something like a bony confirmation. That would be a hard end feel. Compare everything bilaterally when you are doing your range of motions and really understanding the nuances of the sport. If We are talking about a dancer or a gymnast, they might have more flexibility on one side versus the other. It is actually not uncommon for people to have greater flexibility on the dominant side, their hand dominant side in other words, most commonly right, than the other side.  We actually stride larger or stride longer on the right leg than left, so it makes sense that our hamstrings might be looser on the right side than the left. Then also noticing if there are postural issues. Do they change posture or try to cheat the range of motion as you are looking at it?  In other words, hiking the hip up, when I am trying to do internal rotation. We need to make sure we are getting a pure measurement of range of motion without cheating involved, like a change of body position, and then other gait problems that are leading me to look at this range of motion.

Then look at manual muscle testing in the hip. Again, just kind of taking you back. We started supine. We did the log roll and palpated. We looked at range of motion, and manual muscle test. We want to check the strength of the pertinent muscles and I like to do them all just because I like to be thorough, and I want to compare bilaterally because you are surprised sometimes the athletes are blown out on both sides and that is going to make you look in a different place and if you just tested the affected side and it seemed weak.

Let move onto talking about femoral acetabular impingement for a moment. The femoral acetabular impingement is a point where the femur and the acetabulum abut. each other and get irritated so they hit up against each other. There are three causes of femoral acetabular impingement. We can have a cam. We can have a pincer and then a mixed. The mixed is it like 87% of your acetabular impingement and we can understand why. Here’s an example of a cam femoral acetabular impingement where we actually have an outgrowth of bone on the femoral head and neck right there. Appreciate if we have this and we have that and then we go into flexion, that is going to hit up against that acetabular ridge. If I have a little bony growth here and I go into flexion, that is going to hit against the acetabular ridge right here. That is an impingement. We can also have an outgrowth of the acetabular ridge and that is your pincer form. The same thing happens. If the acetabular ridge has grown out, the same thing you go into flexion, it still hits up against the femur causing impingement. But we really then can appreciate how someone most commonly has a mixed. Because if we are taking this into flexion, eventually, even if we start with the cam and We are an athlete and we are in flexion all the time, hip flexion, that is going to cause the pincer deformity here. We are going to get irritation at this bone. We can really see why most people have mixed bag more commonly.

Here is a nice picture of what that looks like in pseudo, so to speak. Here would be our cam deformity, this little outgrowth right here, and the athlete let’s pretend it is a rower, that is going into flexion a gazillion times every practice is hitting up against this acetabular ridge, which is causing irritation.

What we are also noticing is a labral tear that was repaired in this particular model here. Here is the stitching of the labrum. This is what that labrum looks like on the inside. That is a good example of a mixed femoral acetabular impingement.

Again, here is the cam deformity. We can see a little cam deformity here, and understand that over time, that is going to get larger. It doesn’t get better. It gets larger with more repetitions of flexions. It is not going to go away. We have to talk about what can we do about this. How do we treat that? With the femoral acetabular impingement, we might want to consider distracting the joint and mobilizing the joint to get it more mobile so it is not quite so stuck. We also need to consider technique in the sport. What is this athlete doing? If it is a rower, do I need to get his knees out so that we can roll the femurs out away from the impingement? Because if he’s rowing with his knees straight, he’s going to continue to hit that femoral acetabular joint and it is going to cause a continued problem. Again, looking at the anatomy, looking at ways to cheat the anatomy, looking at technique, and always comparing bilaterally because it is not uncommon to have this on both sides.

All right. So, we did our log roll, manual muscle testing, palpation and we looked at formal acetabular impingement, which I will show you a little bit further how to orthopedically test for that. We are going to begin with the scour test as our next order of business. With the scour tests, we are looking for labral tears. Begin slowly. If they have a labral tear, you will know it. You don’t need to kind of jack them into flexion. Basically, We are bringing the hip into flexion and then you are pushing down on the femur and pushing your femur into the acetabulum. Then you are doing a circumduction motion to almost try to agitate that labrum. That is what I am doing here in this picture. You’ll see it further on as I show you the videos when we move on. That is your scour test for labral tears. Go nice and slow as you push down. Start lightly and then circumducting. Watch the patient’s expressions and if they’re kind of like, “That doesn’t feel good. That doesn’t feel good,” you don’t need to keep going. You don’t need to make a tear worse. You are just trying to see when you add a noxious stimulus to the area if it makes it worse. Here’s what a labral tear looks like in surgery, right here. It causes a lot of fraying and irritation.

Those then would be our supine exam. Log roll, femoral acetabular impingement, scour test for labral tears, muscle testing, and palpation of the anterior bony pelvis.

As we move onto the side-lying, I want you to just take a minute. I want you to think about what structures would I look at on the side. What is going to be? What is my exam that will look like on the side? That always starts with looking at the anatomy. Here is our side-lying patient right here, understanding and appreciating the muscular components, the bony components, and the functional components. We have to have all that in your mind as you are evaluating your athletes. Of course, we cannot forget about the gluteus medius and minimus and what is really critical to think about is the insertion point. Look down here on that femoral head and I want you to appreciate that. Gluteus medius is just slightly posterior than the gluteus minimus, which is slightly anterior. This is very important in diagnosing high-grade tears of the gluteus medius muscle, which is not uncommon at all, and tendinopathy is of the gluteus medius muscle is not uncommon at all. If we can tease these two out, we can really isolate which rehabilitation exercises we need to do and what functional corrections we need to do. Everything starts with that laser focus diagnosis, and that’ll help your overall success in recovery.

This is gluteu minimus, appreciating that it originates a little more anterior, we like to say this at 12 or 1 o’clock position on the femoral head. I like to, when someone’s side lying for evaluation, think of this femoral head as our clock. It is really where most of those muscles that I am interested in are inserting. I kind of Imagine this circular clock called the femoral head there and understanding and appreciating that your gluteus minimus is up in this one o’clock position here. Your gluteus medius is going to be about this 10 or 11 o’clock position here, and then your hip external rotators are posterior to that. Here’s quad femoris back here. Looking at that like a clock when they’re on their side actually helps you grasp what is going on. Then, if we go slightly interior in this three o’clock position, that is your vastus lateralis. I didn’t think I was palpating the origin of my vastus lateralis side-lying, but you are.

Let us talk a little bit about gluteus medius and TFL because we see these injuries very common in athletes so that gluteus medius we just talked about a little bit. I have a little graphic here and this is going to show you the motion of that gluteus medius with abduction here when it is called into play. That is really its major function is this abduction and really understanding that it is really used a whole lot more intensely than we give it credit. It is not the hugest muscle.

Let us look now at our tensor fascia latae with abduction and internal hip rotation. This is also your gluteus medius function because it is an abductor and also helps with internal rotation because of the way it originates and inserts. We can appreciate that TFL and that function of the TFL as well.


Iliotibial band and tract assessment is the other side-lying assessment that you are going to be doing. Basically, let’s take a peek at some functions here. Again, similar to gluteus medius. That is why we always see these two a hand in hand is abduction and a little hip internal rotation, and really understanding that when someone has a TFL injury, they’re going to have a lot of pain up here. When you palpate this area, if you get your thumb right in the front of this band, you are going to feel a nodule here. You are going to need to release that for them to have pretty quick pain relief. But understanding the function of the muscle is also very, very important here. Let’s look at that iliotibial band and tract as it traverses down and approximate the lateral knee and understanding how that problem that starts with tightness at the hip predicates a knee injury or lateral knee compression on the lateral structures. For someone with hip and knee pain, we need to make sure We are looking at the iliotibial band and tract and understand what I need to release. Again, a lot of times this particular condition is footwear driven. Do I need orthotics placed on this athlete? Are they trying to run barefoot shoes and maybe they don’t have the full intrinsic muscle strength to support that? Do they have old shoes that are broken down? Are they running on one side of the road? If the road is curved, they typically create the roads curved so that the water drains off. If We are always running on one side of the road, say I go out on my run on this side and I go back on my run, on this side, I am always running with the right long leg, left short leg. That is going to predispose this iliotibial band to work over working. I need to think about how I can direct that athlete. Looking at the footwear, looking at foot structure, looking at foot intrinsic muscle strength, but also looking at the terrain of training and guiding them to run out on one side of the road and back on the same side of the road. That way one leg is short on one, half of the run, and the opposite leg is short on the other half of the run. In that way, we kind of even them out a little bit or try to get them on this flatter surface is actually optimal.

I talked a lot about this iliotibial band and tract because we work really well with some release techniques side-lying, but making sure as you are evaluating on their side, that your palpating the whole breadth of it and really starting a little more anterior than you think you should. Because as I said, once you get your thumb in there usually right about here, there’s a big nodule in somebody that has tensor fascia latae and then iliotibial band and tract issues. Then I want you to appreciate how the confirmation of the gluteus maximus comes and invests with an aponeurosis into the iliotibial tract. That gluteus maximus insertion is really more into fascia that is part of the iliotibial band and tract. I have anterior pull, and posterior pull on the hip that comes and tethers together. How does tightness in one or weakness in one call to action that hip differently? If I have over tightness here, that hip is going to be an internal rotation, creating faulty patterns. If I have a weakness here and overactivity here, then my hip is going to be externally rotated. What injuries are we going to have there? Make sure We are looking at the synergy of muscles as We are doing evaluation and that they’re both activating when you need them to activate. We are going to talk a little bit about that when we go through the functional assessment section of this and how to really notice that and how can you screen for that.

Again, going back to our side-lying evaluation, we have manual muscle testing. We are going to test that gluteus minimus. Gluteus minimus is a straight to the side, toe pointing forward muscle test. Gluteus medius is the hip is slightly extended, toe pointing towards the ceiling. TFL you are 45 degrees flexed at the hip with your toe pointing towards the floor. That is part of your side-lying exam. I start my side-lying exam with palpation. Remember that clock we talked about, looking at the gluteus medius and gluteus minimus, vastus lateralis, understanding the TFL tensor fascia latae, iliotibial tract, and the gluteus maximus.


Now, we are moving to muscle testing. We are going to check these three muscles. Then, we are going to move into Ober’s Test. This Ober’s Test tests for tensor fasciae latae tightness or IT band syndrome. Basically, we make sure you stabilize that hip and a 90-degree angle. See my left hand here is really holding that hip. The athlete wants to roll forward and cheat that motion. You’ve got to take good control with your left hand and hold that hip in that steady position. Don’t let them roll forward or back. You are going to abduct and extend the hip, and then you are going to release the knee and see if the knee drops. When somebody with a tight IT band syndrome, we are going to see that the knee only drops a little bit. It is like the brakes are on. Somebody that is looser, that knees going to collapse towards the table quite nicely. So, somebody that has hip pain, we want to evaluate if all these lateral structures are too tight. Therefore, we talked about that if the lateral structures are too tight, the external rotators quite possibly might be overworking.

The Faber’s Test is one for the supine position, not the sideline position. For Faber’s Test, we could be looking for sacroiliac problems, lumbosacral problems, or hip problems. As you are doing Faber’s Test, really understand where the pain is coming from.

Back to side-lying, palpating these structures we talked about, we have got to think about the bony confirmation, the bony issues, as well as the muscular issues in talking about that anatomy. We talked a lot about that today. Understanding where am I going if I suspect the gluteus medius tear? I muscle test and the gluteus medius is weak, where am I going to palpate that insertion where it most commonly gets injured? I am going to go down on the femoral head. I am going to go right at that eleven o’clock position right around here and palpate for tenderness. A lot of times they have exquisite tenderness there. That is going to make my confirmatory diagnosis that I have a gluteus medius tear. Then your IT band, when your proximal tensor fascia latae, greater trochanter, and we can’t forget to rule out bursitis because we have a tight IT band and tight TFL that actually causes friction over the greater trochanter. Wherever we have hip and tendon friction, we have an increase in the bursal size, so we develop bursitis. When you see hip bursitis in somebody, that is point tenderness right on the greater trochanter, right in the center of the greater trochanter. If this is our clock, so to speak, right in the center of the clock here and slightly inferior, if we have point tenderness here, and the athlete says, “Oh yeah, that is really sore,” we have bursitis but understand that bursitis, a lot of times, is caused by a very tight iliotibial band and tract. We need to then keep going and see if that is the issue as to why we have bursitis. Bursitis is an okay diagnosis but it doesn’t tell me why or what happened. Looking at the anterior superior iliac spine and the anterior inferior iliac spine, again we talked about that those are growth plate injuries for our youth athletes, making sure the ASIS is our sartorius, the AIIS is rectus femoris, very commonly injured, and We are going to look at the hip capsule. With them side-lying and their knees slightly bent actually puts the capsule in a little bit of a relaxed position so I can feel inside the capsule and see if We are talking about more of a labral issue with the area or if it is soft tissue issue with the capsule.

We got through our supine exam, and we did our side-lying exam. Now, we are going to move into the prone exam and think about what structures you need to evaluate prone and why are you looking at that. Let’s put that together. Again, always start with inspection. In all these positions, you should be looking at muscle symmetry, muscle confirmation, position that they’re lying in for comfort. Is their hip internally rotated or externally rotated? What are their feet doing? Is one hamstring smaller or larger than the other? What are the gastrocs doing? What are the glutes doing? Then of course, we cannot forget about looking at the upper back. Looking for scars. Looking for swelling. Looking for atrophy. When the hip is prone, we are going to start with a range of motion. We are going to look at internal external rotation prone. We are going to look for knee flexion. When I flex the knee up, I am looking for the hips to pop up so then to kind of flex their hips. I call that a hip pop. We should be able to bring that knee into flexion up to about 110 degrees before they start flexing their hips, a hip pop type of thing. When I see that happen prematurely when they flex their hips too soon, it is a sign of core weakness or instability. We need to just take your time when you are looking at that knee range of motion, I am really looking for the hips to pop and at what angle they’ll pop up. That is going to tell me what is going on with the hip and the core.

We are going to manual muscle test prone. You are going to manual muscle test your gluteus maximus, your hamstrings, and hip internal and external rotators. At this point, you should kind of almost have your preliminary diagnosis. You need to then think about what your possible positives are, and maybe consider flipping your patient and redoing some tests your questionable on. You should be able to go back and review and take a relook because sometimes when you do an orthopedic test the second time, the patient doesn’t have any pain. Maybe they’re just a little apprehensive the first time. If I am really suspicious and I am not sold on the diagnosis, I will go back and I’ll relook at it again. This is where you are going to order any follow-up tests. Do they need an MRI of the area? Do they need an x-ray of the area? Do I need to refer out to an orthopedist? Then you are going to create your treatment plan. I am going to talk a lot about that as we get a little bit further into evaluation, functional assessment, and rehabilitation. But we need to think about creating treatment plans for the acute athlete, the subacute, the chronic, and those that are not getting better. Those that are not getting better, you’ve got to go back to the drawing board and reassess everything again including a functional evaluation and a video evaluation. Video evaluation is huge for you to pick up any discrepancies that might be promoting the prodromal nature of this injury.

As we put it all together, let us take a look at the hip. I have a video, and some videos in each of the positions. I am going to kind of talk them through the first time letting you watch them, and we are going to play each one two times. In that way, I want you to really get in your brain the order of events, and how I would like to see you develop your hip evaluation.

Let us go to our supine and remembering our supine exam. We are doing the log roll. We are doing flexion range of motion. We are going to look at hip internal and external rotation. We are going to scour. We are going to look for femoral acetabular impingement. Femoral acetabular impingement is where We are flexing the knee up and noticing if the knee drop straight or to the side. I am going to go further into this and we’ll go through it on the video but I want you to watch it first. The scour test we talked about and We are going to manual muscle test. Rectus femoris, sartorius, pectineus, and the adductor group, and We are going to tease apart those muscles. We want to do an iliac compression test for hip fracture and We are going to palpate the pertinent muscle groups. Again, considering male or female, considering that We are being appropriate in palpation, and then also the age of the athlete.

So let us look at this evaluation here. Log roll, comparing side to side, very important to really get a sense of what is happening with that hip. Our manual muscle testing rectus femoris, pectineus, sartorius, and checking the adductors. We are going to do pectineus again. Roll the foot in a little bit. Do adductor brevis. Foot straight forward. Adductor longus, a little weak there that is why I tested it two times. Adductor magnus slightly internally rotated all the way in, gracilis. I am looking at femoral acetabular impingement here now. You walk the knee up. You want to see if it drops to the ipsilateral shoulder or drops out laterally. If it drops out laterally, it is a sign of femoral acetabular impingement. If I suspect that, then I am going to internally rotate her in-flexion and see if that irritates the problem. Again, I am comparing side to side to see that this knee is going up to the ipsilateral shoulder which it is. In this case. Really paying attention to that bilateral comparison. Here is my scour test. There is internal rotation. Again, I am checking for an impingement. Now, I am looking at range of motion, hip internal-external rotation. It is very important that you take your time for Faber’s. Good scour test. Checking femoral acetabular impingement with flexion and internal rotation. Then checking the internal-external rotation range of motion comparing that to the other side. Muscle testing, Faber’s Test. Iliac compression test, palpating the important structures that we reviewed on the bony pelvis. ASIS, AIIS. We talked about all those iliac crests.

Let us play that one more time just so you can get that in your brain. It is very important that we get all the structures down. Log roll. We are looking at labrum possible labral tear or intra-articular pathology, also arthritis. Rectus femoris. Is this a youth athlete with a rectus femoris avulsion? Pectineus. Sartorius. Checking that adductor muscle group and appreciating the vastness of it that we talked about in anatomy at the beginning of it. And goes pectineus, adductor brevis, adductor longus, and then slightly in is adductor magnus, and then all the way internally rotated, is gracilis. It is important to know which muscle is injured, not just an adductor. I don’t think that is acceptable. This is your femoral acetabular impingement, looking if the need drops out to the side or straight to the ipsilateral shoulder. If it drops out to the side then I flex it to 90 and I internally rotate it and see if that causes pain. That would be a positive test for femoral acetabular impingement. Compare everything from side to side, particularly when you are looking at femoral acetabular impingement because that is really how you pick up the nuances. Scour test. Again, labral tear. Flexion internal rotation for femoral acetabular impingement. Hip internal-external rotation for range of motion. Faber’s Test. Is it painful in the hip? Is it painful in the sacroiliac joint? Is it painful in the low back? Very important for Faber’s for us to understand where the pain is coming from. Scour. FAI. Hip internal-external rotation. I want to get to at least 40 degrees in both directions. Faber’s. Iliac compression looking for iliac fracture. I picked up several discrete factors with it. Very simple test. Get the supine exam down. Wonderful. Let’s move on. Like I said, make a copy of this and just watch it over and over until you get it.

Let us talk about the side-lying exam. Manual muscle testing. Gluteus medius, minimus, and TFL. Ober’s test for TFL tightness, palpating the pertinent muscle groups, and the bony regions for tenderness.That is what We are going to see here in this side-lying exam. So manual muscle test. Extension. External rotation. Really control that hip with your right hand. That is gluteus medius. Here’s gluteus minimus and you got to hold the hip with the other hand steady at a 90-degree angle, and that is TFL. Oberst test. Flexion extension, abduction, and drop the knee down. Comparing that side to side is really going to be your tell-all as if we have a problem or not and then palpating the important structures. This is a great time to palpate because the patient feels less guarded than lying on their back and you can get a little bit deeper in that rectus femoris area, which is the AIIS, and then also around the hip capsule. Remembering that femur as a clock and looking at gluteus medius, gluteus minimus, and then also understanding where We are going to get bursitis.

Let us watch that one more time. You are going to compare this side to side. See me grabbing that right hand and holding her pelvis steady so she can’t cheat. Gluteus medius. Gluteus minimus. TFL. Ober’s test for TFL tightness. I always do it a couple times and just really try to see if that knee is dropping and compare that to the other side. Then We are going to palpate important groups. I am going to palpate the proximal TFL. I am going to palpate the ASIS the AIIS, the hip capsule area. Then I am going to use my femur as a clock and I am going to palpate gluteus minimus, gluteus medius, where there’s bursitis and the whole TFL and tensor fasciae latae and IT band.

Did you get it so far? We are going to move on to the prone exam now and talk about the prone exam. We are going to look at again. Everything is an evaluation. Looking at how they are using their body parts differently. Do the glutes have symmetry? Do the hamstrings have symmetry?  Do the gastrocs have symmetry? How is she laying down? Is she favoring one side? We are going to look at the range of motion, not only knee flexion, but I am also going to look at hip internal-external rotation. Craig’s Test. Now, we talked in the beginning about femoral anteversion. Craig’s Test is the test to determine if there is femoral anteversion or not. We are going to walk through how to do that. I am going to show you and then we’ll go through it nice and slow. Nachlas and Ely’s Test. Manual muscle test for hamstrings and glutes. Hip internal-external rotation. We’ve got to look at foot structure. You cannot evaluate the hip unless we look at foot structure.

All right, so let us play that through. Hip external rotation. Internal and external rotation, comparing side to side. I blocked the sacrum base so that they can’t cheat and rotate the sacrum when we are testing. I always block that, so I get pure hip motion. See how she tends to flex her hip up, as I am getting her into external rotation there. This here is Craig’s Test. We are going to talk about that for a minute. If We are going to check for femoral anteversion, what We are going to see is they’re going to have an increase in internal rotation, and a decrease in external rotation. We use Craig’s test in this manner. We bring the knee to 90 degrees. We palpate, you see my left hand is palpating the greater trochanter of the hip, as you bring her into internal rotation. You are going to feel the greater trochanter disappear from under your fingers, then you are gradually going to bring the knee back into neutral and feel when that greater trochanter is most prominent and stop there. At that angle, you are going to evaluate where the leg is. If it is a greater than 15-degree angle and internal rotation from neutral, then you have femoral anteversion. Let’s look at where I stop this here. This would be a little more than 15 degrees internal rotation. That would preclude her, which would include her as having femoral anteversion on the right side. Again, we talked about why that is significant and what injuries they might be predisposed to or what technique I might be able to do differently. One example of this particular injury here is I had a powerlifter who’s having chronic low back pain for over a two-year period. He came in to see me, we did an evaluation, and I looked at his low back. It was certainly jacked up as how powerlifters are but wasn’t overly impressing me.  I had him shift only his squat, and I noticed that it looked like he was having some hip issues with his squats. I put them back on the table, evaluated his hip, did Craig’s test, and noticed that he was femorally introverted on the right. I stood him back up and had him squat again, externally rotating his foot 15 degrees. In doing that, he had zero back pain. Again, speaking to training according to how you are structurally derived is something that is important. Now the powerlifter lifts significant weights. I see him on Instagram, all the time. He had his foot just a little bit rotated externally and he has zero back pain. That is just what his body– he’s femorally introverted on that side. So, we are just trying to compensate for that by just changing his technique the littlest bit. It is okay sometimes to not in-fit into a box, and that is my point with these exams. Our body is not structurally perfect. We are not all the same and we need to understand. We need to be diligent enough to notice when there’s a difference to guide them in a path of success.

That is Craig’s test. Then we are going to move on to Nachlas and Ely’s. A very important point, I look at every hip when I look at low backs. I look at Craig’s Test on every single person now because I see it is so common. I think that hip position plays a huge role. Here’s Craig’s test here. Manual muscle testing, hamstring in two positions. We checked the top, the proximal, and the distal aspects of the hamstring. Then the gluteus maximus of course, too. Hamstring in more 90 degrees and then more extension so we can check proximal and distal and checking gluteus maximus. it is very important that you are not forgetting to palpate the low back and look at all the low back structures as well as alignment, and leg length differences. Do they have an AS pelvis or PI pelvis? That plays a huge role in the position of the hips. As I said, hips and low back are so commonly related. That doesn’t mean because they’re athletes, it is different. She has a right hip problem here. You can see she jacks her hip up when you asked her to go into flexion and internal rotation. But she has that extra internal rotation much more than 40 degrees which is telling me we, more than likely, see how she goes out, more than likely having femoral anteversion on the right. Look here, see if we can stop this in time. Let me just take this back just the littlest bit there and look at her feet. This is why it is so important to take a look at the feet when you are evaluating your athletes and anybody with hip pain, low back, or low extremity. That right foot is so different than the left. She’s using the right foot completely different than the left. The toes are in a different position. The arch is very different. The heel is different, her great toe is different. We need to think about and watch her move and function. After I get them off the table in my preliminary exam, I get them on treadmills. You see a treadmill in the background here in the back of this picture here. I have a couple of treadmills in the office. I typically will get them off the table and on a treadmill and do some video analysis of them moving in them. In my mind I have the idea that she’s femorally introverted on the right and in my mind, I have that she’s got a little higher arch on the right than left, and she’s using her toes more on the right than the left. Why not the left?

I want to put all that together as to the whys. But if we go back here, see if I can get her in a prone position for you. There. Can you appreciate the findings of her having a femoral anteversion on the right in this position? Can you appreciate that, this hip is internally rotated versus this one? That is a little bit of a look of an introverted hip there on the right side. Let’s just run through that whole thing. So I stopped at a hundred times, one more time so you can just have that evaluation your brain. Good. Holding that sacrum and really, really concentrating on do I have at least 40 degrees in both direction. If I have much more than that in internal rotation, I need to be looking for FAI. If you are limited in external rotation, it also is an indication that there might be femoral anteversion.

There we go. Craig’s test again. Take your time and check this Craig’s Test out. Again, we are looking for anything greater than 15 degrees from neutral, for a positive Craig’s Test to determine femoral anteversion. Checking manual muscle testing, hamstrings. I do hamstrings proximal-distal so that I can check up by the ischial tuberosity as well as checking distally. Then your gluteus maximus. Look in here. Good gluteus maximus. Really notice as you are doing this manual muscle testing, I want to talk a little bit about this in your next section, your functional assessment, what muscles are activating. Athletes’ bodies are pretty crafty. When I am muscle testing, they, maybe, can do the action but are they using the appropriate muscles to do that action? What muscles are firing first, second, and third? When I am checking glute strength, are the glutes activated or is the low back doing that exercise? Noticing that as a key component in our functional evaluation, that is going to lead to creating your treatment plan because if you are asking for the glute to contract and they’re doing that with their lumbar paraspinals first and the glute doesn’t kick in till way later, I’ve got to go back and I’ve got to do some neuromuscular control retraining and get the glute to fire first before I can get rid of that injury. Not only just muscle test, but I also want you to notice. Does that muscle fire at the appropriate time or is it just lazy and firing too late?

As we sum up this lecture here, we are going to talk a little bit about our takeaway considerations. What are we thinking about? What are we taking away from this lecture? Just think not all hips are created equal. That is my major thrust here. Understanding that we have different structural confirmations. We have different muscle confirmations. We use our muscles differently. Athletes are asked to use their muscles differently, depending on different sports. We are going to look at nuances that might be a factor in predisposing to injury. This picture right here, this athlete right here has femoral acetabular impingement. Notice how this stretch exercise is just so poorly done. He can’t really get into the stretch exercise because of his right femoral acetabular impingement. When We are giving exercises and stretches making sure again, we are not cementing in the problem. We are giving an exercise of stretch that is ameliorating the problem or working away from that problem, and not asking him to stretch into an impingement that is actually causing more impingement. Let us become proficient at a high-quality exam for every patient. Remember the order of events that we did. Supine, side-lying, and prone. Remember what structures you are testing as you do your manual muscle test. Is that muscle firing appropriately or are they just strong and they’re using lumbar paraspinals instead of using the glute or the hamstring? Making sure that We are really answering the why’s. Laser focusing on your diagnosis, and then we’ll be able to add in all the great functional stuff that you are learning in the upcoming lectures.

I want to thank you so much for taking the time, it is my pleasure to teach for you today and I look forward to working with events with you guys in the future and seeing you at some of the FICS events. Thank you so very much.


1.4 - ICSC05_Functional Assess Hip and Knee

English Direct Download PDF –ICSC05-1.4 VIEW Functional Assess Hip and Knee Dr Tim Stark53.30.mp4

ICSC Lower Extremity Module 5
Section 1.4_ICSC05
Instructor Timothy Stark
Video Lesson: 53:30

In this lesson, we are going to look at functional assessment, namely of the hip and knee. There are a whole lot of programs for the foot and ankle foot. Foot and ankle are a little bit different. Hip and knee have a lot of similarities and how we might assess the hip and the knee joint. We thought we would put it in a single program. As we have shared in previous presentations like this, this is a high-level instruction.

We are giving some general concepts and not doing a drill down, and spending hours recording videos for you to basically spoon feed a bunch of information. It is really important that you are able to read and critically evaluate literature that’s available to you. In these videos, we are just giving you high-level instruction, and we hope that you truly do find this to be valuable and basically establish a foundation for further knowledge.

As we get into our outline for today’s discussion, we are going to talk mostly about assessment. We are not going to get into rehabilitation on this PowerPoint, that will be another upcoming video, and succeed in this functional assessment lecture. What we traditionally do when we teach rehabilitation, we talk about progressions of functional assessment, progressions of rehabilitation. It is very important to understand where you should start and how you should progress. We will be discussing that for the hip and knee in this presentation.

Generally, where do we start? We generally start with touching.  That is very non-invasive. The patient has tenderness or dysfunction in the hip joint, maybe the labral tear, for example, taking them right away into Orthopedic and range of motion assessments probably isn’t the best place to start.

Before we get into our functional assessment, let us look at our structural assessment needs. Look and identify how they are standing and holding themselves.  In Tier 1, we are looking and maybe touching to identify tones, there is no movement, and other than gravity, there is really not going to be any load on this page. We are not going to be applying pressure against muscles or putting pressure on the joints.

Some of the things that we might want to look at in regards to hip and knee dysfunction, and particularly with the hip, I have noticed that paradoxical breathing can be an issue with slowing the process of healing and rehabilitating a chronic low back and hip issue. You don’t know much about paradoxical breathing, and again as I said, is a high level of discussion. Do a deep dive, do a look up at paradoxical breathing in PubMed and explore for yourself. What that is and how it might affect lumbar spine and hip dysfunction slow rehab.

Faulty mechanics are something that we want to look at? A sports chiropractor is really good at identifying joint play of the hip and joint play of the knee, including the patella and the whole knee complex, and certainly the whole kinetic chain? But this is a hip in the lecture. If there are junk restrictions and capsular restrictions with our skills of mobilization and manipulation where people imagine those faulty mechanics, we certainly want to look for them right away.in our functional assessment.

Then, static posture. Static posture, oftentimes, can give us some pretty good information in regard to what is happening with muscles, out of which might be a little bit hypertonic, hypotonic, or chronic soft tissue contractures, and general posture. If we look at this athlete, in these top two  pictures, we can notice that looking at her from the back, she has a slightly increased thick angle on the right-hand side. Well, what is causing that? She could be overchronating, she could have some tibial torsion, she could have some femoral torsion, she could also have retroversion of the hip, coxa retroversion, or just chronic, externally rotated of the hip. Maybe she sprained her ankle quite some time ago and she was used to walking slightly, externally rotated, to take some load off the dorsiflexion movements. A lot of things can be contributed to how one person basically holds and stealth while they are standing and walking.

As I said in our earlier presentation, that is when we are identifying one little problem, it doesn’t necessarily mean much after that. It usually means that we have to keep looking and find another piece of the puzzle and see if they could appropriately see what that picture actually is.

Another consideration for this particular athlete is that we can see that there is more space between the right arm and her trunk versus the left arm. That could be an indication of scoliosis or pelvic un-leveling. Maybe the scoliosis is secondary to it in anatomical short leg, but certainly, it could be affecting hip and knee dysfunction. It is just a piece of the puzzle and we need to do some further investigation and identify what the issues are.

Then if we look at her from the side, we can see that she probably has this anterior tilting of her pelvis with a increased lumbar spine doses which is kind of hidden behind her arm little bit but certainly would be affecting general muscle tone and hip position. If we consider the knees, there are a number of things that we can also consider, whether they have Genu valgum or Genu varus presentations, which certainly would be influencing how healthy that need might be or could be down the road if not addressed.

Functional knee posture. As we look at somebody’s posture standing but we know that certainly, our athletes are very active when they are lifting weights or maybe even our athletes spend a lot of time in a seated position throughout the day, so we want to observe them while they are functioning and moving around.

As our weightlifter is starting to do deadlifts, clean and jerks, or snatches, we want to certainly assess their biomechanics. We can see that his knee is probably coming pretty far forward of his foot and ankle, and if he’s reporting to you with anterior knee pain, it might be because of his mechanic. He probably needs to get his bum a little bit further back, get his knee further back over his ankle a little bit, and there would be less load on that anterior aspect of the knee joint. This is just one example of how somebody in their dynamic environment on a day-to-day basis might have an influence on their new presentation. It’s an individual that was probably asked to jump in place or do a squat, and we can clearly see that there are some Genu Valgus presentations here that could be coming from the foot and ankle, could be a knee issue, could be a hip and low back issue, and again, that’s just one piece of the puzzle. We need to do some further investigation.

As I mentioned earlier, athletes might be rather stationary. Many of them are students and they have to study for long periods of time, and maybe some of them work in a workplace. We want to assess the ergonomics as well, ask them some simple questions about what type of chair they have, the setup of their desk and whether that’s conducive to a healthy environment.

We talked about dynamic movement and as I said, watching your athlete perform various different activities is going to be killing and I can see that my media is not found here but I apologize for that. What we have here should be a video of an athlete that’s running and every time she was fully weight bearing on this leg, her opposite pelvis or her opposite hip would drop. What’s happening is on the closed chain side, her hip is going into adduction. One person might say that her glute medius is weak and that may be true but we can’t conclusively say that based on a video of just watching one person. We would actually need to muscle test that glute medius effectively, preferably using a handheld dynamometer which we’ll get to here in a bit but quantify whether that glute medius is truly weak compared to the other side. Maybe it’s a neuromotor problem, maybe it’s not that the glute medius is weak, maybe it’s that the muscle is simply stupid. It might be strong; it just doesn’t know what it’s supposed to do. It doesn’t know that it’s supposed to stabilize the pelvis when they are in a closed chain environment.

Presentation 09:16

Continuing into Tier 2 functional assessments, Tier 2 as compared to Tier 1, there is no movement and there is no load. We are just looking at touching as you noted with Tier 2 with that previous video that unfortunately, didn’t work.  With Tier 2, we are now making the athlete move throughout their environment sometimes and perform simple functional tests and this Lower Extremity Clearance test is super simple to do. If you are in almost any of your treatment rooms, you don’t need any extra equipment to do it. It doesn’t cost you anything and gives you a set amount of information. So, as we consider the athlete performing a squat, which is the lower extremity clearance test.   We are trying to identify is, how low can he bring his bum to his heels.

His hip joint is going through a lot of flexion, but also, if you look at what’s happening with the ankle, the ankle’s going through a lot of flexion as well. The athlete is unable to lower the bum all the way to the heel, and what commonly happens, in my experiences is that they get to 90 degrees of hip flexion, and they just say, “I can’t go any further.” and then you asked them, “Why can’t you go any further? Are you feeling an issue with your hip? With your knee or with your ankle?” and commonly, the response is, “I just can’t go any further. I just feel like I am going to fall over.” I think this is a tell-tale sign of a chronic foot and ankle issue, not necessarily a hip and knee issue. When you watch the foot and ankle in the clearance test you need to consider all of that.

The next step in this test, let us say that this athlete was unable to go, and you gave several attempts, then ask the athlete, “Okay, well can you go low enough to create more knee flexion. ” Also note that you should try to see if the athlete can go a little lower than they are used to with their knee. The next step is to now, go ahead. Raise the heels.   As you can see in this picture the athlete is able to lower their bum all the way to the heel, with their heel elevated. What it tells us is it that it was probably not a knee problem that stopped them at 90 degrees. It probably was not a hip problem that stopped them at 90 degrees.   What’s stopping them at 90 degrees is an issue with the foot and/or ankle. Hence, the lower extremity clearance test looks at and rules in or out hip,  knee, ankle and foot issues when performing this simple test.

We have to certainly appreciate that when we are performing this test, we want to perform it not just by looking from the side, but also at that place in the front. We can see as this athlete is going into the same squat, that went pretty normal from the side, it doesn’t look all that normal looking at him from the front. We can see that he might be overpronating a little bit on his right side, maybe the knees are going into a little bit of Genu valgus. He is shifting his weight a little bit to his right, what does that tell us?

Well, it doesn’t tell us a lot other than that. There is something not symmetric in regard to how his lower extremities are working through the lower extremity clearance test. We need to do further investigation in regard to this, being a hip and knee program. We certainly would want to perform a further range of motion assessments of the knee and hip, some neuromotor control assessments, maybe some handheld dynamometer, and other types of muscle testing for the knee and hip joint. So we are getting them to that right now.

Another functional assessment that we can do for the hip joint is part of Janda’s assessments. Now, Janda’s assessments, I think had a lot of merits back in the day and there have been some studies that have come out to basically add some further challenges on how we think about Janda’s assessments. The way I have addressed Janda’s is that when I perform a particular Janda movement, I don’t think it means one particular time. I’m walking out movement, generally.

In the next slide, you are going to see one of the things that we look for in a video. Let us start off with what Janda’s Hip Abduction Test. In there, we have a patient lying on her side, the bottom leg is flexed at the hip and knee so that the patient has good balance. We want the patient to abduct their hip and ideally, we want their toe and knee to point forward, keeping their toe and knee pointing forward. While they are abducting, if they can externally rotate that, it might be their neural pattern. They might have a neural pattern of where they naturally want to externally rotate. That might explain why when they stand, they have a cone of posture. That might explain why when they walk, they also walk with a total posture because that is their normal neural motor pattern.

Another thing that I look at, however, and that is why I have a mirror behind my athlete here because when they are starting to go into hip abduction, I want to watch their PSIS and I want to watch how early that pelvis starts to hip hike. If it starts to hip hike really early, it tells me that they tend to be really dependent on their lumbar spine paraspinal muscles for hip movement and that might be why they have chronic low back pain, and that might be why they have some atrophy within the hip muscle structures.

Again, a couple of things with this Janda’s Hip Abduction Test, we are looking for external rotation of the hip joint. We are also looking for the deep-sea labral PSIS to hip hike a bit early.

Let us look at an example of when we see some early motor controller contraction of the hip. This is an athlete we had, lying on his side, and we had him starting to abduct his hip. If you watched the video, you will see that the muscle tone fire’s really early when his hip had abducted. There is a lot of early hip hiking occurring before the hip actually goes into abduction.  Even when we were queuing him to just abdominal brace a little bit and try to control his pelvis, there was still a lot of early hip hiking occurring. What would cause this whole again? We can’t say that this means x equals y, we have to do some further investigation.

When we talked about hip rehabilitation, we are going to show you how we addressed this and try to make some corrections to this aberrant neuromotor pattern of him hiking his hip.

Another Janda’s assessment and neuromotor retraining assessment actually is Janda’s Hip Extension Test. There was probably even more controversy about this particular assessment and some of this other stuff. Again, we are still in Tier 2. We are looking at movement and neuromotor control, no loads other than gravity. In Janda’s Hip Extension Test, what we are looking for is, Janda’s first initial claim was that muscles should fire in a particular order. And Janda’s hip said that as we are palpating the hamstring, the glute, and the lumbar spine, Janda’s said that we should have the hamstring fire first, then the glute, then the opposite low back, and then ipsilateral low back. Subsequent research got me independently found that that’s probably not the case, especially in healthy individuals.

What is a concern for us, for patients with chronic lower extremity symptoms and chronic low back pain is that their glutes are firing or elevating in tone really light as we ask the patient to actively hip extend. The motion here is asking the patient to actively hip extend and I just tell the patient, “Keep your legs straight and elevate your knee just an inch off of the table or the floor. Lift your knee an inch off the floor, couple centimeters off the floor.” As soon as they start to do that, you can start feeling muscle tone in crazy and various different areas. If they have a significant amount of lumbar spine muscle tone increase long before the glutes increase in tone, they might be really dependent again on the lumbar spine paraspinal for neuromotor control of that hips and that lumbo-pelvic relationship. If the glutes fire pretty early, maybe about the same time or maybe even a little bit before the lumbar spine paraspinal muscle, that might be a little bit more ideal. Clearly, there is strong research for that, the research does show that if there is a significant delay, including motor firing, that can be a contributor or at least an outcome of chronic low back pain, possibly that could be retrained.

When we talk about rehabilitation of the hip and knee in another video, we’ll discuss how we can potentially work with retraining this.

Continuing on where we are still addressing the movement of the hip and knee, but we are not applying alone, we want to measure proprioception. Yes, I said measure proprioception. If some of you may not be aware that this can be quantified, they are very low-tech and very easy to do.

For the hip, what we are going to do is we are going to have the patient lie, we are going to have the patient assume a position, so we are going to stop it right there. I backed it up just a tad. What we did is we have the provider, you as inclinometer, in this case, it is a digital inclinometer. We position the patient’s leg somewhere in between full flexion and their neutral position where they started lying on supine. We brought their leg up, halfway into that position, it doesn’t have to be exact, just somewhere. Then, with the digital inclinometer or your analog inclinometer, you want zero it up. This will be the zero position. Then we have them go into full flexion, we have to lower their heel all the way to the floor, and then they try to recreate that starting position. His eyes are closed, he can’t see what his foot is doing, and then while he is trying to recreate that position, the provider comes in here, again, to measure how many degrees off he was compared to that first position. If he is more than 10 degrees off consistently, that might be clinically relevant.

What is more important is to measure the hip and knee and we will show you a new one here, a little bit, to compare it to the good side. If you have an older athlete who had a hip replacement, that would quantify proprioception. Compared to the other side, let us get the good side and see how many degrees off is consistent for that good side. If he is consistently 6 degrees off, that might be his normal for his good side. If you are 16 degrees off on the painful side, that’s clinically relevant and we might want to rehab this patient to reflect back on these proprioception assessments. Again, a really easy quantifiable measurement for measuring proprioception in a kinesthetic sense.

Going back and watching that video one more time, I just want to make sure that you have it. We can have the athlete position or you can position them in a mid-range of motion position, be of 0 of the inclinometer. We have them going a full flexion back down to the floor, then trying to recreate that starting position, and then re-measure to measure how many degrees off he was.

Continuing in our Tier 2 discussion, we can assess the stability and neuromotor control of the lumbopelvic and other areas. Here we have got a supine bridge exercise, a supine bridge assessment actually. When we have the patient lying in a supine bridge and the left leg in the mirror here, the left leg is the closed chain side. When we raise the right leg that we see in the video here, we are really placing a lot of load on that closed chain hip.

Now, there are textbooks and I have read some articles that says that when they raise the right leg, if the right hip drops, this is referred to as the supine Trendelenburg, it is a glute medius weakness, and that’s not accurate.

This is not a glute medius weakness. If they dropped the open chain side, if they dropped this hip, in other words, the closed chain hip is unable to maintain the pelvis being level. It is not a glute medius weakness. It is most likely, a no motor control and or a weakness of the internal, rotators of the hip, the internal rotators of the hip. Let me explain this. When this hip drops on the closed chain side, that hip joint is going into external rotation. It’s unable to hold a neutral position. The internal rotators cannot withstand the load, or aren’t smart enough to withstand the load, and they cannot hold back a neutral position, then the hip starts going into extra rotation. Think about that, if you have any questions I am happy to take any questions offline. This is a really simple test, again, commonly done and it actually ends up being a rehabilitation exercise for us as we discussed rehabilitation.

Another Tier 2 exercise, in other words, it was not much movement with the hip or basically having them assume a lunge position and I’m more concerned about it, there is a little bit of movement, but right there, I’m more concerned about what’s happening with this hip joint in this position. Can they hold this position? In other words, no movement. Can they hold this position as stable as the other side? The other side was pretty spot-on, it was in the sagittal plane and didn’t really have much for difficulty. As he goes into his right hip, he is unable to hold his position. It either is muscularly stupid or it is muscularly weak to be able to sustain this leg in a sagittal plane.

Similar to the lower extremity clearance test that we discussed earlier, we saw that he went into Genu valgus in this another lunge test. It goes a bit basically what we have already discussed so I am going to cross past that and discuss a little bit further about another Tier 2 test that I like.

I like this Star Excursion Test, gave me a lot of information of quantifiable, it does include a little bit of movement, but the closed chain side of the movement is not excessive by any means. It’s not going through their full range of motion and the load is just crappy again. The Star Excursion test is basically real simple, take some tape, put it on your carpeted floor or your tile floor, and use a marker or a piece of chalk, and mark where he’s going to be touching his toes. Let’s start the video here. We are assessing several things, we are assessing your ability for lumbo-pelvic control, so let me just stop right there. One for pelvic control, so we are looking for hip hiking and dropping as well, where there is going to be a little bit of movement of that closed chain side, but not too much. We are looking at stability, we are looking for Jean Nouvel’s presentations and overpronation, and we are looking to see how much control he has of that movement at the closed chain side, and how far he can reach. We know that our athletes are out on pitches and courts all the time and they are extending their legs way beyond their normal walking and maybe even in a normal healthy running state. They are reaching out at times to slow themselves down or to re-accelerate so we want to certainly measure how much control they have on that closed chain side. As you can see the provider, he is placing a mark or a strip of paper here. What we are going to do when we are all done is measure from the starting point out to here, before his right leg.

When we marked it in our notes, we mark that the left leg is closed, and what I have in my notes is I have a star in my notes and I will say, left leg closed, then I’ll write down 23 inches or 53 centimeters, and I will write down the measurement on all these lines. You will see that we go through a lot of different motions. Here, he is crossing over, which is a typical athletic sport, there is extending back backward, where we see our athletes doing this all the time, reaching as if he is crossing over with his closed chain side.

These Star Excursion maneuvers are maneuvers that are rather consistent of movements, we see our athletes perform on a regular basis, all we are asking for and what makes it different than being out on the pitch because we are asking for him to control it, barely touches toe down, we don’t want to put in any way on his toe. We barely want him to touch his toe and we are identifying how much control he has of that lower extremity side.

Another proprioception test for the knee, we showed you earlier proprioception test for the hip, it is the proprioception test for the knee. We are going to ask the patient to be laying prone, we are going to be in position, her leg in a mid-range position, somewhere between full flexion and full extension, it can be anywhere. somewhere around 45 degrees seems to be about a good position to start. It doesn’t have to be exactly 45 because what we are going to do with this inclinometer, is zero out our inclinometer where their starting point is. Then, we asked the athlete to fully flex and fully extend and return their knee joint to that same starting position. So, he is going in full flexion, full extension, and he is going to try to recreate that starting position so that if you’ve noticed, he did not come up nearly as much into full flexion or the starting point. He was probably good, 15 to 20 degrees off with this particular test so we would do that a number of times so that we can get an average and then certainly compare it to the healthier side.

This is a non-weight-bearing proprioception test, if published in peer-reviewed journals and has at least fair validity this is a weight-bearing test. This is the weight-bearing test and I have not seen any weight-bearing proprioception measurements using low tech technology such as an inclinometer. A big individual actually is testing here, he was working on a paper on trying to identify a closed chain proprioception weight-bearing assessment.

Again, we are going to have the patient assume a natural posture, a natural position and then come down into a squat, eyes closed, somewhere between full extension and full flexion, and then we are going to place the inclinometer and I’m just going to back up a little bit. We are going to place the inclinometer on a spot of the thigh that can be repeated. We might want to put a mark on the thigh if you want, a little piece of paper or whatever, so that we can put that inclinometer right back in that mid-thigh, then we are going to ask the patient to go into a full squat, all the way up to standing, and then replicate that starting position. A lot of proprioception is happening here between the ankle, the knee, the foot, and the low back for this patient to be able to quantify and replicate the same angle that he started off with.

It is an interesting study. His outcomes were pretty interesting. What he further evaluated in his study was, does fatigue affect proprioception? You will have to wait for the outcomes of the research, not even sure at this point in time, what the outcome of that study is yet but we have the athletes walking and fatiguing themselves, jogging on a treadmill,  and then retested them again after they were fatigued.

Tier 3. This is now the applying a load. We are going to apply a fair load to the athlete. In this case, the athlete is sitting on the wall. You can see the diagram at the back here, she is sitting in a 90-90 position or a wall sit. She has no chair beneath her, her angles are 90, her knees are at 90, her hip going through at 90, and we want the knees, foot, and ankle to be pretty close. So, I think this is too far apart. I would suggest that you bring the foot and ankle a little bit close to each other because of the next step that we are going to be doing. We have the patient make sure that they can assume this 90-90 wall sit position and when they are comfortable, we start the timer soon as they lift one of their feet, that’s why we want their feet together. When they lift one of their feet, they just have to look it up to the other ankle a bit of an inch off the floor, a couple of centimeters off the floor, it doesn’t have to be very high at all. We want their hands more so on their hips, not necessarily on their thighs. We don’t want them using their hands when performing this test. When they lift their foot off the floor, you can start the timer, and you stop the timer if their thumbs lie down on a wall, they are unable to maintain that seated position any further, or they lower their foot back down to the floor, and you can see that the standardized test that both legs combined, they should be able to withstand a male versus female in this amount of time or an average type of athlete.

I would certainly compare one leg to the other as well and identify whether there is a motor endurance issue. Wow! Left leg versus the right leg. Another test, this requires a little bit of material, kettlebells or dumbbells in your office. This is a published study as well and I have a fair validity, this is a 10-point assessment, and it’s a single leg lunge assessment. We started off with the athlete performing a double of a squat test. Lowering their boundary heel and coming back up, they should be able to go beyond 90 degrees in this test and then stand back up. If they are able to go below 90 and come, and stand back up, that’s 1 point for each leg. Like I said, this is a 10-point test and it is 5 points for each leg. That is the best that you can score, 5 points for each leg.

We go back to this first step, they are able to do a squat, did stand back up, that’s 1 point for each leg. Then we have them perform a single leg lunge, so I just position then. In this lunge position, I haven’t hold it. Then I want her to lower her back knee, all the way to the floor, bending this knee to about 90 degrees, the front knee to 90 degrees, and then extend back up, lifting this knee out of the floor of the back knee, and bringing it, that’s finally, almost in full extension. If she is able to do that, then that knee now has another point so it is 2 points for that leg and 1 point for the other.

Now, her left leg, in this case, has now got 2 points, if she’s able to do that, then we add 10% of her body weight, that’s what the dumbbells here are for. We add 10% of her body weight total. 5% in each hand. So, 10% total. And again, we have her perform a single leg lunge. Lowering her front leg to 90 degrees and then extending back up, if she’s able to do that, this left leg now scores another point, so now it’s 3 points to 1 point on her left leg. If she’s able to do that effectively, we put those dumbbells down, and we grab another 10% of her body weight. Now, she’s holding a total of 20%. She’s holding a total of 20% of her body weight, 10% in each hand and we have her perform a single leg lunge, lowering her back knee, and flexing her front knee to 90 degrees, If she’s able to do that, she puts these dumbbells down, she grabs another 10% of her body weight. So now, she has 30% of her body weight and both of her hands total. 15% roughly in each hand and we have her perform this single leg lunge again. If she is able to progress all the way through these, without hesitation and without pain, she has scored 5 points on her left leg, and then you repeat it with the other leg so that maximum score would be 10 points, 5 points with each leg.

There was an interesting study, the outcome of the study was that they took many athletes, individuals that have no knee pain, no hip pain, and they found that the average score was around 9. You think this would be kind of easy, but in a healthy group, they found that the average was about 9. An interesting study, very low-tech, you just have to have some dumbbells or kettlebells or some sort of other weights and can effectively be done in your office.

Let us talk about muscle testing a little bit. We are still in Tier 3 and what we are going to be doing is applying a load to muscles. So earlier, when your athlete in a previous video and the video that didn’t work again, we were suspicious on maybe a glute medius weakness. Because it is based upon how they function, but there was a prediction and not a confirmation. This is where we confirm it. If you are concerned about a strength or weakness, you need to muscle test, you need to use a muscle test. Ideally, you can use a handheld dynamometer and actually quantify how much force output that muscle or that motion, in this case, hip abduction and hip adduction, how much force that those motions can produce? Then you are actually quantifying muscular and qualifying whether there is a weakness there or not.

In 2017, there is a systematic review that demonstrated a very high correlation with handheld dynamometry testing of the hip was completed and there was moderate correlation when testing the knee and ankle when compared to the case of kinetic testing. I published a paper back in 2011, handheld dynamometry as well. You can look up start and you can read my paper on handheld dynamometry. That was just another systematic review, mine was a systematic review as well. This is a new systematic review, I mostly looked at knee and hip, and so certainly, an appropriate part of this discussion.

Isokinetic testing is the gold standard for measuring muscle force output. There is that gold standard and like my systematic review, and in 2017, when they compared the handheld dynamometer, a small little device that costs you probably less than $1000, roughly around $1000 USD American, it lines up well with the findings of isokinetic testing that might cost you $200,000 for an isokinetic testing device. It’s a worthy investment. A thousand dollars is not asking a lot to be able to quantify force output. If we can take this offline as well, you can email me if you want any recommendations of handheld dynamometers out there.

Here on the picture, on the left-hand side, we have a picture of this provider, assessing a patient for their abductors, so she’s lying on her side, the top leg, as you can see in the mirror, she’s basically using that for support and stability. The bottom leg, in the mirror, in the bottom leg here, she is going to be asked to elevate her knee, the side of her knee, off the table just a little bit. In other words, contracting her abductors, then the provider flies into a consistent spot down by the medial malleolus with the dynamometer and applies pressure, instructing the patient to push up into the device. It’s really important and I think I have commented on this in my paper from 2011, that patient initiation is really important and that’s all based upon how you phrase it to your athlete. We want the athlete to initiate the contraction. There is the right way, we tell the patient to push up into the device. Push, then you are resisting, and then you are going to overcome this thing. That is going to measure their maximum force output into abduction. The wrong way to do it is to tell them to resist you. If you tell the athlete, “Resist me.” They are not really sure how much force you are going to be putting into them and the research shows that the consistent output of the athlete is less consistent. The output is less consistent. So again, the correct wording is to have the athlete push or pull, depending on what muscle you are testing to initiate the contraction first, so that was abduction.

The abductors, you notice that the patient’s still lying on her side, the bottom leg is now flexed, like we had in the Janda’s position, Janda’s abduction position of hips, flexed knees, flexed or balanced. The top leg is straight, and the ankle, knee, hip, and shoulder are all in a straight line. We are going to ask the patient to abduct just a little bit. You notice that she’s pretty much in her anatomic position. You can take her out into abduction, just a little bit, but we don’t want to muscle test away. I want a 45° abduction. Because our athletes, do spend some time there. In that position, they spend probably most of their time with their feet about shoulder width or slightly wider so we want to muscle test them in that position.

You can see in the mirror, you can also see in this closer shot of a video of the picture that the Dinah loggers is in between the patient’s hand, and again, a consistent spot just above the lateral malleolus. Importantly, in both pictures, you’ll notice the provider is stabilizing the pelvis. This other hand has to do something, it has to stabilize a patient. If this provider did not stabilize the pelvis, the ghastly is going to use a lot of low back muscles, it could try to fire the abduction, or fire into adduction on this picture and we are not going to be effectively measuring in motion and force output. So make sure that you stabilize, it’s very important to get accurate testings.

Some other muscle testing and handheld dynamometry positions for the hip joint for the hip flexors, we can have a patient lie supine, bring that hip just into a little bit of flexion. If you are strong enough, you can probably put the dynamometer just above the knee. But using a longer lever, you are going to be able to overcome that patient’s hip flexor mechanism, which does include the rectus femoris, the rectus femoris is certainly firing it. If we use a longer lever and place a dynamometer lower in the leg, you can see that the output provider is stabilizing the opposite pelvis.

I am going to state here on the hip extensors, the provider is stabilizing the pelvis, the knee is extended, the hip is extended, and the knee is a little bit off the floor. Again, we are using a long lever. Some of the muscle testing textbooks, tell you to place a dynamometer, your hand here. When you use short levers, the provider has to use more output. The validity and consistency is less. If a provider can easily resist the muscle output and overcome their strength, which is called a brake test, the consistency and validity of the test increases.

Lastly, for the knee flexors. You can see that the provider is stabilizing that issue of tuberosity, and the knee is flexed, the knee is on the floor or on the table and the dynamometer is on the distal end of the leg once again, and again, most of the textbooks, tell you to position only at 45 degrees. In my experience, even average strength athlete or really strong at 45 degrees, it’s really hard to overcome them at 45 degrees. Research also shows that hamstrings will tear, oftentimes, at about 20 degrees of knee flexion when firing eccentrically. You can see that we have this athlete roughly at about 20 degrees because of that reason, that’s probably where the hamstring is probably out of one of its weakest points. So, why not test it there?

You know, holding test. For those of you about a little bit savvier with lumbar spine. Lumbar spine rehabilitation of functional assessment, you might be familiar with Sorensen’s Holding Test or Lumbar Spine Extension Test, and that’s referred to as holding test, is basically asking the region to fire against a resistance for a longer time. When we are muscle testing on the earlier slide, we just have them do a maximum output for about 2 seconds and that’s it.

For inner holding, for asking for a submaximal muscle contraction submaximal for as long as they can hold. Let me explain how we might do this or a hip muscle, and this is just one example. Here, we have already performed a maximum output for hip abduction. We already know what her maximum output is. Let’s say, it’s 38 kg, she’s able to abduct against this handheld dynamometer or the maximum output of 38 kg. What we do is we take about 70% of that. Let’s say it’s about 28 kg, we have her push into the device, the device is telling us how many powers she’s pushing until it gets up to 28 kg and then we start the timer, and we have a whole of about 28 kg of force for as long as she can. And then when she fatigues, can we stop the timer? We are able then to quantify how long she can withstand a submaximal load and prepared to be non-injured side. So, that is an example of an inner holding test.

Another published test is this test for assessing level pelvic stability, which would include the lumbar spine, the hip joint and some of the extensor mechanisms of beneath, and we go help the athlete extends back to about 70 degrees – so let us see if we can stop that much of why it dances.

So we have asked the athlete to extend that to about 70 degrees. How do we know that? The provider is using an inclinometer right here, we are measuring, or they started at 90 degrees and they extended back to about 70 degrees, and then the providers are going to keep their hand in the back right at 70 degree mark. We are going to ask the athlete to come back up to that starting position and he is going to go back and forth as frequently as he can in 60 seconds and what we are looking for, is fatigue on his lumbo-pelvic stability. If he starts to flex his hip right here, we want him to be a straight line from the shoulders to the hip, down to the knee. He should be able to maintain a straight line. If he starts flexing as tip, we know that he’s lost a lumbo-pelvic control. Or maybe his lumbo-pelvic control is very good but it just doesn’t have the endurance of the knee extensors to be able to eccentrically recline him back.

As far as I could tell in this study, there was not any standardized data. It’s a starting point so we can count how many times he was able to do this in 60 seconds before he broke his form, and then as we are rehabbing the patient, we can determine whether he is improving them in his outcome.

Box drops are really easy to perform if you have a couple of steps. Even when you are out, you can certainly perform on there or just build a box, or just stand from a chair. You can see the height of this box is roughly the height of maybe a small chair. Again, there is some potential risk of an athlete of hurting themselves. We want to make sure that it’s done in a safe environment, and this is only done if we think of patients able to effectively do it. If the patients recovering from hip replacement or labral surgery, we are probably not going to be progressing into a Tier 4 exercise. Tier 4 is beyond adding just lower, it becomes more of a ballistic, more sport-like activity and making it a higher-tiered functional assessment. These box drops, there is evidence to show, and support box drops have given us some really good information.

You can see that as he drops, he comes overpronated, he goes on the genu valgus just a little bit and it could be that he’s enjoying rotating his hip joint as well. Maybe, there are no neuromotor controllers and weakness there. So that leads us going back to our handheld dynamometry to determine if there was a weakness. There really isn’t weakness there, maybe it’s a neuromotor control issue. Totally, box drop’s really easy to do because it’s a fair amount of information. And then last week with functional testing again, this is much a higher load testing, we are into Tier 4, this isn’t ballistic, but it does go. We do take the athlete to what is called mobilizer fatigue. In other words, she’s going to be performing a living press. There are various different tests available out there that are standardized. Some of them have 100% of their body weight on the leg press, some of them is 1.5% or even two times their body weight and we are looking for certain number of repetitions. So, again, you can do a quick little search for standardized tests for leg press if you happen to have this device, but we have a leg press available to you.

Another simple way of measuring mobilizer fatigue and maybe even maximum mobilizer endurance output is we are going to bring close to this discussion. This was, again, a high level of discussion to help you understand how we can functionally assess the hip and knee. I think some of the things that are really helpful for me, in helping my athletes over the last many years are measuring proprioception and also some things that aren’t necessarily discussed much in your undergraduate, Chiropractic program. In this certainly, postgraduate program, measuring proprioception, I think, is really easy to do as low-tech, it can be done weight bearing, it can be done non-weight bearing, and pretty easy to measure. In a Star Excursion, I use that a lot as well. Again, it’s low-tech, it doesn’t require much of anything more in regard to materials and financial involvement, but yet, gives me a lot of information and handheld dynamometry.

Handheld dynamometry, I have kind of fallen in love with it over the last twenty-some years. I think it really gives me some really good information on whether a muscle truly has a motor weakness or not. What’s interesting as a sports chiropractor is if you are assessing your athletes before you treat them, then perform a treatment, adjust them, then do that handheld dynamometer test again, and see if there is an immediate change.

Let me give you a quick little case study before we bring closed. We are working with an Olympic athlete, this was right before the 2016 Rio games and she had already qualified for the 100 meters, and she had flowing in to work with us because she was a little on the small side. She was 5’3″ compared to the 5’9″, 5’10” sprinters that she was going to be running again. She was looking for some thoughts and ideas on how she could be a little bit faster so when we are evaluating her, we did the Star Excursion, we get all these tests that you saw in the videos including handheld dynamometry.

We found that her right hamstring was 28% bigger. Her hamstring was 28% weaker compared to her left side. Well, that’s quite substantial, she didn’t have any pain, she didn’t have any complaints, but that was quite substantial. I told her, “We have a finding here, we are going to explore to see what the potential cause is.” I started looking at the foot and ankle and found a restriction and adjusted it and remeasure the hamstring, and there was no change. That worked my way up the leg and the fibular head was stuck. It’s over-restricted as compared to the other side. I thought hamstring attachment should be credible and get that moving.

I adjusted that, rechecked her hamstring, and still went 27, 28% weaker, it didn’t really help out at all. We worked our way to the soft tissues of the quad and hammy, up to the hip joint, found that the hip joint was restricted and [inaudible] while inflection and it internally rotated so we adjusted that, really influenced that posterior capsule big of joint, reassessed the hamstring. Right hamstring ended up being now 7% stronger. It was like 35% swing and strength.

As I said these handheld dynamometers, they can be very valid if used appropriately. I have been using it for a long time, I had my fellows in the office as well and we couldn’t believe the outcome that was supposed really impressive. This whole sports chiropractor thing can be really impressive, use some of these tools if you want to spend a little bit of money, handheld dynamometers are great little investment to help you identify and dial in your athlete. Make sure you are working well.

It has been my pleasure to guide you along a functional assessment discussion for hip and knee, and I wish you continued success as you move through the rest of your sports chiropractic training. Thank you.



1.5 - ICSC05_Rehab of Hip Tier 1

English Direct Download PDF – ICSC05-1.5 VIEW Rehab of Hip Dr Tim Stark Tier 1 – 35.40.mp4

ICSC Lower Extremity Module 5
Section 1.5_ICSC05
Tier 1 Rehab of Hip
Instructor Timothy Stark
Video Lesson: 35:40

We are going to continue this discussion on the rehabilitation module, and this particular video will be specific to starting or initiating your rehabilitation process for the hip joint, certainly within the chiropractic field, and especially the sports chiropractic field. Working with extremities is very important and I think if you spend most of your time really wrapping your head, around shoulder, and hip, you are going to be helping your patients out quite substantially. As we zoom in a little bit on specific measures and interventions for the hip and shoulder, you would have already viewed a functional assessment video for the hip and knee, and the functional assessments are very similar, as you probably noted, to the Star Excursion Test, for example, for measuring just the whole lower kinetic chain.

As we get into rehabilitation, however, we are going to break these apart a little bit more and break them down into sections. We have a rehabilitation process that we use at Northwestern Health Sciences University, USA and it has worked out very well. As you probably have discovered for yourself, when we are looking at protocols for rehabilitation, there is not a lot of protocols out there that can be utilized, in other words, that are held to the scrutiny of research; a lot of them are anecdotal. I will be showing you a protocol that we use here at Northwestern, which is a step-by-step progression.

This is that first step, which is called Tier 1. The outline for the hip is to address these five different steps or tiers, basically for rehabilitation, including removing the negatives. We are going to discuss what those negatives are later in detail. At a higher level, generally, the negatives are basically anything that is going to slow down your rehabilitation process or slow down the rehabilitation and healing process of your patients. What are these negatives? It could be a muscle spasm, joint restriction, neuromotor control, or things like that.

The next step is talking about static stabilization, which will be covered in our next lesson, not in this lesson. In the third lesson, we will talk about dynamic stabilization, and lastly, mobilization conditioning, in other words, strengthening the area. You will notice that it takes us quite a few steps before we get to strengthening the hip joint. I think several physical therapists and chiropractic rehabilitation people use the word “strength” long, and we want to make sure that we look at hip stability and lumbopelvic stability before we get into strengthening. Lastly, our last step is ADLs. For our athletes, particularly, these activities of daily living could mean running and jumping and landing from tall heights, grappling against somebody. We want to make sure that our athlete is stable and strong before returning back to their sport.

As we get into the first tier of hip rehabilitation, we want to revisit a pyramid. If you have already looked at rehabilitation for the foot and ankle, you will have already seen something similar to this. This is a rehabilitation pyramid that we utilize here at Northwestern, like I said. In this first tier, that is where we are really discussing removing the negative, and looking at what that includes.

You will see that respiration pattern. We talked a little bit about paradoxical breathing patterns in the past, and especially for the hip, paradoxical breathing patterns certainly can influence how the hip pain might linger a little bit longer and maybe not recover well enough. If we have a patient with COPD or some sort of other breathing pattern it is probably going to slow the process of them recovering, so certainly do a little bit deeper dive on your own at paradoxical breathing patterns and how to recover from them. That extends outside the scope of our discussion here. As we move up to our second tier, third tier, and fourth tier, those will all be subsequent videos that we will have within our program here in that rehab module.

As we did with a rehabilitation pyramid for the foot and ankle, we are going to discuss how important education is for your patience, and then also, addressing engrams, motor behaviour, or muscle memory and how important that is for your patient’s recovery for hip issues. The first thing we want to address is removing these negatives. We are in Tier One, and we are beyond functional assessment; we’ve already assessed them. We have already come up with a decision that certain muscles are asymmetric in regards to their strength. They might not be functioning at an adequate tone. Maybe the muscles are a little bit on the short side, complicating hip extension, for example, so maybe the reflexes are a little bit tight. How do we address that? We want to address that right away within this first tier.

There are several different ways that we can lengthen tissues. I use the word “tissue lengthening” for several reasons. One, when you tell a patient to stretch, it seems like a lot of patients roll their eyes right away and say, “Oh, I don’t want to stretch. It is too painful,” but if we talk to them about how certain muscles might be a little bit chronically short, and we need to lengthen these a little bit and show them a tissue lengthening intervention, it sounds, maybe, a little bit more clinical and maybe doesn’t have that bad feeling of stretching a muscle and it being painful.

We are going to talk about some Myofascial Release Techniques or MRT. Traditionally, in literature and several textbooks, they talk about five different ways that you can provide myofascial release. Also, there is another technique that we will show you called reciprocal inhibition. In addition, it is not necessarily a sixth level; it is just another way of applying a myofascial release technique. We will also show you some techniques for soft tissue manipulation. It is HVLA, High-Velocity-Low Amplitude. Soft tissue manipulation works very well on a good percentage of people.

As you can see here, we have the abductor. Here, we are showing a starting position and an ending position. You can see in the video that she is starting in an abducted position, and she is ending in an adducted position, while we are working on her abductors. Same thing with some of her glute extensors and external rotators, if we were looking at glute medius, for example, here’s her starting position and somewhat more of a neutral position, and then We are going to bring her into hip flexion and slight control rotation while we are stretching. That is a high-level explanation of what these MRT levels are. Let’s take you through a bit more of a tour of it.

This is just another example of a hip flexor, but we have a video that will be able to explain it a little bit more effectively. Let us look at this video. For MRT 1, we want to position the muscle that we are providing the care for in a shortened position. You can see, we have the rectus femoris, for example, in a shortened position. This is the MRT 1, you can see the hip joint is not moving. You can see that the provider has a very broad contact. She is not using the tip of your thumb; she is extending that interphalangeal joint. She is using the broad part of her thumb, making it a little bit more comfortable, and then you are less likely to bruise your patient, as well. Patients always wonder the next day when they are getting dressed where these bruises came from, and then if they are thinking about you, that probably isn’t positive. Using a broad contact, your thumb or a couple of broad fingers, generally work, but again, MRT 1 is used when the muscle is in a shortened position.

Why would we use this? Maybe they are coming out of a cast or maybe they have been immobilized for an extended period of time, maybe their joint hurts so much that we don’t want to take it through a range of motion, so we want to keep the joint still, or the patient is more comfortable, maybe, depending on the condition, more comfortable in this flex position. That is MRT 1, and we will probably do anywhere from four to ten, maybe 12 passes on this muscle. It really depends on what’s going to benefit that patient. That is something for you, as an artist, really, the art of some of the care that we provide, to determine how that patient is going to respond. Maybe we will start off conservatively with just four to six passes, but we find out that maybe on the next visit, the patient could have actually tolerated more, and then we would progress appropriately.

The next MRT level, and it is not necessarily you do 1 first and then you do 2, you pick whatever MRT that is going to be appropriate for the state of that patient. In this case, the patient is not in a contracted state. We can put that hip joint in an extended position. Here, we have the rectus femoris again in the extended position but let us just say that maybe the hip has a little bit of pain in it, or maybe there is a stress fracture in the hip, and so any hip movement is painful. Again, for MRT 2, We are not going to move the hip through a range of motion. The patient can tolerate a lengthened position, that is why we have it kept in this length and position. You can see, again, the providers at a very broad contact, going distal to proximal, usually, in a short distance or amplitude. To patient tolerance, how much pressure do we apply during MRT 1 under an MRT 2? Well, some patients have a very low threshold of pain, and some have a very high threshold. We need to certainly be sensitive to that. If they have a very high threshold of pain, we are not going to be applying more pressure than what we need to. After you have done it several times, you certainly start to develop an art of touch, if you will, no pun intended, of how much pressure is absolutely necessary, but if they have a lower level of pain tolerance, maybe they are a little bit more inflamed, we don’t want to apply any more pressure than probably a 6 out of 10 pain level. If it is much more than that, maybe they’re going to start squinting. They are not going to have a very good experience or probably less likely they will be compliant with their continued care.

Now, we are going to look at MRT 3. MRT 3 allows us to move the hip joint through a range of motion. The hip isn’t painful when we move it, but then, passively, you can see that the providers are lifting and lowering the hip, so the patient is not contracting muscles with MRT 3. The provider is basically doing a pin and stretch. If you want to rewind this video and watch that again, you certainly can. We might have been aware of that type of technique. While the muscle is short, she is pinning it, and then she is lengthening the muscle underneath that pin. Again, it is done passively; the patient isn’t actively doing it.

In MRT 4, it is a similar concept, but the patient now is actually moving their leg. The provider is applying pressure when the muscle is short, and then the patient is actively extending their hip. While the patient is actively extending the hip, the provider is just sliding just a little bit, a centimeter or so, over that lesion that is in that proximal or hip flexor.

MRT 5 involves eccentric muscle contraction. What’s happening here is that the provider, again, is providing a pressure, a pin, and stretch application, in a shortened position; that is when she applies the pressure. Now, what the patient is doing is trying to pull his knee further to his chest, firing the hip flexors. What the provider is fighting that and stretching that contracting muscle in an eccentric manner. Personally, I am not a fan of MRT 5; I think it is very uncomfortable for the patient. It forces me to be very superficial in the muscle structure I’m trying to treat, and it does not allow me to get very deep, so I generally don’t do MRT 5. I generally start off with MRT 3, for example. It is nice and relaxed, and I get to control the pace. The muscles are relaxed so I can apply deeper pressure, and then I generally go into this reciprocal inhibition.

For reciprocal inhibition, that is when the patient is going to fire the antagonistic muscle group. As We are treating, we see in the picture here, note that she is moving her hand to the opposite part of the leg. She is no longer grabbing the shin and pulling it down; she is putting her hand on the underside of the shin. What is going to happen here with the reciprocal inhibition technique is that the provider is going to apply pressure, a similar pin-and-stretch, to the proximal hamstring. The patient then is going to fire the antagonist, in other words, the hip extensors, and apply pressure down into the hand.

Let us watch this video here as it progresses. The patient is pushing the heel to the floor, firing to ease extensors. What is happening is a reciprocal inhibition of the hip flexors. In other words, the hip flexor should be turning off a little bit or toning down, allowing the provider to be a little bit more effective with getting a little bit deeper with the thumb contact. How many repetitions do we do with this? If it is a new patient, I might do four to six repetitions just to see how the patient responds. Especially if the patient is already responded well in that four to six number of repetitions, I am ok with that. If I feel like the patient can tolerate more, I might do a few more repetitions.

Another manner in which we can provide this therapy is using a technique called Post-Isometric Relaxation, PIR. When I describe this, a lot of people might call this PMF, Proprioceptive Neuromuscular Facilitation. PMF is very complicated and involves several different patterns of movements on usually diagonal patterns, D1 patterns, extension patterns, reflection patterns, and D2 patterns. Instead of calling this PMF, we should accurately call it PIR, which is basically a contract and a relaxed stretch. For example, the hamstring is probably a very common stretch. For the hamstring, the provider is taking a patient into a stretched position. The knee is extended, the foot is in dorsiflexion, putting a very good stretch in the posterior structures, and the provider brings the leg into a comfortable stretch; it shouldn’t be painful. If it is painful, then the patient’s going to be fighting a little bit. We hold that stretch for any time that you think is going to be appropriate.

Generally, I hold this stretch for about five deep breaths, which should take about 20 or 30 seconds, then I back off just a couple of degrees and make it a little bit more comfortable. I have the patient then push against me, firing now this muscle that you are trying to stretch. They push not real hard, maybe 30% of their muscle contraction, so it is not a real intense contraction, and they hold that force, that contraction, for about seven seconds, maybe about one breath, maybe two breaths, and then you relax. After they relax, you should be able to take them into a slightly greater stretch.

How many repetitions do we do? Generally, my response is that we perform the repetitions until we see no longer greater improvement. In other words, if I’m on my third rep and I got some more range of motion, I’m going to hold that stretch, back off, hold that stretch for five deep breaths, back off, and have them push for seven seconds, push, relax. If I could not move them any further into a stretch, I feel like that patient is probably not going to benefit from another one and another one. Generally, also from experience, three to four repetitions are usually sufficient for performing these types of PIR stretches.

Here are some examples of how to stretch or position the patient for abductors and for piriformis. This is a video that I think will be helpful for you to understand how we perform this PIR stretch for hip flexors. You will note that as the provider is taking the patient into a flexed position, the athlete has their foot on the chest, the knee is in full flexions, and as the provider is leaning forward and taking the hip into further flexion or even into the pelvis, we should see the hip go into extension. The femur really should not move, but what you will note is when the provider was hitting the hip, that left leg, the left hip was coming up into flexion, so basically, a Thomas test. That is telling us that that hip flexors are a little on the tight side and could benefit from some stretches.

Let us watch how the provider then provides a PIR. You saw her cue. The patient by tapping on the leg to lift up that left leg, in other words, it contracted deflectors. Now, you see her pushing down on the leg to get a little bit more stretch, and then after seven seconds a stretch, he is instructed to pull the leg up into more hip flexion against her resistance, and then about 20%, 30% muscle contraction, and then relax again so that she can push him into further stretching. Very effective.

Somewhat traumatizing, honestly, for the hip flexors, my experience is that when athletes now pop up into a seated position, that hip flexor is a little bit uncomfortable because that stretch is pretty strong, it is pretty powerful. You may want to do some real simple actual PNF patterns, taking that leg through a diagonal pattern, D1, D2 patterns. If you are not familiar with that, you can just take them through a range of motions and how to de-traumatize a little bit, if you will, that hip flexor, because it is a little bit uncomfortable.

This is a video of an assessment for performing HVLA manipulation of the soft tissue. You can see the provider here, identifying fascia glides and also assessing the sector of the different muscle bundles, and just trying to look for a restriction. When we find what we think might be a restriction, we want to assess the lateral, S to I, and I to S, and find out where that restriction is. She found out I to S restriction of this rectus femoris muscle group, and then she does an HVLA manipulation, just like what you saw. She might need to hit it a couple of times just to make sure that that faster restriction that she identified, truly, was remedied. Very fast.

Again, if you get in the habit of performing some sort of paradoxical maneuver such as, let us say the patient had pain when they were squatting. They go into a squatting motion, they have this quadricep pain. The provider, you, will assess the soft tissues, do a quick HVLA for that restriction that you feel, and have them stand up, and see if their squatting pain is improved. If it is, magic, the patient is able to see that what you are doing is beneficial to the complaint.

We will now talk a little bit about some evidence, though, of soft tissue therapy. This was a study published not too long ago in 2016. They are looking at the effectiveness of physical agents. This was an interesting study where they looked at 10,000 papers that mostly look at ultrasound, cryotherapy, shockwave therapy, low-level laser, different types of strapping techniques, and how they benefited soft tissue injuries. Well, it probably will not come as no surprise that there was a lot of bias, as well, especially if it were a laser. Maybe it was a study or was done by a laser company, maybe it was a cryotherapy product, then there will be some bias there. That is not uncommon, and we need to critically read these types of documents.

Of the 10,000 articles that they found, they found 43 that really met their inclusion criteria. Of those 43, about 20 of them had some pretty strong bias, where they then narrowed it down to about 23 papers that had some decent non-biased outcomes in the paper. Basically, what they found was that the effectiveness of most of these interventions that I just described – ultrasound, shockwave therapy, etc., the outcomes or the effectiveness were rather unclear.

Another recent study, a systematic review, looking at a lot of different things that we probably have in our office, again, the outcomes really aren’t that beneficial, possibly. We just don’t know if it is that effective. Keep that in mind as you reach for your next laser, your next cryotherapy, but really, the proof is in the pudding. If it helps the patient, great. If it does not, you should not be surprised and you might want to consider them another type of intervention. One of those interventions might be foam rolling. Foam rolling was really common; it is rather inexpensive to offer in your office. The compliant seems to be generally pretty good.

Here is a 2017 study, not long ago, and they look at the effectiveness of myofascial release through foam rolling. It was a narrative review, and they found that foam rolling seemed to improve range motion. Great, that is what We are trying to do. If the range of motion was one of those negatives that were going to prevent our patients from recovering from the rest of their rehab, that is great, then foam rolling has the role.

Foam rolling will impossibly improve range of motion, but there may not be any effect on strength or performance. I don’t understand why they’re measuring performance because to me, range of motion certainly is a performance indicator, but there seemed to be no clinical trials addressing myofascial pain, which blows my mind. It should be a pretty easy study to look at myofascial pain patients and just intervene with foam rolling and see if it helps them. I think this might be a study that I might have to encourage my fellows’ review.

Let us look at some of these foam rolling techniques. This is more for the lateral hip, really simple. The only complication is maybe for some of our aging patients to bear weight on their upper body and get into this position, but I would assume that most of our athletes should be able to assume that position. Looking at more of the proximal anterior medial thigh, maybe some of those anterior abductors could certainly benefit, as well, from foam rolling. There’s certainly a need for increasing trials for looking at foam rolling for myofascial pain syndrome.

We will look at a couple more videos here for foam rolling. Here, we have something more of a proximal anterior hip, which works great for that rectus femoris that we are showing from MRT techniques on earlier slides. I’m a fan of this. I think a lot of my chronic low back pain patients have some chronic shortening of the rectus femoris, and this is a really simple technique for them to implement, especially for my athletes. When they come in, we have them foam roll almost right away before we can start doing some adjustments. Foam rolling for the posterior chain, for the posterior calf, bend down to hip, and cross from the hamstring, again, fairly effective. Again, it is just a little bit more challenging position for some of our aging patients or if they’ve got a proximity problem, as well, but again, most of our athletes should be able to get into these positions.

Now, I like to put a little curl on some of these key things that I think are important. I think it is very important that our patients go home with knowledge: some things, ideas, and lessons and exercises that they can do at home. Home stretching, I think, is one of those key things that we should be sending our patients home with. Home stretching, I think, is really important. A really simple piriformis stretch while they’re seated in a figure forward position, good chest up posture, leaning straight forward at the hip, not so much at the low back, getting a good stretch in the piriformis.

Another picture down here at the bottom is a stretch for a hip flexor. It is really important that the knee does not go past the toes, so that might put a little bit more pressure on the anterior knee. We want to be cautious of that. We want the shoulders to be over the hips, not leaning forward at the waist. We want the shoulders over the hips, and then we want to instruct the patient to push their hips forward and focus that stretch a little bit more on the hip flexors. That is why we also want to always review the stretching with our patients on that second or third visit, to make sure they are doing things right.

I think active stretching is very helpful. What is active stretching? Well, earlier, we showed PIR of the hip or the hamstring muscles, the posterior chain, probably reached for PIR. This is an active stretch, so the patient can very easily lie in their bed or lie on the floor, we have them keep their knee straight, dorsiflexor ankle just like we did with the PIR stretch and we have them actively contract their hip flexor mechanism. They actively contract this, strengthening and bringing their hip into flexion as far as they can, until they feel a stretch on the back side, on the hamstring.

One theory behind this active stretching is they are actively contracting the hip flexor, which, theoretically, should cause a reciprocal inhibition of some of those hamstrings and posterior chain muscles. It is a very effective stretch. Oftentimes, if they have got very tight hamstring muscles, for example, in this case, their hip flexors are probably weak, as well, which, then, this active stretch, not only is lengthening the hamstrings but is maybe, to some degree, strengthening and conditioning the hip flexors.

Here is another example of another abductor stretch as we are forcing this one leg into abduction. There’s a whole book and a plethora of different stretches that we can certainly consider for our patients.

Now, one of the considerations, as well for our patients with removing the negatives is neuromotor control. If you would remember from the hip video you probably watched on hip assessment, you saw a close-up. We are talking about Ianda’s hip abduction test, we saw that when he was trying to hip abduct, he was getting early engagement of his hips. The lateral paraspinal muscles and the pelvis was starting a hip hike before he was even going into hip abduction. In other words, he was not controlling his pelvis very well.

Here is how we were correcting some of that neuromotor control. We were having him actually push against the provider’s hand, so he is actually pushing his pelvis, his hip joint, inferiorly, and then while applying pressure against his hand, he was then abducting. What you will notice is that his hip, his pelvis, does not hip hike nearly as early as what he did earlier when we were watching the functional assessment video. This was part of our assessment, actually. When he was coming to our clinic, we were including this as part of the treatment plan, have him push into his hand, and then work on this neuromotor control. We always want to think about what we can do to send the patient home with a similar exercise.

We found some programs or elastic strappings, the CLX strap. We had him put his foot into this loop. He would then provide tension; he was pushing his heel downward just like he was doing it to this provider’s hand. You are pushing against the resistance of the TheraBand. While he was pushing against the resistance of this TheraBand, he was going at the abduction.

What is happening here, from a neuromuscular perspective? Well, we get better engagement of the hip abductors, and what is happening with maintaining the pelvis in this depressed state, especially above, is that the opposite adductors or the downside abductors are contracting, holding the pelvis into that depressed state, and not engage, so we constantly see these cross patterns happening. Again, with him pushing his heel inferiorly, we are getting increased adduction contraction, which is helping with stabilizing the pelvis with his open chain hip abduction, and then the hip abductors are able to contract more effectively.

There are a lot of different interventions that you probably have in your office, instruments, such as mobilization. Certainly, you are adjusting the extremity in the hip, in this case, maybe doing some other therapy or strapping techniques, kinesiology taping, biomechanical taping such as dynamic taping, and maybe some other passive supports.

Let us just look at some of the literature on this. We might have covered a little bit of this with the foot and ankle if you recall back, but this was a systematic review looking at IASTM. I remember the IASTM, Instrument-Assisted Soft Tissue Mobilization, is fairly new at the time of this recording. It really became quite prevalent in the ’90s. I know guasha has been around for probably centuries, but not much regarding literature or research on the topics until about the ’90s. This is a systematic review, and I believe it is about 200 abstracts and narrowed it down to about seven randomized control trials.

Certainly, one of the complications is that these randomized control trials were not very similar; there are a lot of differences between the studies, so it is really hard to do a systematic review on these studies. The outcome was that there was some evidence to support the ability to increase short-term range of motion. Like foam rolling, there was some benefit from range of motion. Again, it could be one of those negatives of preventing the patient from advancing into rehab is because their range of motion isn’t improving. Again, foam rolling, IASTM might benefit to help that patient with their range of motion deficits that they might have.

Everybody’s eyebrow should perk up a little bit. When we look at the manipulation of the lower extremity, what type of evidence do we have for the benefits of manipulation? This study goes back a little way in 2009. It was a merger review, and they looked at roughly 39 citations. There were quite a few citations that they went through, but they narrowed it down to 39 citations. They found that manipulation of the lower extremity was safe, so that is great information that we can share with our patients.

The lower extremity where the joint was hypermobile, where hypermobility was identified, it may be appropriate to clearly include manipulative therapy. With joint hypermobility, in order to identify that, you need to be really good at motion palpation. Motion palpation is a lot of different complex combinations of movement, especially with the hip. We know the hip can circumduct, which means it goes through all different types of motions. We can have hip flexion along with internal rotation and along with abduction. Just the combination of those three movements is going to influence the capsule[?] in a way where we might find a restriction. We need to be able to be quite savvy in motion palpating the hip joint in complex motions, and maybe not just in motion, but also adding muscle contraction. Maybe we need to do weight-bearing motion palpation, which means probably weight-bearing manipulation, as well.

All of this lower extremity motion palpation hands-on experience and training come with our hands-on modules. With the CCSP through Northwestern and the ICCSP or the International Certificate for Chiropractic Sports, the hands-on modules take you through the step-by-step on how to assess an athlete in a complicated manner, so be sure to attend those hands-on courses.

Lastly, the study showed that it appears that manipulation therapy with stretching, that is why We are talking about myofascial release and other tissue interventions, if we do manipulative therapy with stretching, it seems to be superior, the combination of those, versus just providing one of those therapies by itself. Again, the practical application to the study from 2009 is that if We are looking at the lower extremity kinetic chain, then we not only want to do just manipulation, but we certainly want to implement some sort of active care exercise, hence, our discussion on rehabilitation. It seemed to be beneficial, especially for knee osteoarthritis.

If you follow along with this entire rehabilitation module, you will probably see me discuss the slide along each region as we get into the knee, and it was beneficial for the ankle, as well, but not so much. It didn’t seem to be as helpful for hip OA, but it really depends on the severity of the osteoarthritis. Clearly, in earlier stages of hip OA, my personal experience was that it was very beneficial. As a hip joint becomes more arthritic, it does become pretty complicated to manage that patient.

As we finish this lecture, I want to thank you for attending this Tier 1 conversation with hip rehabilitation. The next tier, of course, is going to be addressing hip stabilization exercises.


1.5.1 - ICSC05_Rehab of Hip Tier 2-4

English Direct Download PDF – ICSC05-1.5.1 VIEW Rehab of Hip Tier 2-4 – 37.14.mp4

ICSC Lower Extremity Module 5
Section 1.5.1_ICSC05

Tier 2 to 4 Rehab of Hip
Instructor Timothy Stark
Video Lesson: 37:14

Tier 2 exercises primarily include two components; Aerobic Conditioning or Cardiovascular Conditioning and Static Stabilization.

In Aerobic Conditioning, there is plenty of evidence to show that as an injured athlete is healing, we can improve cardiac output and improve systemic blood flow. Their healing time decreases and they tend to have a more successful rehabilitation outcome as well. If we are discussing hip rehabilitation and Aerobic Conditioning for the hip, we may want to consider aerobic conditioning exercises that don’t necessarily include a lot of hip motion, especially if they are simply just coming out post-surgery or there is general pain within the hip active and passive ranges of motion. We may want to consider exercises such as using the Concept 2 rower and only performing upper extremity exercises to improve cardiac output. Another great intervention would be performing a seated cycling exercise such as a Schwinn Airdyne where there are generally pegs that are right around this area where the mouse is. She can put her feet up in this area and then simply use the upper body portion of that intervention. Again, Cardiovascular Conditioning is a great consideration for Tier 2 rehabilitation and it is very important for rehabilitation outcomes.

The second component that we are going to now discuss over the next main slides is Static Stabilization. What I mean by Static Stabilization is that the hip joint is co-contracting, in other words, the stabilizer muscles around the hip joint are all co-contracting or co-activating. Multiple lecturers use different languages, but the hip joint is not necessarily moving. I am a fan of closed kinetic chain exercises, especially for the lower extremity. We have a couple of exercises. As we see in the picture on the left-hand side, the supine bridge exercise. It is very common. The lumbar spine, pelvis, hip, and even knee stabilization exercise. You can see how she has a stable base with her hands flat on the table. She has elevated her hips. The close chain side, as we can see in the mirror here, is her left side. She is required to co-contract the muscles in and around her hip, as well as co-contract the core to maintain this position. If this patient was able to perform this exercise well, another exercise that we could make a little bit more challenging is to decrease the stability of the base. The base stability as you could see, she still has her hands flat on the ground, roughly about 30 to 45 degrees of abduction. She is still pretty stable here, but we have now added a ball underneath her legs, which increases the instability. It is making it more challenging to co-contract her hips and core.

My goal for my athletes when they are performing these very basic Tier 2 types of exercises is to be able to maintain a static hold or static co-contraction for 90 seconds to 120 seconds. If they can do that, they have already reached moderate fatigue, then we can make things more challenging for them. If she were to march in place, for example, performing this supine bridge in several repetitions or marches, it does not appeal to me. I am more concerned about the time when we are talking about the stabilizers of a joint. We are more concerned about developing motor endurance. We are interested in reaching 90 seconds to 120 seconds. Here is a video example of how we will perform a supine bridge. This patient or athlete has his hands roughly out at 30 to 45 degrees creating a stable base. He brings his feet in, and he elevates his hips by extending his hip. You can see that we have the close chain side on the right-hand side. Now, he is going to switch and now we have the closed chain side here on his left-hand side. This is an exercise where he is marching back and forth. We will play it just one more time. He is marching back and forth and I am more concerned about the closed chain side. You can certainly just sustain and maintain a closed contraction exercise or pull just on one side and not march back and forth.

My objective is 90 seconds to 120 seconds, where he can march back and forth if we are rehabbing the hips. If we are rehabbing just one hip, 90 to 120 seconds upholding just that one hip. Now, to make things a little bit more challenging as you will probably see through the next two slides, it is to bring his hands closer to his midline or even bring his hands up over his head. That will decrease the stability of the base. Another great closed chain exercise is this 4-point position. We call this a 4-point position that we are going to see more so when we get down to the lower right video. He is in a 4-point position, with two knees and two hands, he is in this 4-point position and what he is going to do is raise one hip. It might be easy to believe that the hip we are exercising is the hip that is elevating, but that is not what our objective is. The hip that we are exercising is the closed chain hip. Because the closed chain hip, which is going to be his left side or the one in the mirror, is co-contracting as well as orchestrating its ability to co-contract with the core. That is important for the normal function of stability, it is to have lumbar pelvic stability that is also well-coordinated with the stability of the hip. Here, we have an athlete who has knee inflexion. Not a lot of our athletes have an inflexion, but we are going to show you more closed chain hip extended exercises.

Again, he is in a 4-point position, going to a 3-point position. The closed chain side is the side that we are more concerned about. The outcome goal is 90 seconds to 120 seconds. What if he fatigues at 30 seconds? We will help that out with something that he is going to continue, including his exercise routine or rehabilitation program. He will continue that exercise until he develops enough neuro-motor endurance and until he reaches 90 seconds to 120 seconds. Here is another exercise that is a little bit more challenging. You can see that this is going to be more consistent with the Bird-Dog type of exercise where he is raising one hand and extending one hip. He is going into a 2-point position. It is pretty challenging, but again, we are more concerned about the closed chain side. If we do have an athlete who has a left hip issue, it is common in my experience, that the athlete probably has had some right shoulder issue as well. Because of the kinetic chain diagonal pattern that we often see in movement throughout the sport. If we have an athlete that does have that complex issue with contralateral hip and shoulder issues, this is a great exercise for establishing co-contraction stability.

Earlier, we mentioned developing static stabilization of the hip while in extension. Here are a couple of videos that we are going to show you now. I am a fan of slosh bars. I am a fan because this is simply a PVC pipe or pipe that you can get from your plumber. What I placed in here is roughly anywhere from six pounds to about 16 to 18 pounds of water. For my international students, you’re going to have to convert that to kilograms. But anywhere from six pounds to about 16 pounds works well. I would not go heavier than that or the weight of the slosh bar just becomes too harder to handle. You might be more prone to injuries. Quite honestly, 16 pounds is hard. High-level athletes are incredibly challenged with simply 10 to 12 pounds of water. The ends of the slosh bars are sealed, and this is roughly five feet long, just to give you an orientation of what the slosh bar is made of. Here, we have a slosh bar, and it is close to his core so it should be a little bit easier. It is important to understand progression. You can see that he started with his feet wide, and now, he brought his feet in narrow. If he is challenged to just stand there with his feet narrow and holding a slosh bar while these waters are trying to develop a balance, we are just going to hold him there. We don’t want to advance him. We don’t want him to fall, especially if that proprioception is efficient.

If he can stand with a pretty good balance with his feet together, we can ask him to raise one leg and balance on one leg. Again, we are more concerned about this closed chain side developing a well-orchestrated and coordinated manner of balance and stability between his core and left hip. We are just going to fast-forward here, and we can see that he is trying to balance this water while he is co-contracting on that hip. Now, if this patient can reach that simple goal of 90 seconds to 120 seconds with hardly reaching moderate fatigue, we can make it more challenging. As I said, progression is very important. How do we progress this to another level that is not too challenging, but just a little bit challenging for him? Well, let us add some movement. Let us add some movement on the upper body, which is going to result in that water wanting to slosh a little bit more and increasing the challenge of him being able to co-contract his core in conjunction with co-contraction of his hip. You can also appreciate the entire lower kinetic chain. It would include the ankle and knee. As you continue with this rehabilitation module, we will get into knee rehabilitation. You are going to see a lot of the similarities like this. Now, this was an exercise brainstormed by one of my students. He was doing this across the room when I was teaching rehabilitation and I thought, “What is this crazy student doing?” As I saw him and I played around with it, I do like it. We just call this an offset slosh bar.

We now have a lot of the potential weight of about a 12-pound slosh bar all to one side, which loads up the core a little bit more progressively on the opposite side. His right QL, for example, is a little bit more toned if you will when he is trying to co-contract his core. This athlete is also raising one leg resulting in a good closed kinetic chain balance. We can appreciate that our athlete is under a lot of different asymmetric loads. This is a good example of how we can implement that in a strategic manner. The outcome goal for him to stand in this position would be 90 seconds to 120 seconds. If he can do this well, we can progress. How do we progress on? As I said, progression is very important. I said that many times, so you are probably going to see that in the quiz question. It is important because this is how you proceed in a safe and effective manner for your athlete. Let’s talk about some progressions. If we are going to do a wall sit exercise, for example, we might start with the patient’s back against the wall and maybe her hips and knees at roughly 35 to 45 degrees. We will have her co-contract her core with co-contraction of the hips, knees, and ankles, and hold that position. The outcome goal is 90 seconds to 120 seconds. If she can knock this out of the park with very little fatigue, we will have her lower herself on the wall to 90 degrees. Where her hips and knees are at 90 degrees and hold that position. If she can do that very well for 90 seconds to 120 seconds, we can decrease the stability of the base even further.

These are all Tier 2 exercises still. How do we decrease the stability of the base? We can put her feet on an unstable surface such as the cushion of your couch or a pad that is a little bit softer. Or we could decrease the stability of the wall and have her place her back on a gym ball. She truly must increase the co-contraction ability of her core and her hips when she is on a more unstable surface. These are all Tier 2 exercises. Progressing onto Tier 3 would involve adding more range in motion of the hips [inaudible]. We are adding a range of motion on the hips and knees. We are going to continue this discussion further in the next video, but you could see this athlete has a little teaser here. He is performing an exercise that we were doing here, but now we’ve added some movement to the hips and knees while he is having to co-contract his core and knees. Now, you did notice that he started with his hips rather wide, right? His feet are rather wide where he was more stable. We will say that he was able to knock out 90 seconds to 120 seconds easily, so then we want to make it a little bit more challenging. We brought in his feet, decreasing the stability of his base, and making it more challenging. The last slide here is just to introduce something that we will talk about and demonstrate a little bit further in the next video and that is vibration.

Vibration plates are fairly common. There is fair evidence to show that these vibration plates do increase muscular tone by stimulating the muscular spindles or muscle spindles. It may benefit some of our patients who are very proprioceptive-deficient such as our senior population. Now, I would not put my grandma on a pad such as this without any type of protection. Most of the vibration plates you see would have some bars where they can help them out to balance. We will conclude that in the video here with Tier 3, we are discussing mostly something that is discussed and titled Dynamic Stabilization. Dynamic stabilization of the hip involves co-contraction of the hip muscles in coordination with the core, but also while the hip is dynamically moving through a range of motion. Of course, we know the hip is very mobile, it can circumduct. It can go through all of the planes; transverse planes, rotational planes, sagittal planes, et cetera. We want to make sure that the hip is stable first and coordinating well with the core in these multiple planes that we will be discussing in the next few slides. As we progress onto Tier 4, Tier 4 discusses more on building strength on that stability.

Tier 2, we talked about Static Stabilization, the hip joint remaining stable when it was also not moving. In Tier 3, we are talking about the stability of the hip and core, while the hip is also moving through a variety of ranges of motion. As you can imagine, performing just a simple squat exercise from a hip extended position to this hip flex position, it is going to require the hip to maintain some level of stability in conjunction with the core stability whilst it is moving through that range of motion.

If the patient finds that squats are very easy to do, reaching that 90 seconds to 120 seconds pretty easily, we can have the patient progress to a single-like lunge. if they can perform 90 seconds to two minutes easily with the single-like lunge, we can decrease the stability of the base as we see here. These products here are from TheraBand and Performance Health. This is a pad that is not as stable as the ground would be. If the patient was able to progress easily, 90 seconds to two minutes on this, we will progress him along these more challenging pads which creates less stability. That will be making it more challenging. We can see that the athlete here has a little bit of a wiggle right in his core particularly, maybe a little bit of wiggle along the knee and hip as well. This is something that we will continue to monitor, assess, and make sure that he is stable before progressing. Earlier, in the Tier 2 lecture, we finished briefly discussing the vibration pads or vibration platforms. The evidence is decent regarding showing that it tends to balance out the tone if you will around a region. In this case, we are talking about the lower extremity, and even more specifically, the hip. What we are going to see in this video is this athlete on a vibration pad. He is pressing the on button and the vibration pad is going, and he is going to perform a little step up. These arms or little bars here are there to allow your patients to stabilize themselves if needed. This athlete is just challenging himself quite a bit by doing a step-down or step back while on this vibration pad.

You can see that there is a fair amount of motion on his ankle, knee, and hip. It is probably a little bit less on his core compared to the previous athlete, but right there in his lower extremity, there is a little bit more instability. My goal is for him to be able to perform this for 90 seconds to two minutes. I do not care about the number of repetitions. I just want good, slow, and controlled stability. If we found out that his knee was going into genu valgum or his hip is going into internal rotation quite dramatically, we can facilitate external rotation of the hip by taking a TheraBand and strapping it onto the bar. You can see that he is pushing out against the pad, firing extra rotators on the abductors at the hip, which might retrain the neuro-motor pattern of the hip while performing this challenging exercise. Those exercises can be done without the vibration plate, but we are just including the vibration plate. We are showing you just another concept of rehabilitation. Another concept of rehabbing the hip in this dynamic stability manner is to have the hip joint move, but not in the sagittal plane as we saw in the previous videos. What we are going to do is have the hip joint move more on the transverse plane. What we are going to be doing in a closed chain pattern, we are going to have the pelvis rotate over the top of the femur that should be moved. Here, we have the lower extremity, which is not technically necessarily moving. We have the hip joint, the acetabulum, moving over the femoral hip. This requires an incredible amount of co-contraction and stability of the core and hip. It is an exercise that should be implemented for all our athletes. We see this activity in a variety of different sports.

You can see that he is grabbed some Theratube in here now, just to encourage a little bit more unilateral resistance while he is co-contracting his core and hips. We will talk about unilateral resistance a little bit more in the upcoming slides. We can make Tier 3 Dynamic Stabilization exercises as dynamic as we want. Here, we have a slide board. This is a slippery surface and she is wearing special slippers that allow her to slide across the slide board. As she is pushing from one side to the other, she is catching herself, decelerating her body, gathering up her mass, and then pushing it again across this direction. Just that pushing motion, the sliding motion, and catching at the end and decelerating herself, are activities for her hips, core, and knees. They are doing that on a regular basis throughout sport and more so in sliding sports such as ice hockey, but similar motions in a variety of different sports. So even while she is translating that across a slippery surface, the amount of core and hip stability is quite elevated. Now, we talked about this transverse plane when we were on the vibration pad. If you have the ability to have them on slippery surfaces, and quite honestly, if you just have linoleum or a tile floor, this also works pretty well. We will just have the athlete actively internally and externally rotate their hips by just sliding their feet in internal and external rotation while in a closed chain manner. It results in a pretty good co-contraction of the hips while dynamically stabilized throughout a range of motion, internal and external rotation.

Another Tier 3 exercise, a couple of my favorites, is monster walks. Here, we have a young athlete with a TheraBand around her legs. We can also place that TheraBand a little bit higher, but while she is walking around your rehab center or even sending this home as a home exercise. While she is walking around, the hips are actively having to contract and increase their tone a bit more into hip abduction while she is in the open chain state. When her leg is in the air, of course, the TheraBand is going to want to pull that leg in so we have to increase the tone a little bit on these hip abductors. They are very functional. She is in a great position. She is on her feet. She is going through open-close and open-close while she is walking around. This would be great for an athlete who has maybe glute medius and some other hip abductors that are just not functioning the way they are supposed to. I know there is a common exercise out there called the clamshell exercise that a lot of people love to prescribe to their patients because the EMG study shows that the clamshell exercise is very good for hitting the glute medius, but I just don’t see my athletes in that clamshell position very often. Even though there is an EMG study that I am aware of yet that showed that these hip abductors are as high level as the clamshell, I know from practical and anecdotal experience and outcomes that this works very well in a much more functional manner for my athletes.

Another very functional exercise going from a standing position to a lunge position is this exercise. Again, here we have an athlete that has a little bit of a deficiency in being able to maintain his knee over his ankle when he goes into this lunge position. One thing that you can do is implement some biofeedback. You could see that he is touching that glute medius and he can also touch his external rotators or abductors of the hip. You can create some biofeedback to try to re-establish a sagittal plane movement by keeping his knee under his hip and over his ankle. It works well. I have pretty good compliance with that type of exercise with my patients. Another high compliance outcome is using TheraBands. We are just on a different medium now. If he is turning in, we can tie this TheraBand to a door or just furniture and have him fire out against the resistance and keep the knee beneath the hip and over the ankle. Firing out, in other words, requires probably some hip abduction and external rotation. Increasing the tone and doing repetitions repeatedly will hopefully retrain the neuro-motor patterns. That is the outcome. I have a very good outcome with this type of intervention from a compliance perspective, as well as my athletes responding with appropriate stability, and eventually, strength when we talk about strength. We are not so concerned about strength. With Tier 2 and Tier 3, we are mostly concerned about neuro-motor control. It is very important as we progress with some more Tier 3 exercises.

Here, we have this athlete in a supine bridge exercise. There is a very wide base, 45 degrees out, and he is pulling a gym ball into his backside. This is a great hamstring exercise as well as a hip and core stability type of exercise. To make this more challenging, what we would want to do is decrease the base even further. How do we decrease the base? We bring his arms in. We are bringing his arms into his side and making it far more challenging. Some of you will recall that and some of you will already the answer. How do we know when we should progress from this to this? The answer is that magical 90 seconds to 120 seconds. If he can perform leg curls in this position for 90 seconds to 120 seconds hardly reaching moderate fatigue, he or she is ready to progress to a more challenging position. When this athlete can do it for 90 to 120 seconds in this position with very little difficulty, then we are ready to progress to another level. What is that next level? Advancing the arms over their head. This is pretty darn challenging. To put the feet on the ball, elevate the hips as high as we can. Ideally, on a straight line, but you can see he is a little bit low. It is a straight line from the shoulders, hips, knees, and ankles when he is out straight. I don’t care about the number of repetitions; I am more concerned about the time. If he can knock out 90 seconds to two minutes, you can add another progression, and ask him to do a single leg. We might want to train the athlete to do a single leg exercise by bringing their leg in and then elevating one leg and slowly returning the ball to the extended position.

You will notice that we did return him to his more stable platform, the stable base, with his arms out at 45 degrees. That would be my suggestion. If the athlete is able to progress well, in other words, reach those 90 seconds to 120 seconds, make him bring the hands in and elevate them over the head as we did earlier. Slosh bar, as I said, I am a fan of slosh bars. We are going to talk about slosh bars in a dynamic manner, in other words, the hip joint is now going to be co-contracting but also throughout a range of motion. Here, we have a slosh bar close to the axis and spine. He is simply doing a squat and he is doing a squat with his feet wide. If he is able to knock out 90 seconds to two minutes performing this exercise, you can bring his feet closer and do some closer-based squats and try to reach that goal of 90 seconds to two minutes. Another option is to have him perform lunges. The slosh bar is close to his core again and he is simply doing some walking lunges nice and slow and controlled. If his knee is going a little bit in front of his feet, I would prefer his foot to be more outward so that the ankle dorsiflexion is much lower on his hands and knee. Or we can have our athlete perform backward lunges as you can see there. Again, my goal is not to have him perform X number of lunges, it is to be able to perform this for 90 seconds to 120 minutes before progressing. Another progression that we can consider is performing an overhead squat. Holding that 12 pounds or 10 pounds of water, sloshing back and forth in that bar, and having him or her perform an in-place squat. We can start with a wide stance squat, and if the patient is able to knock this out easily, we can narrow the base and make it more challenging.

Another squat with a push press, just adding a little bit more complexity to the squatting motion that we saw earlier. You will notice that his hands are wide on the slosh bar. We can make it more challenging by narrowing the hands on the slosh bar, which adds more load to the core and hips as well in this context. If the patient was able to do well with this, you could even narrow the base of where she is standing. The outcome goal for this is 90 seconds to 120 seconds. As we saw earlier on the vibration plate with the other athlete, he was performing a TheraBand exercise, there is another version of it. It is on the stable ground without vibration. His closed chain side is his left hip and what he is doing is he is rotating his pelvis over the closed chain. The femur is not necessarily moving, it is the pelvis that is moving over the top of the femur. What he is doing is he is contracting the internal rotators against a unilateral resistance. This is a closed chain, which means his hip and core are co-contracting. We are working on the stability, but now we are working on the stability with a little bit of resistance. Now, we are starting to just progress a little bit in Tier 4, and Tier 4 is talking more about strengthening and not necessarily discussing neuro-motor control. We are just verging on some Tier 4 exercise with this. Here’s another motion of it, this working more on the external rotators. We are working on the right leg now and it is now in a closed chain pattern. His pelvis now is closed, in other words, his hip joint is in internal rotation right here. And then he is firing his external rotators to rotate the pelvis over the top of his femur. Again, co-contracting of the core and hip, but now we just add a little bit of a unilateral resistance.

It is a great way to progress. It is the later stages of Tier 3 before going into Tier 4 exercises. Another dynamic holistic exercise for Tier 3, working on neuro-motor control is a box drop. Earlier in the functional assessment video, we saw the athlete drop. When he dropped and landed, we saw his knees come together, in other words, he went into genu valgum. His lower extremities were unable to maintain a good and stable position. The stable position is for you to have that knee directly between the hips and ankle. In the case of the video earlier, the functional assessment video, his knees went into genu valgum. What do we do? We try to facilitate hip abduction. We have got a TheraBand wrapped around his knees, and he is having to actively fire against this TheraBand and firing up his hip abductors. You can see that compared to the earlier video, he is doing a bit of a better job of maintaining his knees in between his knees and ankle. There is a little bit of a wiggle there, especially on his left side, on our view, it is right. Nonetheless, done repeatedly, that should help establish some holistic neuro-motor control. Tier 4, we call it Mobilizer Conditioning, but it is a strengthening phase. Traditional strength training exercises are implemented such as performing a leg press. Some other Tier 4 exercises are using weights at the end of your limbs. As you can see, we are now talking about open chain exercises.

A lot of these strength-building exercises for the lower extremity are a mixture of either a closed chain where the feet are fixed or an open chain where the core can move. Here, she is working on some abduction on the left-hand side, she is working on the abductor. We are working on strength; this is not a neuro-motor control exercise. This is a strength exercise. It is very important to build that base of neuro-motor control before we start working on strength exercises. In the picture on the right-hand side, you can see now that she is working this down her leg, and she is working on the abductors by lifting this weight on the end of her leg. What are the outcomes? What are the goals? It depends on what sport they are playing. If they are playing a sport that requires high strength and high power, I would be looking at performing a strengthening exercise with lower repetitions. If she was participating in a sport where muscular endurance or strength over a long period of time is necessary like soccer or wrestling; a wrestling match is three minutes to five minutes, we might want to consider doing higher repetition exercises. Here is another example of an exercise for working on abductors in the picture. On the left-hand side, she is working on the abductors as she is firing that abduction against this resistance. You can see that she is balancing herself on this bar. Now, she is just turning the other way, and she is pulling into that abduction against the resistance of this TheraBand. It is another open chain exercise. Here, we have this athlete firing into hip extension as you can see in the mirror. She has this TheraBand strapped over her lower leg, and she is simply firing into it in an open chain manner with the hip extension.

She might want to use something for balancing. Now, she is just turning the other direction, and she is firing a hip flexion against a resistant TheraBand with her knees straight. With her knees straight, she is working a lot of her hip flexors. Now, she is flexing her knee and she is got the TheraBand wrapped around her heels, so it does not slip around too much. This might be more consistent with working the knee flexors or hamstrings. There are a lot of different exercises in fitness centers or gymnasiums where we have machines such as leg extensions or leg curl machines. This would work well also for developing strength. As we take our athletes through higher levels of Tier 4 strengthening exercises, the squat applies to that type of exercise. We might want to add some variety. Occasionally, our patients might be plateauing regarding their strength, then maybe we just want to add a little bit of challenge. Here, we see this athlete doing a front squat with elastics with added weight, and the weights are moving around a little bit. It creates a little bit of movement on this front squat and makes it a bit more challenging. With this athlete, we are going to back off on the weight because we are making the bar more unstable and adding some perturbations to his exercise, so he is not going to be able to lift as heavy safely. It is very important that we consider that. This is just simply a variation of a squat exercise that we could have our patient perform. With that, I thank you for your attention to this, we have now completed the rehabilitation of the hip.


2.1 - ICSC05_Knee

English Direct Download PDF – ICSC05-2.1 VIEW Knee C Foss 1.54.00.mp4

ICSC Lower Extremity Module 5
Section 2.1_ICSC05
Instructor Christine Foss
Video Lesson: 54:00

Welcome to Assessment of the Knee. Today we are going to be looking into how we assess the knee on and off the field, some treatment strategies for the knee, and then just really trying to kind of wrap your brain around how we might look at a knee differently in different populations. I hope you enjoy this lecture, as much as I enjoy giving it. The knee is one of my favorited lectures, so, hopefully, we will have some fun with it.

Let us just take a quick minute and do a little review of the anatomy of the knee. Since we are going to be talking a lot about the anatomical structures today, it is worth us just taking a minute, stepping back, and appreciating not only the anatomy, but the mechanics of the knee. We always describe the knee as this simple hinge joint, but really, the knee does not only flex, but it also  flexes and rotates. As it flexes, it kind of pivots on that medial aspect of the inside aspect here. This is why we see more medial injury, why more posterior horn of the medial meniscus tears, is that instead of that simple flexion that we kind of learned on how the knee flexes, it  flexes and kind of rotates on itself a little bit as our foot pronates when we are walking. So, really appreciating what structures can get affected with which mechanics.

We are going to kind of start looking at simple vectors of force that cause injury, and then we are going to tier that out to multivectors of force or fault lines, what I call, looking at a whole pattern of events that might cause an injury. But first, we have got to figure out how to laser focus your diagnosis for each particular structure. Let us begin with that.

Today, we are going to look at the evaluation, diagnosis, the treatment plan, and also the return to sport plan for the knee. Objectives for today are discussion of and looking at the anatomical structures, the mechanism of injuries, our evaluation protocols, injury assessment skills. Very important. I want you to really take those and practice those when we are done with the lecture today and kind of keep doing them over and over, so you get a feel of what normal and abnormal feels like. Functional mechanics in injury, physiotherapy protocols for the knee, and then the return sport plan. So, lots of things going on.

Let us start with the medial knee or the inside of the knee, which is the most injured structure in the side of the knee. We will look at why just a little further on. If we look at the graphic on the left side of the screen here, this is your medial collateral ligament. We think about which vectors of force cause a medial collateral ligament injury, and it would be a valgus force. The test we do for that is your valgus stress test. It makes perfect sense. Valgus force would be if somebody hits you from the outside, and this ligament stretched on the inside. So, understand it is kind of like that bow and arrow, where we hit on one side, and it stretches on the outside. Then this ligament on the outside would be the injured ligament. That is your medial collateral ligament.

Also appreciating the anatomy here on your medial side. This is the medial patellar retinaculum. This helps form that kind of capsule of the knee. It is an investment, like an aponeurosis of the vastus medialis muscle as it comes down. When you are near assessing a knee injury, we think about the major structure that is injured. But I want you to appreciate the other anatomy in the area that probably is also affected. We would be kidding ourselves to think that if a valgus force came in, and we got hit enough to tear this ligament, that nothing has happened to any other structure. So, this is why in this lesson, we are going to really teach you to do a full evaluation on each injury, and that way we do not miss anything. You know, you got hit from the outside, it is only a medial collateral ligament and that is it. I think we are kidding ourselves to think that. There are other structures here that we also need to look at. We therefore need to do a nice, complete evaluation on everybody.

Then if we also peel off this top layer here and get rid of this medial collateral ligament, we are left with this, which is your medial patellofemoral ligament. This is a ligament that when it is torn, you get a patellar dislocation. You can have a partial tear where it stretches, and your patella moves slightly laterally. In that instance, we can rehab that conservatively. But in the instance of a complete rupture, that becomes a surgical case. This ligament here is kind of like the check strap that holds this patella in place, right in the midline of the knee. We can track superior and inferior with quad contraction in that trochlear groove under it.

If we look at the lateral side of the knee, conversely, we can understand that the lateral collateral ligament, which is this little ligament here. There is also an anterior lateral collateral ligament, which is this little branch here, which we do not hear a lot about. But the new literature is coming out with some interesting facts on this anterior branch. Let us just put that to the side for a minute and let us just talk about the lateral collateral ligament, which is here, or fibular collateral ligament, depending on which nomenclature you learned. This would prevent a varus stress to the knee. In other words, if we got hit on the inside of the knee, and it bowed out on the outside and tore, a varus stress would cause that. A varus stress test would be an orthopedic test for that.

Again, here is the lateral patellar retinaculum or the patella. It is kind of that aponeurosis that is formed from the vastus lateralis muscle as it comes down and inserts on. Again, speaking to the fact that we really need to appreciate that there is lots of structures that are kind of affected with a knee injury. We really need to make sure that we are doing a good job at looking at all the structures that get injured in the area, and not just the one structure, the lateral collateral, because you see how tiny that is compared to this patellar retinaculum. So maybe some of this is injured as well. I want you to make sure you really grab that concept that we are going to be looking at all the structures.  This anterior branch of the lateral collateral ligament is quite interesting. Now, as I said in some of the newer literature, it is really speaking to the fact that it helps prevent anterior translation of the tibia. So that means the tibia sliding forward on the femur. When that is intact and tight, we have some assistance in preventing ACL tears. That is anterior cruciate ligament tears. We are going to look for that in the literature as it is coming out with some new kind of enlightened facts that we might not need to do a reconstruction of the anterior cruciate ligament if this is holding that tibia in place.

Then just appreciating the medial collateral ligaments from the anterior to posterior view here and understanding it, you know, the length of this medial collateral ligament, which is really known for scarring quite significantly. It is a wide band ligament and fibrous. When you get an injury to the medial collateral ligament, it is quite interesting. It loves to scar over. So really making sure that you are staying on top of keeping them keeping an eye on the status of the healing. I like to put an arch support in the shoe while we are healing with this injury so that the patient can have a little lift on the medial component. It does not pronate as much, therefore they do not stretch the medial collateral ligament. Scraping of this ligament during rehabilitation is important to making sure we are checking that scar tissue does not form. Scar tissue of the medial collateral ligament becomes more painful than the injury itself, and causes what we call prodromal injury or a long-lasting injury that limits them for a very, very long period of time.

I had an athlete that came in that had been able to participate in sports or run for one year and she was only seventeen. She had had a medial collateral ligament injury and just not rehab properly, therefore, it formed a lot of scar tissue which became more painful than the injury itself. So just keeping an eye on that way. A little clinical pearl regarding that medial collateral ligament and its rehab.

Looking at the menisci, medial and lateral meniscus from the anterior to posterior view too. I want you to really appreciate this trochlear space. We will call it the trochlear groove of the knee. We will look at that for patellofemoral issues. And then the pencil thin and a little bit more fibrous lateral collateral ligament not injured as much as the medial collateral ligament.

The anterior cruciate ligament is very, very commonly injured more in females than males. There is lots of research as to why we are seeing this increased predisposition for ACL injury. We are going to talk about that as we go through our case studies today and having some fun with that. I want you to really appreciate where these this ACL is sitting in the knee here and its relationship to the cartilage and its relationship to kind of the check strap, as this ACL prevents the tibia here from sliding forward. As you plant, if this is your tibia, the ACL stops it from doing this. It is kind of that check strap from pulling it back.

We think about the ACL injuries. You can have a contact ACL injury. In other words, if somebody hits your knee, and it pops out or ruptures the ACL. Or you can have a non-contact ACL injury. The non-contact ACL injury is the ACL injury where your foot is planted, your knees flex to 20 to 30 degrees, and then you internally rotate on that planted foot. That is the motion that the ACL is under the most tension, and we see rupture in a non-contact injury. These are the injuries that we are researching quite heavily right now because we want to figure out what are the mechanics involved that are predisposing somebody to that injury? If we think about that and we could really solve that puzzle, we can think about how to correct those mechanics in the preseason to prevent ACL injury. This is what we are going to talk about as we get further along. This is kind of one of my things that I love to do. I like to pre-screen athletes before the season, correct these biomechanical faults to avoid these types of injuries. That is something where I feel chiropractors can really jump in and be champions with, is that we have a good idea of movement of the body, and symmetry, and we can pick up the faults whether it is not only with the knee, but with the whole system, and we can correct these faults early on before an injury occurs.

We look at the left picture here of your ACL. That is normal. As compared to the right, that is a torn ACL. The ACL is called your anterior cruciate ligament, cruciate meaning cross. This is because it forms a cross between the posterior cruciate ligament and the anterior. That is why they are called cruciate. The posterior cruciate prevents the movement backwards, the tibia sliding backwards. The anterior prevents the tibia sliding forwards. They form that cross so they can check straps.

If we look at that posterior cruciate ligament here, we can really see it in green, how it comes back, and it forms that nice stable structure. Remember some of these slides you have seen in the biomechanics lecture that was just presented to you earlier. I wanted to just make sure that we went over it thoroughly because you really need to picture that anatomy as you are assessing. Understand what structure you are affecting. Thanks to Dr. Steve for giving us some of these previous slides to put into this program.

This is your posterior meniscal femoral ligament, not really talked about quite frequently. It attaches from the meniscus, the posterior horn here of the meniscus, into the femur for stability. And then here is your medial meniscus. And really understanding how that medial meniscus forms kind of that little shock absorption between your femur and your tibia. When we look at that posterior cruciate, we are going to be looking for a posterior sag sign. We are going to talk more about these orthopaedic tests as we get further on. We will demonstrate them to you. We will show you a full knee exam. That way, by the time you are done with this class, you are really going to feel confident with the knee.


This articular cartilage is a very important part of the knee when we talk about patellofemoral issues. Patellofemoral mal tracking, patellofemoral pain is the most common pain of all injuries, athlete and non. It is the most common complaint. If there is one injury or one pathomechanic fault that you really need to comprehend, it would be understanding this patellofemoral mechanism. What happens is when the patella does not track in this trochlear groove appropriately, it starts bumping up against these femoral condyles here, and then it starts wearing away this articular cartilage. But why that is significant is you might not feel pain until this articular cartilage is severely worn down and we get down to the subchondral bone. By the time they are having pain, they have already gone down the road of mal tracking for a long period of time. You need to unpeel those years of mal tracking in your rehabilitation concept. We will talk about that again as we get further along.

Here is that posterior and anterior cruciate. I said it formed a cross. There is a better look at that cross. And then your medial meniscus, how it forms a large shape C, and then that lateral meniscus is almost like an O shape.

The axial view here, again, is looking down at the knee. I want you to appreciate the medial meniscus here, the posterior horn of the medial meniscus, and the lateral meniscus. Also, in this view, we really can get a good idea of this medial collateral ligament from an axial view and the lateral collateral ligament. This is your patellar tendon, anterior cruciate, posterior cruciate, and your fibula.

Look at this wide space here of non-protected area. You can imagine with a valgus stress, in other words, someone gets hit on the outside of the knee while running or tackled here. That can cause a varus stress quite easily to this part of the knee. Therefore, we probably see more medial knee injuries than lateral. It is just a little more unprotected area on the medial side of the knee.

Again, looking at that superior view. We talked about the menisci as having white zones and red zones. Red zones are the areas that have high proliferation, a lot of blood flow, and they heal easier. When we see an injury to the white zone of the meniscus, the healing takes a longer time and sometimes does not occur to that area. Those types of injuries would be a referral to an ortho if we see a significant tear in the white zone. We can see we have a red zone here with good blood infiltration, and then kind of a medium healing capacity here. And then your lowest healing capacity would be these white zones.

The most frequently torn is the posterior medial aspect. Posterior horn of the medial meniscus is your most frequently torn meniscus here. Sometimes we get what we call bucket handle tears, and that is a tear where you get a tear of this posterior horn, it flips up and gets stuck in the joint capsule. When that happens, the patient’s knee will get stuck. Then we will have to kind of jiggle it and then we will be able to straighten it. That is a typical what we call a bucket handle tear. You can also get a bucket handle tear for the lateral meniscus, posterior horn. Those most times become surgical. Whenever we see getting stuck or a locking of the knee, we have got to go in and clean out that tear.

Here is just a different view of the medial lateral meniscus of the knee here. Understanding here is the lateral meniscus, and we talked about that posterior meniscus femoral ligament kind of holding that in place, and the medial meniscus here. The ortho tests that we use for those are McMurray’s test, Thessaly’s test and Apley’s test. I will tell you that Thessaly’s test is the most sensitive for meniscal injury. We will go over how to do that in a little while. McMurray’s test is also very good. But if we look at the literature for meniscal testing, we know that not no one test singly is the best test. We really need to have a good thorough history. We need to have a mechanism of injury. We need to understand past injuries. And then we also need to include our whole exam. That way, we can get a really laser-focused diagnosis.

If we move out to our muscular layer of the knee, we can understand this whole idea that it is unlikely that we just get one pure injury. Like, a medial collateral ligament. We have got to really know that there are layers of anatomy here. When we evaluate somebody, I want you to think about those layers and how they could be injured in that mechanism of injury or the way that that athlete was injured. So, if we just appreciate the quadricep complex here and our whole attachment of our adductor group here, Sartorius, Gracilis, and Semitendinosus, which is hamstring, and then your iliotibial band as it divests down into a little portion that goes off to that patellar retinaculum, and then down to Grey’s tubercle, where it attaches. We need to make sure that we are looking at everything when we look at a knee, is my point, with these muscular layers.

Here is the medial muscular layer here and understanding that this green structure is your medial collateral ligament. So, with an abrupt valgus stress to the knee where we injure this medial collateral ligament, we must understand that there is some injury to the structures that are superficial to it. It would make sense. This is your Sartorius, Gracilis, and Semitendinosus here right in a row, and then this is Semimembranosus back here. Do not forget to look at that medial hamstring complex. Also, assess that when you are assessing a knee injury. I think that a lot of times that is often forgotten.

Then if we look at that muscular layer of the lateral aspect of the knee, again, here is your iliotibial band and tract as it divests down into the joint capsule to attach on to the lateral aspect of the tibia. And then your foot extensor group here, your anterior tibialis and then your lateral collateral ligament, the anterior branch. And then we must also understand that we have your biceps femoris. Here that is coming right over that lateral collateral ligament. Making sure we are evaluating those hamstrings. This is your extensor digitorum group here and anterior tibialis. Extensor digitorum, anterior tibialis, bicep stim, IT band. Make sure you are assessing all those also when you are assessing the knee.

This patellofemoral articulation from just a different view. Understanding and appreciating this trochlear groove here, and how that shape of the patella, see the shape of the patella, is designed to slide in that trochlear groove and go superior and inferior with quadricep contraction. I tell my patients it functions like a monorail. It is got to glide in and out. Appreciating that when we have weakness of the vastus medialis muscle, this patella is going to start tracking laterally. And when that patella starts tracking laterally, that you get this inferior aspect of the patella hitting up against this lateral femoral condyle. Understand the lateral femoral condyle in most patients is larger than the medial femoral condyle. So, with that very strong quadricep group pulling laterally, and most times the vastus medialis muscle, the VMO muscle, not as strong as those, we get that Patellofemoral Mal tracking Syndrome. It used to be called chondromalacia a long time ago. Now we call it patellofemoral mal tracking more appropriately. This is what wears down this subchondral bone that we talked about earlier.

Our job is to kind of get this patella realigned with rehabilitation, different types of scraping and taping protocols, to try to get that patellar to drop back into the trochlear groove and adequately train that vastus medialis muscle. So really thinking about what fault patterns of our long mechanism can contribute to a weakened vastus medialis muscle.

Here is another look. It is my favourite look. The sunrise view of the patellofemoral articulation. I use this view a lot to kind of assess the status of that patellofemoral joint with somebody who has kind of like peripatellar pain. If you look at the picture on the left side, you can see that we do not have symmetry of this patellar in the trochlear groove. It is tracking quite laterally here. We are going to get what I call a kissing injury where it is kind of rubbing up against this lateral femoral condyle. You can appreciate in that picture that we can almost see a little spur forming on this lateral side, and that is that tracking spur from the strength of those muscles and the capsular pattern pulling on the lateral aspect of that patella. So, that becomes quite painful.

The picture on the right is a status post-surgical partial knee reconstruction of a recent patient of mine. During the partial knee reconstruction, they cut his medial patellofemoral ligament by accident. Therefore, it is an unsuccessful surgery. So, we do not have patellofemoral tracking. He still had the same pain he had prior to his surgery here. We did not fix the problem. This is an iatrogenic cause, which means doctor induced. I was doing his rehab. It was during COVID. He was coming in for me to do some rehab on his knee, and I noticed that his scar was just sitting more medial than most scars and I assessed him. I said, “I am pretty sure they slashed your medial patellofemoral ligament here.” When we did the sunrise view, yeah, that is not even a little attached. He had to go in and have a surgical repair to reconstruct this medial patellofemoral ligament. So just keeping an eye out for that can also tell us how we want to tape or how we want to treat them. We can do, and we will go over a little bit later, a McConnell taping to help pull this back over. That is a successful technique to use if looking at patellofemoral issues.

We talked a little bit about the iliotibial band. Understand that it has a relationship to the knee, and that you will get lateral knee pain when you have a tight IT band. When you are evaluating a knee, do not hesitate to evaluate the hip also and the foot, because we have got to really understand how to laser focus our diagnosis, and then how to open that diagnosis up to look at the surrounding joints, so we can see if there are contributing factors. Why did this injury happen? Or why does this injury not get better? Looking at that whole mechanism of injury and that faulty pelvic alignment. Is there a pelvic alignment issue? Then we need to look at footwear, very important, particularly for the iliotibial band. If we have excessive pronation, we are going to have an iliotibial band problem for sure.

Looking at the terrain. We will have iliotibial band injuries if the runner is always running on the same side of the road. Here in the States, the roads are kind of what we call a cambered surface, which means it is kind of home like this, so that when it rains, the rainwater trickles to the side. If we have runners that are always running on one side of the road, what that means is that one leg is longer and one leg is shorter all the time, and they develop this tibial band syndrome. We try to get them to run on a flat surface or if they are running on a Cambridge surface, to run out on one side and run back on the same side, not switch sides of the road. That way different legs are short and long in the same run to kind of even it out. That is helpful.

I want you to look at the structure, the function, the biomechanics of the joints, above and below, how it relates to the low back and the pelvic alignment. Do not forget to look at the foot and the ankle and the shoes. For now, we are going to start with just trying to laser focus a diagnosis, and then later on in the lecture, we are going to open up to how to kind of look at the biomechanical faults in somebody.

We will go back to how to assess a sprain. This is an example of ankle sprain, but it can be applied to any ligament. If we look at normal ligament architecture, it is kind of a nice vertical pattern here. A grade 1 might be some stretching and some small tears in the substance. A grade 2 would be a larger tear, and a grade 3 might be a rupture.

Remembering that the grade will also kind of be depicted by the amount of inflammation and the amount of joint gapping that we see with orthopedic examination. We are going to talk a little more about that as we get into the ortho evaluations. We can kind of appreciate that this is not going to swell as much as this. We understand that. When you see a whole load of swelling in an area, know that you probably do not have a grade 1 sprain. A grade 1 will have very little swelling to it, and that is whether it applies to the ankle, the knee, the shoulder, the elbow, hand, wrist. So, really imagining the amount of tearing that happens with each one and which ligament is affected.

What I thought we would do is to kind of make this a full immersion type course. We are going to present a case study; we are going to work through the case study. I want you to stay invested in the topic and I want you to think about what you would do. Then we are going to present the whole case and work through a case to completion. We have several cases we are going to be going through today. Let us get started. Think about what’s your first most important aspect of your patient encounter. When you are evaluating the injury, whether you are working on the field with a team or you are in your office, what is the component that is most important? Honestly, it is getting that mechanism of injury, the history of injury. If we think about what the biggest predictor of injury in the body is, the answer is always history of previous injury. Take those few minutes and really talk to your patient and figure out if they have had an old injury to this area or an old surgical repair that you need to consider when evaluating.

Let us talk about our first case. These are all real cases that are currently in my office, by the way. We are going to work through them together. A 17-year-old female reports with left knee pain and swelling. We think about things. First off, is there swelling there? There certainly is an injury, and if there is swelling, it is something that is newer. It is a 17-year-old female. We have to understand, am I looking at growth plates or not growth plates? Are growth plates closed? What’s the tanner stage of this athlete? How are they in skeletal maturation? And what activities do they do?

We are going to look at the onset of symptoms, she said it happened while playing soccer, and she said she was running to get a ball, she pivoted on that leg to move quickly to the right. She’s got left knee pain, she was planted on the left, she pivoted on that to go towards the right side. I want you to really imagine that mechanism of injury. She does not recall getting tackled or being near any players when it happened. She reports feeling a pop in the knee when she felt the pain. We have got to think about what structures are you thinking about already? What are you thinking about? She was planted on her left and she went to the right. If she is planted on the left and went to the right, then we are going to think about possibly medial knee injury. You should already be formulating these in your brain as you are hearing somebody’s history and what they are telling you. We are going to ask these questions to grade the severity of injury. Like, were you able to continue playing? Did you ever have this injury before? Did you get much swelling? Were you able to walk off the field? Did somebody have to carry you off the field? Were they walking into your office? Did they have a limp? Did they need crutches? All these things give you an idea of severity.

Now we need to start gathering our facts. She has a history of ACL rupture and surgical repair roughly one year ago on the opposite side, on the right knee. She is injured her left now. She reports that she completed 9 months of rehab and was released to play. You really need to understand that the ACL is an interesting structure. She underwent a right ACL repair and reconstruction, and she did 9 months of rehab. That is a long rehab, and it is quite a rigorous rehab. It is a painful rehab in the beginning to get that range of motion back after they put the graft in.

The interesting thing about swelling tells us severity. Bruising also is very important. When we think of bruising and think of fracture sometimes or severe grade 3 if it bruises right away. Bruising the next day or two days later, this is going to happen with a sprain.

I want you to think about your plan of action. What would you do now with this athlete? 17 years old, left knee pain and swelling, happened while playing soccer yesterday. She hobbled into your office today in a lot of pain. What is your evaluation protocol? Would it be this? Probably not. We want to think about when is it appropriate to do certain evaluation protocols and when it is not. It is not necessarily appropriate to do a whole functional evaluation on somebody that has an insufficient region. Whether it is ankle, knee, hip, shoulder elbow. We want to think about the appropriate evaluation at the appropriate time. We are not going to be doing functional movement assessment on that day with her.

That is her squatting. That is not that day. That was her squatting in her rehab before this injury. Before this injury, she was functioning quite nicely. Here she is again. Again, we talked about the left side. She had a right ACL injury. You can see on this squat; she is putting more weight on the right side. She feels a little more comfortable on that right, and that was that surgical repair. Can you see that little lean there to the right side?

We talked about that thinking about that mechanism of injury, formulating in your brain what structures you want to evaluate. We talked about the structures. Let us just keep moving forward. What are your thoughts? What is your plan of action? Here is her before this injury again, from the side view. We do tons of videos in my office. She had a nice squat, she had good mechanics. What we see for ACL is they go back too soon, and they go back with bad mechanics, but not the instance in her case.

What ortho tests do you want to include with this evaluate? What functional exam? We are not going to do a functional exam today. That is a trick question. What is your plan of action today for her?

This is a terrible picture right here. It is very important to talk about. This is on my Instagram post. On the importance of starting every knee exam with girth measurements, very important. We want to make sure that you are truly evaluating the knee. We are going to watch this little video of me doing girth measurements of the knee, and I think it is very important to include on all your initial knee exams.

We are going over why we do girth measurements for knee injury, in assessing a knee injury. If you think about the idea of taking girth measurements, it gives us an idea of the nature of the injury. Is it acute, is it sub-acute, or is it chronic? To do this, we take three locations of measurement. We take one intra-articularly and [inaudible] the joint lines. You are just going to find your joint line, and you are going to just take measurements, and you are going to compare these to the other side because we are looking for any edema. We are looking at size difference and girth measurement difference.

Then we are going to take it again, 3 and 6 inches suprapatellar. I have already marked out 3 and 6 inches on each of her quads here. Then I would take the tape measure. Just go ahead and check the girth measure on each side, 3 and 6 inches. Do the same thing here, comparing. Now understand, in the joint itself, I am looking for edema. I am going to look for it. This is larger than the other side. Up here, I am going to look for atrophy. The atrophy tells me a story about the knee. If there is atrophy 3 inches suprapatellar, that tells me there is an acute compensatory mechanism.  The VMO is wasting on a shorter time span. If there is atrophy 6 inches, suprapatellar, long-term compensatory changes.

If I have swelling in a knee, and they have atrophy greater than an inch in the squat as compared to the other side, I am really looking for an acute-on-chronic problem. Because the 6 inches is long-term compensation, and if they have new edema, that tells me we have a new problem. Then in that instance, I would need to go back and look at my whole kinematic chain and my gait cycle to see how she’s compensating that predisposed her to knee injury, or why does she have that long term compensatory change? Girth measurement really gives us a lot of information when we are assessing a knee. Consider implementing it into your exam.


As we move forward, very important component, I do this with every knee evaluation. You see the pen sitting in the middle. I have a pen and paper. I compare side to side, and I have my starting point. Then I will use this as my reference to come back to every 3 weeks or so just to see that we are improving and moving forward with kind of creating that harmony or the synchronicity or symmetry in the lower extremity.

Here is our exam procedure. We want to think about, for every extremity that you work on, what are my ticking points? What do I need to get done to get a good quality evaluation completed? MOI is mechanism of injury. What are my predisposing factors? Footwear? Was the terrain wet? Was it raining that day or snowing? Was the athlete not warmed up? What are my functional examination assessments? Inspection and palpation, range of motion, manual muscle test, passive and active ranges of motion special tests, neurovascular imaging, and referral patterns. Or like who you want to refer to or who are your favourites to refer to. So, really thinking about how do I put this in a jar or a can? So that every time I evaluate somebody, I am making sure I am getting all these ticking points done, because this is how you need to think about an evaluation. You know, you need to take some time and talk to your athlete about the mechanism of injury, predisposing factors, history of previous injury.

Functional assessment may or may not be done depending on the severity of the injury or the chronicity. If it is an old problem, we can do a functional exam. But getting down to every evaluation, always begin with inspection and palpation, and then move into active range of motion first, manual muscle tests, passive range of motion, special testing, neurovascular imaging, and referrals. Kind of think about that cascade that needs to happen, and that way you do not forget anything. Do everything the same.

We are going to look at some pics of assessment. This is our active range of motion of the knee, and our range should get up to 135 in a healthy knee from 0 degrees, all the way to extension. Then we are going to look at our ortho testing. This is our valgus stress test. Valgus stress test tests the medial collateral ligament. I am assessing the medial collateral. We are going to do it at 0 degrees, which is here, and then we are going to do it again at 30 degrees. This is diagnostically accurate 86 to 96%, and sensitive at 30 degrees. You will see this is 0. When you are at 0 degrees, the knee is locked out. We are going to have a tighter joint capsule. What’s going to happen is we are not going to get as much joint gapping when we are testing that knee. The more severe injuries are going to be seen at zero. When you get joint gapping or that joint opens at 0 degrees, know that it is probably a little more severe of an injury than if you get joint gapping at 30 degrees.

Here is our Varus Stress Test testing your lateral collateral ligament here, and this is a test at 0 degrees. Again, same thing, thinking about what structures could be injured here. That is a varus stress versus your valgus stress. Here is our valgus stress at 30 degrees. Again, we are going to get a more discreet tear or grade 1. We are going to see more at our 30 degrees. Then at 0, we are going to pick up those grades 2 and grade 3s for sure. Thinking about making sure you really have that knee locked out and you are not moving the whole hip; you are just moving the knee. We will show an example of this as we get further along. And then here is your varus stress at 30 degrees here.

Looking for joint gapping. Our meniscus tests. We are going to do McMurray’s test and Thessaly’s test. Thessaly’s test is more sensitive than McMurray’s test. McMurray’s test is great for understanding the sensitivity the patient is feeling as you circumduct the knee and bring it down. You will see in the next picture here on the left, you form a circle. Put your fingers on the joint line, you command control of the foot here, really making sure you have a good quality, have that knee at a 90/90 here, and then you are forming a big circle with the knee, not just flexing it down. This is a circle. You will see as I will show a video of it a little later, but in this range is where they are going to feel the pain or not let you bring it down to this much flexion if there is a posterior meniscal tear. We are looking for our posterior horns here. So really going slowly and making sure that we have a good idea of facial expression when the knee is bent like this. If they are kind of getting a little nervous or it is painful, get that meniscus diagnosis in the back of your brain.

We move on to our ACL tests or anterior cruciate tests. This is our Lachman’s test here. Again, we are going to be pulling the tibia, translating it anteriorly. You are just stabilizing that femur. You are holding the femur stable, and you are pulling that tibia anteriorly towards the ceiling just to see if you get any gliding, to see if that ACL is insufficient. Our ACL tests are Lachman’s, anterior drawer and pivot shift. This is a Lachman’s test. This is your anterior drawer test for ACL. If you notice that I am kneeling on the foot. I will kneel or sit on the foot because you do not want the foot to slide. Your fingers go to the joint line and drop down right onto the tibial plafond or plateau. Then you are pulling like you are opening a drawer. You are pulling that tibia out towards you to try to see how much gapping you get here. You are going to feel a clunk when you do it if the ACL is torn, but you are also going to see a lot of movement and anterior translation here.

Really understanding when you are doing orthopedic tests, though, that you are doing them bilaterally, and always start first on the uninjured side. It gives you an idea of ligament laxity in the patient first, and it also gains their trust in you. So always start with that healthy side, go through your orthopedic tests, then go over to the injured side and do your orthopedic tests. Number one, the patient is going to know what to expect, and there is not going to be so much guarding, and number two, you will have an idea of their status, ligament laxity-wise, so you know what normal and abnormal is. It is a very important part.

This is a good example of a posterior sag sign. We can see that the posterior cruciate ligament is torn, and it drops posteriorly. You can really get an idea of a function of that posterior cruciate, that we have this drop off point here in the knee, and that would be a posterior sac test or posterior sag sign.

Let us go back to our case study now that we ran through our orthopedic tests here, and we are going to see what our findings are in our ACL. She had a +1 inch plus edema around the midpoint of the left knee. She had good symmetry, a quarter an inch at both 3 and 6 inches, suprapatellar, compared bilaterally. We say within a quarter of an inch; it is decent symmetry. She has 1 inch of edema around the joint line. I know it is a new injury. Intra-articular swelling. When we think of intra-articular swelling, we think of two things that swell the joint the most in acute injury, and that is the ACL and meniscus. When you have a lot of swelling, think of those two structures, and then she has good symmetry. She rehabbed her old ACL pretty good because she does not have that 1-inch greater deficit at 6 inches on the opposite side. We have no long-term issues here, even though she has that history of ACL.

Medial joint line tenderness. If I am thinking about medial joint line tenderness, I can think of meniscus or medial collateral ligament pain with valgus stress at 30 degrees. It does not say zero degrees. 30 degrees are more discreet, medial collateral ligament injury. Negative varus stress, so lateral collateral ligament is in good shape. McMurray’s is positive for pain and clicking at the joint line. Positive for what? Meniscus. Positive anterior drawer. Anterior drawer is for ACL. Negative posterior drawer, so PCL is intact.

After you have run your orthopedic tests and you have these findings, you should be able to come up with your differential diagnosis. You should have an idea of what you think is going on.  Here is a look at her knee. We can see some edema even posteriorly. But that is an important picture, because most patients with a knee injury will come in and tell you that they have this pain in the back of their knee, and they are going to keep telling you about pain in the back of the knee, and that is, again, for mostly all knee injuries. But really understand that swelling goes where there is room to go. Thinking about the knee this pop fossa has a lot of room for your intra-articular edema to drop to. When we look at images, MRIs, we can see that that edema loves to sit in this posterior capsular area and the pop fossa.

I just want you to make sure if someone has posterior knee pain, that it is not an anterior knee problem, and all the swelling has dropped posteriorly, that is why they are feeling the pain there, and teasing out whether they truly have a posterior knee problem. You are going to have to make sure you evaluate both and know when to recognize the difference between edema pain from another injury or true localized pain from a localized injury.

Again, we are looking at the history of an ACL case. What is your different diagnosis? From that ortho evaluation, we should have come up with the unhappy triad. The unhappy triad is a term we call when we have injury of three structures in the knee. They happen all together because they are all interconnected, where we have an anterior cruciate tear, a medial meniscus tear, and a medial collateral ligament. Remember, there is a portion of that medial collateral ligament that divests into the medial meniscus. We do see those two happen simultaneously, very frequently. Because she was planted and flexed and pivoted off that leg, she tore her anterior cruciate.

Whenever you hear an athlete or a person tell you they heard a pop, particularly the word pop with a knee injury, think of anterior cruciate. Okay? Because it has a very classic sound, a very classic pop, when it gives way, and then again, not able to finish the game, too much swelling, too much pain, couldn’t bear weight. Those are all the things you are looking for.

If we think about this ACL reconstruction, there is a lot of research online about ACLs, and it is kind of one of the things that I like to read about. But we really are trying to understand why do we see more females than males? Why do we see the re-tearing of the grafts, and then also the contralateral side tearing, which was the case of this athlete? She had the ACL reconstruction last year, went back, did a whole return to sport plan, and re-tore the opposite side.

Let us talk about that. First, why females more than males for ACL? Females tend to jump and land more with their quadriceps. Males tend to jump and land more with glutes and hamstrings. If we think about the origin, insertion, particularly insertion of quadriceps, and how that might how that might contribute to ACL injury, we can think about the quadricep attachment down onto the tibia, and if we really have eccentric loading on that attachment of the tibia, we are going to facilitate anterior translation or put that under tension. We are already putting under tension the ACL. Whereas a male has attention on the posterior elements, which is his hamstrings, which is pulling that tibia back into alignment. So basically, the male is protecting themselves from ACL injury, and the female is predisposing themselves to ACL injury just based on this mechanism of action of how we jump and land. The biggest service you can do to your athletes is train your females postseason, how to jump and land, and then also do jumping landing drills. What we do is we video and analyse our athletes’ preseason jumping and landing and making sure that they are trained properly in the preseason to avoid the ACL injuries during the season. However, we do see graft re-tearing, sometimes if the graft is not too tight. But then again, for everybody, you can do everything correctly and they still retear, we think about why does that happen?

You have this athlete on your table who came to you the day after her game, who walked in with crutches, and you saw the edema, swelling and the pain. What is your plan? You are going to treat them that day. You are certainly not going to adjust with that type of positive anterior drawer and McMurray’s test is positive, valgus stress is positive. So basically, we are going to send out for an MRI, and send to an ortho for more than likely reconstruction surgery.


This is her post reconstruction. These are newer pictures. She is just come back to rehab. We can see the surgeon signature so nice here. This is the day after surgery here. This is a couple of days after surgery. I always like to look at the patterns of edema, and take note of the patterns of edema because it tells you where most of our injuries happen, you know? We think about where that healing is really taking place. When we reconstruct an ACL, they drill into the femoral condyle and they lace the ACL through to the medial tibial. So, they form a new ACL here. Therefore, we see the bruising here, and of course, here is the scope bandages. Always notice those patterns of edema and try to keep an eye on you know where we are at for healing.

Let us jump into our next case and clear our brains from that old one and start forward again. A little something different. I want you to take a moment to read it. This is a patient currently in our office as well, who’s a 35-year-old male with a history of cerebral palsy. He did have his meniscus repaired in this knee on his left knee one year ago. So, same knee injury. He tripped and fell on the carpet. He has high tone from cerebral palsy. He tends to fall quite frequently, which we are nervous about repairing his meniscus because we wonder how that is going to hold up with that type of gait.

Let us go through this case. What is your Evaluation Plan? Are you going to do something different? What would you do differently when evaluating a cerebral palsy athlete? We have a lot of para-athletes that we work with. What would you do differently? Are you going to look at the same structure? You are going to evaluate him differently? Will you alter your exam? We want to think about these things as we evaluate. No, we are going to look at the same things. But understand in this cerebral palsy patient, we are going to maybe see a higher tone, we might not get as much joint gapping or as much motion unless we can really get that joint to relax. If you have high tone, and the same thing when you are evaluating your patients that are non-cerebral palsy, you need to get them to relax to get a good idea of what’s happening with the joint.

I put a knee evaluation together for you; how I do it. Here is kind of my ticking points, what I like to look at when I am jumping in. And then I videotaped it for you so you can get an idea and maybe go over and over in your brain and practice running through a smooth evaluation. That way you get all the tip ticking points done and do not forget any structure.

Let us look at this knee evaluation. We are looking at quadricep contraction, and I am looking at the symmetry of the quadriceps. Does the patella track superiorly and inferiorly? Do we get good VMO contraction? Range of motion is next. I am checking to see. This is a meniscus test too. If they cannot flex the same amount on each side, it speaks to swelling and maybe posterior horn tear. I always kind of just do a Lachman’s. Here is my Lachman’s here. I do a very mild valgus, and then I will take a 30-degree valgus looking for more discreet, and then I will do a varus at 0 degrees looking at lateral collateral, and then a varus at 30 degrees looking at lateral collateral. Then I flex the knee up here, and I am checking the ACL with your anterior drawer. Then I bring it right into my McMurray’s for meniscus.

That is that circumduction I was telling you about. They are not going to let you bring that into flexion there. And then you check the medial and you check the lateral by rotating the foot in the opposite direction. Then I am checking quad and hamstring contraction here. Then I am checking the passive range of motion, trying to see how much flexion I can get them into. Remember when you are doing this, you are going to do it on the good side first and the worst side second.

Then I move into my palpation of structures: medial structures, lateral structures. Bend the knee and I palpate again the medial joint line, the lateral joint line, the patellar tendon, quadricep tendon, making sure I palpate the lateral collateral ligament, medial collateral ligament. Check for the popliteus here. I do both foot eversion and inversion even though the popliteus is just the one. I am finding a better result there. I palpate the pop fossa, the hamstring insertions, and the gastroc insertions. I have them check the hamstrings for strength, rec fem. There is your knee evaluation. It does not take that long to do a nice thorough knee evaluation. You can run through that quite nicely with ticking all the structures off.

There is another portion of the exam that is here. This is called your Pivot Shift Test here. I bring the knee here making sure they are passive. This is another ACL test. A lot of people do not like to talk about this test. This is an older school test, but I like to do it. That pivot shifted right there, the tibia will derotate when you get them into extension. Redoing a McMurray’s test just to get a better idea of it. We are going to watch it again. The first portion of that test is the bounce home. Bounce home is when you let go of the pop fossa and let the leg drop into extension. That bounce home test kind of tells me… If you are not really finding a whole lot on somebody, let us show you the bounce home. Really making sure they are nice and relaxed here. There. That is a bounce home test right there. What I am looking for is do they have any pain? Are they sensitive? Because even in the most discreet knee injuries, that is going to be painful. If that is not even a little painful, then I am really going to start my hunt to see what’s going on and why they have pain.

This test here is Thessaly’s test. This is the one that I said was the most sensitive for meniscal injury. Basically, they are going to stand. Holding onto your hands, they are going to flex about 20 to 30 degrees, and they are going to rotate on that foot. You are just kind of loading and grinding the meniscus, you can see why it is such a sensitive meniscus test. If I cannot find a positive meniscus with McMurray’s or palpating the joint line, I always stand them up and do Thessaly’s test. It is a nice exam so that you really can pick up most meniscal injuries. Let us watch that one more time. This one is really important.

Now you are building your knee exam. Let us go back to our case study. Here are your findings. I want you to read them and just think for a minute to see what you think is going on. He is ambulating with the straight leg. Is that CP related or is that pain related? He has edema. His pain is over the medial patellar border. This area here is where all his pain is. He does not want to flex his knee because it makes him nervous to flex it, which is a big red flag. His medial collateral is negative, lateral collateral is negative, anterior drawer is negative, negative posterior sac. Okay, so what are you thinking? What structures are you thinking about? I worry about this medial patellar border here. When someone has pain here, and they do not want to bend their knee, I think of patellar dislocation. They are going to tell you it felt like it popped out, and when they straighten their leg, it pops right back in. It is like a subluxation. That was my suspicion with him. He did tear his MPFL, medial patellofemoral ligament.

What is your treatment plan for today? He is sitting in your office on the table. What is your plan? He’s a bit of a crossfitter, and he is like, “Can I work out?” What’s your plan? I love when people say that when they are laying on a table looking like that. What’s your plan? What are we doing? I want you to think about how you are going to guide patients with injury and how you are going to direct them about training and not training. Remember, when we are talking about athletes, sometimes you need to think about goal setting, and we need to think about communication, which is very important. But for that day, it is palliative care. For that day, it is ice, low level, maybe interferential current type stims, elevation, and then wrapping and bracing in full extension until we can get him to get to a referral.

When thinking about this case, does your evaluation add up to the pain? That is for all the cases that you are going to see. I want you to think about your diagnosis. Does it match the mechanism of injury? Does it match the patient’s complaint? Do all the answers get satisfied? Do all the questions get answered? I should say does it answer the why? Why did it happen? That is your functional evaluation question. Not only do I have a medial collateral ligament injury or a patellar dislocation, why did it happen? If we think about a CP patient, they have very high tone, and with very high tone, that is very strong quad contraction. The three muscle, lateral quadricep muscles versus the very weak vastus medialis is not much of a competition. You throw into it a force of tripping, and there goes the MPFL. The medial patellofemoral ligament tears easily.

This is him post-surgically here. And then this is the first day off with the wraps post-surgically, just checking the wound. Sometimes what surgeons will do if the surgeons are at a distance from me, and I refer to them, they will send the patient back for me to keep an eye on them post-surgically, just making sure the wound is healing without signs of infection and getting the adequate passive care at home and rest that the patient should be doing, so that way, it avoids the patient doing a several hour commute in a car just to look at the surgical site.

It is very important that you understand the protocols of the surgeon if you are going to do this follow up type of work. Knowing if the surgeon wants this patient to bend his knee or keep it extended, and the whys. What is his plan? I will make sure I get a copy. Every surgeon usually has a copy of their post-surgical protocol for every injury. I get a copy of that and keep that on file so that I know he wants them in full extension for 6 weeks, or he wants them to get to 20 degrees by week 4, or what he’s thinking. That way when the athlete goes back, he’s satisfying his goals for each week interval. I am protecting that athlete, making sure that they are not undermining their surgery.

His surgical repair, because he was CP, they did a translation of the tibial tubercle. Instead of reconstructing that medial patellofemoral ligament completely, they know that is going to scar down, they took the tibial tubercle and detached it, and moved the tibial tubercle medially, and then reattached it back in. This pulls that whole patellar tendon and the patella with it, and translates it more immediately, and that way, it cannot dislocate. This is a firmer fix for someone like a CP patient, and that would be different for that MPFL reconstruction. Thinking too about if you are keeping an eye post-surgically, not forcing too much flexion particularly in this CP case, because it is going to pull apart this bone. Here is the bone piece right here that is screwed, and it is going to pull that right off and undermine his surgery.

This is him a couple of weeks later. I think he is at week 4 now. Surgical site is healing quite nicely. He has the ports here. You can see for him, they just moved that tibial tubercle over, more medial, so that that patella can track more in the trochlear groove as opposed to pulling it this way, because they know in a CP patient that that is going to pull too laterally. Again, we talked about the doctor’s protocols, range of motion, restrictions, and surgical healing.

We are going to get into another case study. Take a moment to read. We have a 35-year-old female runner with one history of right knee pain. She admits that the knee was drained about 9 months ago, and she got a cortisone shot to it. It is increasing, it is getting worse, not better. What do you evaluation? She is obviously still running, having more pain and finding that she is getting a little bit of edema post-exercise, but it is not really limiting her range of motion, except she does have pain. She is feeling like maybe she should not be running as much. Again, we go back to our knee evaluation. Remember, do the same evaluation on everybody for the most part, unless the injury does not allow you to do it, unless it does not make sense to do it. I want to make sure we hit that. If somebody is acute, and they have a fracture, we are not going to run them through McMurray’s and do festivities and all kinds of crazy stuff.  We need to tailor it sometimes, but I just want you to get in the habit of running through your whole knee evaluation, and as you get better, you will be able to omit in certain cases. But again, even me still, for someone like this, I am still going to run through the whole evaluation because there is a WHY to it. You know, there is something else that we might be missing. Maybe we are missing a mechanical fault, maybe the hip has a poor range of motion, that is why her knee is bothering her, maybe she pronates too much, and therefore the medial structures are a problem.

Again, I am going to play this one more time quickly so you can get it in your brain just for the sake of memory. Quadricep contraction. Looking at them together now. Looking at that symmetry, that patella driving up in the trochlear groove. Having them slide their heels to their butt. Looking at range of motion actively. Looking at the good sites so you can compare good to bad. Lachman’s for ACL. Valgus MCL at 0, valgus MCL at 30 degrees, lateral collateral ligament, 0 degrees; varus stress, 30 degrees. ACL again. Anterior drawer. Looking for anterior tibial translation. McMurray’s test here. Circumduct. Looking for pain in that flexion. Rotating the foot in and out, doing both ways. Extension for quad, flexion for hamstring. Passive range of motion of the knee. Again, we are going to do it on the good side before the bad side. Then palpate all the structures, looking at your medial structures, looking at your lateral structures, looking at your infrapatellar structures, looking at your suprapatellar structures, looking at the joint line medially and laterally for point tenderness. Kind of think of everything in compartments. It is the easier way to think of it, making sure that you are getting all the ticking points. Checking popliteus, the most misdiagnosis of the knee, big structure. It unlocks the knee, gets that first mechanism of bending your knee going, helps to pronate, so internally rotates the tibia. Checking the pop fossa, and then a little more hamstring and glute activation.

I wanted to do those two times just to make sure that you had an extra view of that, and you can start kind of formulating your evaluation in your brain. I want you to go and practice these. Here is our evaluation on our patient, our runner: negative valgus, varus, negative drawer, negative Lachman. So, no medial collateral, no lateral collateral, no anterior cruciate, some mild pain with McMurray’s test. But I will tell you, sometimes you will get a little bit of pain if they have swelling with McMurray’s test. So just kind of know when it is a cartilage versus when it is not. Negative bounce home. We showed you the bounce home test. Some pain in extreme flexion. We are concerned about cartilage. Again, that extreme flexion tells me it is posterior horn of the meniscus. And then there is some pain with McMurray’s. Both of those two items are saying a little bit of meniscal injury. Positive patellar grind. That is your patellofemoral mal tracking test.

I want to just step backwards one moment and look at your list. What I like to think about is doing almost two ortho tests for each structure. We have Lachman’s and we have anterior drawer. Those are two tests for ACL. You are doing it and then rechecking yourself. We must test for valgus, varus, both at 30 and 0. That is two tests. You are doing and rechecking yourself. Pivot shift also checks ACL, so that is a third test. Bounce home is just checking inflammation, and the little posterior cruciate too at the same time. We also could get so many structures with the bounce home test.

Now we are doing Thessaly’s on top of McMurray’s for a meniscal injury understand we are almost doing two things for each knee just to keep reverifying. That is why when you make a diagnosis, you are really making an accurate diagnosis. We have got patellar grind; I see two things that are telling me I have extreme flexion. I have McMurray’s, telling me to look at the meniscus and look at the patellofemoral tracking.

We sent for an MRI. Here is the MRI. Lots of edemas is a T2 weighted image. I like the T2 weighted image because it tells us where our edema is. Edema is the bright white, so lots of swelling in this knee. Here is your A to P here. Here is our medial joint. Here is our lateral. Here is your meniscus. Can you see how I am missing a portion of the meniscus here. It is just not as great. I have edema here along my distal IT band. I better make sure I evaluate for friction or tightness of my iliotibial band and tract. Lateral patellofemoral loading, we call it.

Let us jump over here to our sagittal view. We can see all the edema around the patella. We can see this edema in the distal femur. That is like what I call a kissing injury. This is trauma to this femur from this patella hitting it. Look at this traction spur superior pull of the patella here. Now if we move to this sunrise view here, whoa. Is my patella sitting nice in a trochlear groove like that sunrise view we saw earlier? Not really. This thing is just all lateral loading of the patella. It is all deformed. We have got several traction spurs. We have something happening here with the synovium, injury here, all fluid here. Then look at the bone marrow edema in here from this guy hitting. Look at the bone marrow edema in the patella from these two hitting up against each other. 

Appreciating too in this view, the difference in conformity between the medial femoral condyle and the lateral femoral condyle, really seeing that there is a difference in conformation between the two. What to do with this patient. This is a runner who’s running, but pain is getting worse. I need to think about this patella tracking, if that is something that I can fix or not. Because I have so much edema here, I need to go back and look at that IT band, because clearly all the lateral structures are pulling so tight. Can I fix this problem? I cannot. I cannot change the shape. This is years in the making. I cannot get rid of this spur. But maybe I can improve the mechanics just a little bit. Maybe.

What we did for her was some McConnell taping, patellar taping. FICS has a Masterclass on just that topic. There is a whole long protocol for just the patellar taping, but as we use the McConnell tape or the rock tape or the dynamic tape also has an excellent protocol, we can realign this a little bit, the trochlear groove, and help with the pain quite significantly. We can help with the pain, we can reduce the swelling, we can release the IT band, maybe we can buy some time before this patient needs any type of surgical intervention.

Here on this sagittal view too, let us look at the fragmented piece of menisci here versus the more triangular shape here. We have got a little meniscus injury here too. Confirming that we found a diagnosis. I found this very interesting article, looking at retraining for patellofemoral mal tracking, retraining the vastus, the VMO. As I was doing some research, it is quite interesting. As your knee drops into the trochlear groove… I am going to go back one slide for a moment. What we find in this research is as this patella does not seat further into the trochlear groove. With degeneration, we lose this nice space, and it starts hitting up against this lateral femoral condyle, just like this one. As we start to see this occurring, what happens is we lose not only the VMO from pulling it immediately, but we find that the lateral structures and medial structures are simultaneously pulling it deeper into the trochlear group. If we go to train the vastus medialis only and do VMO contractions, which is important, we must understand that we are wasting our time on someone that has a patella that is sunk into the trochlear groove all the way. We need to first mobilize that patella and get it to disassociate from the femoral condyle a little bit so that it can track in any direction. Once we get that patella moving, then we go back to retraining the VMO. So always begin by assessing patellar mobility and making sure we have patella mobility before we are training that VMO. Otherwise, we are going to get vastus medialis and lateralis simultaneous contraction, and you are driving it deeper into the groove. We do not want to cement a problem in. That is really what this article talks about. It talks about that timing of muscle re-education. We want to make sure we have a free moving patella prior to getting that VMO activated.

Here is our torn medial patellofemoral ligament here. See how this guy is stretched out here. Just wanted to show a picture and idea. It is supposed to be attached right here onto the medial border of the patella. See how this lateral patellofemoral ligament attaches and divests right into the patella. Can you see how this one does not any longer attach to the patella and it is kind of retracted a bit? That is a torn MPFL.

If we look again into the research of how we manage patellofemoral pain, we really talk about unloading the knee. We want to think about our treatment strategy should not be painful action, should not be things that cause pain in the knee while they are doing it. We need to think about doing activities that retrain the quadriceps, the vastus medialis, adductor group focused without causing pain, and then reintegrating more functional movements. Offloading the knee is really the key there.

How do we begin in this runner? And how do we get them retraining so that we can still get some type of activity? I want to think about athletes, they need to be active. They want to be active, and if you tell them, they are not going to be active, they will be active anyway. You might as well form a strategy with them. We want to think about what’s your plan. Do we have full range of motion? Do we have strength? Do we have stability? Do we have proprioception? Assessing these things in your evaluation and deciding what can and cannot we do with rehabilitation. What’s our overall plan? To get this, we need to understand our goals, and not only your goal, but you also need to understand the goal of the athlete or the patient. And then you need to align your goals together.

So having a conversation, typically on my first day of visit, I will be evaluating an injury, and then as I take my history, I will ask about their goals, because I want to hear where their brain is. If it is just able to walk a mile a day, great, then my brain is set in one direction, or if it is to run an ultra-marathon, my brain is set in a different direction. I think you need to understand the patient’s goals, and then you need to align their goals with your goals, so that you all are on the same page.

What are your timelines for this athlete? Do we have a big competition coming up? Is this athlete training for a marathon? What is my timeline? Do I have 6 weeks, 8 weeks? Or do I not have a timeline? That also is going to significantly change your rehabilitation protocol. Not only what’s required of that body part, but I want you to think about what’s required of the whole system, fatigue-wise, endurance-wise. How many muscle groups are involved? What type of activities as a gymnast, a runner, lacrosse player, a football player? We need to think about a rugby player. What do they need to do? What do I need to do to get their physical body ready? Because we must understand if they are out rehabbing their knee, what are they doing with the rest of their body? And how are they circumventing a problem in an injury in another area of the body from disuse? So how am I going to cross train them, in other words, in a safe way? Keep that in your mind as you are working with athletes that need to be doing. Can I have them lifting or doing upper body stuff while I am rehabbing their knee? Yeah, most times you can in a safe way. I just want to make sure that we really talk about what is the safe plan?

Our onset of rehabilitation. What are we going to do first, second, and third for a knee? This is our post-surgical ACL we saw earlier. This was her just a week or so ago in the office. Our first step is always with the knee, is to get that quadricep contraction. Some of the newer research tells us that when we have inflammation in any area, the muscles surrounding that area tend to shut off. They just completely shut off when there is inflammation in that perfusion. Then we have got to think about a post-surgical knee. They fill that joint with fluid, and there is edema and swelling post-surgically. How do I get that quad to remember how to contract? That is your first action with any rehab. It is your first step. Basically, getting that quad to remember how to contract efficiently, and then we are doing it. It is a great learning point for the quad to contract the VMO first. This is a very, very passive light, contraction day for her. We are just going to have a little bit of very, very light Russian stimulation, not contracting too hard, just contracting VMO, and then the rest of the quad. As we progress on, I am going to move my electrode here down closer to the VMO. Move this a little over. That way when the Russian stimulation comes on, it contracts that VMO first, and then I will have the patient doing a quadricep set with them. Quad set would be as the stim turns on. I want you to push the back of the knee into the towel and I want you to squeeze your quad.

Day 1 for her was just having the stim on. We are doing some swelling reduction with some elevation and what not. But just having the stim on to pump the quad, lightly, will be day 1 for her. Her home instruction will be, “I want you to squeeze the quad 5 times every hour.” When you squeeze that quad or try to contract it, it acts as a pump mechanism to flush the swelling out of the knee. You have them do that every hour just about five times. You do not want to overdo it because you do not want to cause patellar tendinopathy by them squeezing.

Then we will be moving on to quad sets, where they are pushing the back of the knee into the bolster or towel, squeezing that quad. We use it with Russian stim. The stim turns on, activates the VMO first, then they activate the rest of their quad by pushing that knee and tightening the quad at stage one, and that’ll look like this. Here. As she progresses, she’s going to push that knee into the bolster, and then straighten it here. We will do that with the stim just as I showed you earlier. But this will also be her home exercises to do. My direction is pushing the back of your knee into the bolster, bring your toes to your nose, and squeeze your quad tight. Remember you are reteaching that quad to contracts. You want to take full advantage and teach it to contract appropriately.

Let us look at the second progression then. It would be a straight leg raise when you do your set. Here, you turn out and lower. Quad set first. Raise to the height of the opposite leg, turn your foot out and lower. Raise, set, turn out slightly, and lower. We are turning out slightly so that we can really focus on that vastus medialis eccentrically on the way down, because we really want to take advantage to get that… We need a little extra to get that vastus medialis working versus all the other strong ones. I have them bend this other leg up just so that they know the height to raise that leg. They are going to be raising this leg to match the height of the other leg. Let us look at one more clip. That turning out is very important, really feeling that muscle contract. That is your progression.

Then heel slides. That is something they are going to be doing at home. They are going to be doing it in the office at first to make sure they know how to do it appropriately. Basically, what they are doing is their heel is on a towel, and they are sliding their heel to the butt. That is the direction. Sliding your heel to your butt and extending. Their goal is to slide it gradually more and more each time. Each time they are bending their knee, it is getting a little more flexion, a little more flexion. In the beginning, they are not going to get full 90 degrees or full flexion. But that active range of motion will pump the swelling out of the knee. You want them getting used to actively doing and partaking in the activities post-surgically and during rehab too, and without non-surgical cases as well, and making sure that they are trying to kind of slowly get it a little further each time. You want them to match the amount of flexion they can get in the good slide over time. Okay, so that is your goal.

Now we are beginning our posterior chain activation as we progress on. Very important to not neglect the glutes and the hamstring complexes when you are rehabbing a knee, particularly glute medius and good glute control. Very important for the knee. We talked about that jump landing drill, how we want their glutes and hamstrings to contract. Particularly, we want hamstring activated so it can act as that check strap for ACL injuries and preventing knee injuries. They are going to be doing a glute bridge which looks like this. Pretty simple. Really feeling they are pushing through their heels and squeezing their glutes at the top of that motion.

This is an example of using dynamic tape to do McConnell taping. This is great for pain relief, again, I am going to point you towards looking at the patellofemoral masterclass that FICS has on the website for more training and how to kind of do this type of procedure, but it is also something else for patellofemoral pain.

Moving on for the patellofemoral patient, these are good for all knee rehab, these exercises. As you progress, pretty much almost every knee injury is going to be going through these. Then we are going to move on to our standing activities here, which I like to do banding. I like to do it with a weighted ball to contract the upper core, get the core stabilized. This is double bands. This is a gymnast, and you are instructed to lift and hold each step. And then we do the same thing backwards. Here. This is a weighted ball again. You are really holding your core and you are really tightening at the top of that action, really squeezing your glutes, really squeezing your glute there. And then we will do three sets of 15 in each direction.

One of my very, very favourites, this is more of your commando walk or your monster walk, forming that C shape. We got to get the glute medius activated for all our knee injuries. Very important for good knee control. We will be doing this forward and backward. Very good glute med. If we really want to get those glute med functioning at high force as we progress, we are going to get them on a treadmill and we are going to have them walking on a treadmill here with a wide gait. Her instruction is to pretend that the balance beam is between your legs, and you cannot touch it. There is a line on the treadmill that you are on either side with your feet, and you are walking. We will start with just 30 seconds of wide walks on the treadmill and a 15 second break, working up to a one-minute walk with a 15 second break doing those four times. That is great for glute med activation.

When the glute med activates, it de-loads the medial knee, it takes the stress off the medial knee. It helps prevent pronation. If we help prevent pronation, we prevent tibial internal rotation, we prevent a valgus stress on the knee. Getting that glute med activated is super important, super important. I cannot stress that enough. Again, activating that posterior chain, making sure that we do the Swiss ball actions which are so great for posterior chain. This is a little bit of progression, so this would be more for glute, high hamstring. They will be doing sets of 15.

This bent leg is a little more difficult. Here, this is the hardest progression of all the exercises. They will do this activity last in our Swiss ball progression. This is the step before that where they are doing a double extension here. Really, hard stuff. That is great. You have got to get the posterior chain working very important. Our first stage of those Swiss ball exercises would be a double leg on the Swiss ball, and then you can move on to a single leg. This is a single leg. So, you just do the first thing with double leg, and then as they get a little bit better. You can see that she is super coordinated and very fit. I want that good hamstring, good control of the knee. We cannot forget about any structures.

As we get them back into activity, we are going to have her running on a mini tramp at first just to practice loading. When we are doing that, we are looking for pain. We are talking her through different actions: ins and outs, forward and back, two feet forward, back with one leg. But we are looking at how she lands and takes off and looking as she bows in if she valguses. For her, her knees drop together there. See that? For this athlete on the left, I am going to make sure that I am doing more glute med work with her.

I wanted to show this one as a comparison with different levels. You see how she struggles a little more with this one than the previous athlete. I know that she’s got a poor posterior chain activation, and I really need to focus on that. She’s struggling with that activity. Understanding who you are working with and where you need to start, and also noticing when they are struggling what you need to focus on, or maybe you need to back it down to a more novice version of that exercise so that we are not causing injury. I always move into, particularly for knee injuries and ankle injuries, a hopping progression. Hopping is very important if we are going to have any athlete that does any activity like running at all or jumping. They need to be able to hop on one foot for an extended period. Understand that a run is really a sustained hop. If we think about getting them started on our hopping progression, first, we like to start with simple two legs, forward and back, and side to side. I formed this X on the floor here, and you will see it. First, I will have her go forward, back, forward, back. I feel she is good with that, and then we will go lateral motions, then she will progress here to an X pattern. She is a status post MPFL reconstruction. She had a dislocated patella there.

Making sure as I am returning to sport, I am returning better than before. That is my goal, and that should be your goal. When you are returning an athlete to sport, return them better than they came to you, because they came to you sometimes from traumatic injury, but sometimes from a mechanical fault. I want to fix that before I send them back.

This is our ACL. We had her activating posterior chain and we put the bands around her knees, then we load her glutes up. We have her do hip thrusts on a bench, really making sure that we are just loading her up.

We want to know what is very interesting when we look at squat patterns of athletes, and we talked about that jumping, retraining, and really looking at females versus males, if you are using your quadriceps or your hamstrings to jump, and I want to make sure I make that correction. I thought I would show you a video of some jumping here. This is a good jump with good use of hamstrings and glutes. But what I want to do is I want to just kind of stop there, and I want you to look at this line of the tibia. If I drop a plumb line down from his knee, it drops right over his second metatarsal or so, metatarsal phalangeal joint perfectly. The more that that knee drops in front of your toe, the more knee loading we have. That is too much knee loading. We want to think about instructing. Therefore, girls are different from guys. Guys tend to keep their hips back when they squat, which is proper mechanics. Girls do not. Girls lean forward on their toes, overloading their knees which predisposes them to ACL injuries. As we do this jump retraining, making sure that we have good mechanics of the jump. We are trying to keep that tibia behind the toes and making sure that we are really using glutes and hamstrings in our jumps.

Our progression with return to sport. They must pass all types of jump progression. We are going to start as they start really going on, just getting them down on the turf. We have a turf in our office for return to sport stuff and making sure that they can jump side to side now. As I am noting, I always will do a bilateral comparison and make sure what she can do on her injured side is what she can do on our uninjured side. Well, there is an ankle injury waiting to happen. I need to make sure that I haven’t overtrained the good side, and now her bad side is a deficit too. Because that can happen. So do not forget about, as you are bringing them back to sport, training the other side and checking them bilaterally, making sure that we are running through all the protocols.

Our next progression from just those lateral hops then on the turf will be straightforward with a little bit of a figure eight. I am going to do a straight and then a turn, making sure that she can hop for a sustained period on each foot. Then I am going to change the cones, and she’s going to have to do a hop diagonal to each cone on that foot, and then she will have to come back.

Think about as we are getting somebody back to sport, not only stopping at their pain being gone or their inflammation being gone, but you have also got to take them all the way. You really need to take them through the whole return to sport plan and thinking about what are those sports specific drills they need to be able to do? Even if they finish the hopping progression and they finish the cone progression on the turf with hopping, now what do we need to do? Is it a marathon runner? Is it a sprinter? Is it a hurdler? Is it a gymnast? Is it a soccer player, a rugby player? Now what do we need to train specific to that sport? That is very important and incorporate that in your rehabilitation protocol. Let us not forget about gait analysis. Very important that you are looking at their gait, you are getting them on a treadmill, you are video analysing their movement patterns, answering why the injury happened. Injury did not just happen, it happened for a reason. Making sure that it is not a mechanical fault that you can correct before returning them back.

Here is our return to sport kind of tick off list here. Can they walk without a limp? That means they can progress to the walking therapy. Can they run without a limp? Then they can begin short distance running type of activities, therapeutic exercise. You begin your sports specific exercise as you increase function, keeping in mind what sport you are returning them to. Begin always with straight movements, and make sure you are always working proprioception from an early point in rehab, strengthen the region, and then strengthen them globally. Do not send them out with other deceased atrophies that have occurred from reconnaissance of the injury. Add in time and intensity to each exercise. Maybe do 5 repetitions in the beginning, and then you are doing three sets of 15 in the end. A continued strength and plan. Make sure as they return to sport, they have a plan with the strength coach on how they are going to continue that plan and keep improving. This is a very important list on how to progress and how to keep them healthy.

One of our last case studies for today is going to be a 13-year-old male lacrosse player. We are just going to go through this one quite quickly because I just want you to be able to kind of gather a different view on an athlete. This athlete got clipped at last night’s game. This was a real patient in my office with his injured knee. He reported to the athletic trainer on the field, he could not walk off the field, he could not stand and bear weight. They sent him home with a brace and told him to follow up with ortho. He came to my office the next morning. What are your first questions? Again, how did it happen? What’s your mechanism of injury? At this point in the lecture, you should be able to understand you need to get that down first. Mechanism of injury, history of previous injury. Could you walk off the field? Did it swell or bruise? Are you walking today? All these things should be the first questions you should be asking.

This is his knee the day after. Understanding what we are looking at here on this knee. You can see the bruising patterns. I love to look at bruising patterns. They are significant because they tell me more severe injury. If somebody walks in with this bruising pattern in the morning after I am worried about a fracture in this area here. If I am thinking of fracture there, am I going to necessarily run through a whole knee evaluation? Heck to the no. That is something we are not going to necessarily do. If I am suspicious of a fracture in this area, then what I am going to do is I am going to just try to palpate structures I think is a problem. I am going to just probably do a little bit of a Lachman’s, a 0-degree valgus, 0-degree varus, see what I get, see if there is stability. That is all you do.  I am not going to overly force this knee. There is a lot of swelling. Notice a lot of swelling distally, even up proximally. This is a severe injury. This athlete has a medial collateral ligament injury rupture. This athlete has a medial meniscus tear, has a fracture of the tibial plateau. ACL and PCL both torn, lateral collateral ligament torn, meniscus torn. You will not see any like this in your practice, hopefully for many years, or if ever. There is nothing left in the knee holding it together. So why do I need to go through the whole evaluation? This is a brace and refer. He needs a whole knee reconstruction and that is exactly what he had.

Understanding that my job that day is to brace it and get him to an ortho ASAP so that he can get an MRI on him and get him into surgery as soon as possible. Maybe we will teach him some what we call prehab or quad contraction exercises, teaching him some transition skills, how to get up and down without injuring, how to walk on crutches, make sure the crutches are fit appropriately for him, making sure he is elevating throughout the day and icing. Those are just kind of like your checklist.

With an athlete like that we need to understand that sometimes we have got to educate the parents or the Guardian on what to expect and how to care for this person, what they should and should not be doing at home. Be honest with your athlete’s best interest above everything else. Making sure that you are informing them appropriately and not being an alarmist and saying, “Oh my, there is nothing attached.” Making sure we are just getting them braced, getting them safe, and truly getting them somewhere where they can get the best care. Be honest with them. That is what it comes down to. We want them to get better, be safe, be able to stand and walk, and be active as they get older.

Speaking of this case, does the age and gender of the athlete matter? What are some considerations for pediatric athletes? You know, we have growth plates that are open when kids are younger. We need to consider the older athlete as well, how those injuries come into play, and what’s different in the female athlete? You are going to be seeing some of these lectures as you get further on if you haven’t seen them already in the ICSC. We will have lectures on each of these aspects.

Understand there are patterns of biomechanical faults and injury. We need to look at these patterns of use. This is a meniscal injury patient. Well, I can see she has a meniscus torn on the left side that was undiagnosed for about a year. Look at this callus here. She’s clearly using this foot differently than this foot. She’s using this differently than this, even though she has a greater Hallux valgus on this side and she’s towing off on this side. I want to look at the gite. Get the shoes and socks off your athletes, making sure you are looking at the muscular contour, look at the quadriceps look at the gastrocs, look at the hips, look at the glutes, the hamstrings, making sure that we are looking for symmetry differences that answers the why we have a mechanical fault. Why does this patient have this injury? Do not just stop at the diagnosis. We need to be able to get the diagnosis right, laser-focused diagnosis, then open up. After we get that diagnosis accurate, making sure we are doing the right treatment, open up for the whys. Why did the fault happen?

Understand there is a cascade of injury. When we have injuries, sometimes it is not just one injury. We have an athlete here who had medial tibial stress syndrome, bilaterally, pretty severe for a period of time and trained through it, and that is a coaching problem, which is a whole other conversation. We must think about what happens in the long term with somebody like this that has a medial tibial stress syndrome, untreated? What are our long-term ramifications for untreated injuries, and how can we help the athlete at that stage of the game? We clearly can see that these long-term injuries affect these athletes quite profoundly more so than just physically.

If we look at the anatomy, we see scar tissue forming. This is an anterior compartment of a lower extremity gross dissection that I was doing in the anatomy lab for a lecture. We can see the scar tissue that forms in these compartments, and we think about untreated medial tibial stress syndrome. Really what they are coming to now is that it forms a lot of scar tissue not only from the periosteum to the anterior tibialis, posterior tibialis structures, but also just right in the lower extremity. Could this be contributing to this chronic long-term pain that is being diagnosed as compartment syndrome for some of these athletes? We think about this diagnosis. See her posture. I love to look at static posture sometimes and see if that is contributing to injury. She kind of has this forward posture, so she is loading her anterior tibialis all day. Can I change her posture to bring her backwards and take that pressure off of her legs?

We also can see how these treatments affect the psychological component of these athletes. The effect of the athlete. Do not forget about that when you are treating athletes too. I make mention of that in some of the other lectures. Let us not forget, with every physical injury, there is a psychological injury, and let us make sure that we are not negating that, and we are addressing that as well, appropriately, or referring them to somebody that they can talk to if there is a problem, because there is a big problem with an athlete like this that has now lost their identity. If they cannot do their sport, the thing that they are good at and the things that they are getting their dopamine addiction from all these years, from doing such a great job, they need to recreate themselves. So please make sure you are keeping an eye on that because that is a thing.

We like to do gait analysis in the office. I put them on treadmills. We look at them from the side, from the back. I analyse where their pressure is, if they are pronating, what type of footwear they are wearing. This is something to consider. We won’t go over the details of it. There are several lectures that we offer on gait analysis, too. But making sure that we are looking at them functionally is the point.

Here is an athlete that came in with knee pain with running. I just wanted to show this little bit of a running gait. Can you see how she is standing, is there any way possible she would not have knee pain? I do not think so. We need to make sure with athletes like this, that we are looking at. I am going to play both at the same time and look at their footwear, because the footwear is critical with any type of gait, any type of running athlete. It is critical. It is their tool. It is their instrument. This athlete was running on a size and a half too small for her, and that was the problem. It is just painful to run. Once we got her in a good running shoe, with some good stability checks, she ran just fine. So sometimes it is something simple. We can do all these fancy evaluations, and it is something that is not so hard.

Want to throw a consideration out. This is me working at World Games for FICS, which is super fun. I hope to see some of you out working some of the games with us in the future. You might only see an athlete one time if you are working events. Make that one-time count and also guide them correctly, making sure that we are just doing the appropriate thing at the appropriate time. Effectively, communicate. When you do some sporting events with FICS, you might be working with people that speak a different language than you. We have got to figure out how to communicate effectively with them, and make sure that they understand their injury.

Do not forget to check to make sure that our athletes are lacing their shoes and also non-athletes are lacing their shoes appropriately, and that they have them tied all the way up, and they are not that fancy non-tied way that they have their shoes. I always make sure I check how we have them laced. This is a great way to lace a shoe for someone that over pronates. It is called a runner’s knot. You use that extra little loop on the top that people forget about all the time. You lace on the same side through that, and then you cross-pattern the tie, and this will lock up and make a little more stability with the heel counter. Because if your heel is moving, your foot is moving. If your foot is moving, you are pronating a little bit more. You are pronating a little bit more, stress on the knee. I will walk them through and tie their shoes for them. Then put them back on the treadmill and evaluate them to see if that made a change.

Remember our return to sport plan. What is your measure of ready readiness? We slowly have them do. When we feel they are ready, they are going to have the instruction to go to practice and just do some drills at 25% for half an hour, and then 50% for half an hour, and 75% for half an hour. Then we are going to increase their time and intensity. We are going to gradually increase their time and intensity till we get them back to contact or full return to play. Understand there is a progression involved when we are returning somebody to sport. This is me in Poland at the World Games for FICS.

Look beyond the obvious. Explore all aspects of injury. Understand that the injury sometimes is a ramification of many faults before it, tracing that pattern back and have some fun with that.

Thank you for your time and dedication to this amazing profession. Thanks for FICS, and good luck completing your ICSC. I hope to see some of you at some future games.



3.1-ICSC05_Lower Extremity

English Direct Download PDF – ICSC05-3.1 VIEW C Foss.1.52-37

ICSC Lower Extremity Module 5
Section 3.1_ICSC05
Instructor Christine Foss
Video Lesson: 1:52:37

Welcome to the ICSC Ankle Evaluation and Functional Assessment module. Today, we are going to go through all the ankle assessment skills and also look at some case studies and understand how we not only take those ankle evaluation skills but look at somebody functionally, and then return them to the sport. Get comfortable and dive right in. We are going to take a close look at the ankle and foot today and then move forward with any questions and follow-up towards the end.

When we consider the ankle we always like to begin with the obvious which is just the regular basic anatomy. My history is that I am also an athletic trainer prior to becoming a chiropractor. My master’s is in sports medicine. I have worked with athletes at all levels, with the Olympic level, the US Olympic team. I have worked in Europe at several world games and international events. My best advice to somebody who’s learning is to go back to the anatomy because the anatomy explains so much as to, not only finding the accurate diagnosis, but also being able to correct problems and get somebody back to sport better than before. I am happy to dive into this with you today. It is one of the areas of the body that I just love treating, rehabbing, and bringing back to the sport, and so much success with it.

Understanding whenever you look at any body part, you might have heard this if you have heard me lecture before. The most important part of your patient encounter is always the history and the mechanism of injury.  We have learned this in chiropractic school, but particularly for injuries of the extremities, the mechanism of injury, how it happened, is huge because you are going to take that bit of information of how the injury happened, describe it to me. How did the body part move? Did it roll? Did you hear any sounds with it? That is all going to speak to your laser focus diagnosis.  Because we need to be able to get that accurate diagnosis so that we know how to treat properly. Always begin with understanding the mechanism of injury. I am going to say it lots of times as we go through the lecture today. Sorry in advance but it is so important.

The basic anatomy of the ankle is that there are 33 bones, 26 joints, and 3 arches. It is the base of support and ambulation, so it is super important that we truly understand how these 33 joints all come into play. When you get inflammation in one area of the ankle, you must understand that you have inflammation that is infiltrating all this area. Think about somebody with an ankle sprain. We are going to look at some acute ankle sprains later in the lecture. Think of where does all that inflammation sit? It sits between all these 26 bones and between these 33 joints.

Now we have to get the mobility of this ankle moving again post-injury. That is something we are going to talk a little bit about as we go further along. Also, consider that the ankle and foot are your first contact with the ground.  It really determines how we transfer force up through the kinetic chain and how when we have a fault with the foot and ankle, this is just going to disturb the whole kinetic chain and we are going to get other injuries. It is just imperative when we have a foot or ankle injury that we really work hard to get them back better than before. I say that over and over again every time I lecture. That is my driving force.

When we are looking at injuries of the ankle, what is the biggest determinant of an injury? The biggest predicting factor of injury is history of previous injury.  If someone’s had a previous injury, they are more than likely to get another injury in that area. Very rarely people do a great job at taking care of all the fault patterns and all the kinetic chain and correct everything and they return to a sport prematurely. It is very, very common, unfortunately. We need to also ask not only the mechanism of injury. Did you hear anything, but have you injured this before? That is a really critical question when you are evaluating an extremity, is have you injured this before, and if you have, what exactly did you injure before? Then we need to understand with the previous injury, what were the mechanical changes that happened? What has happened here that caused the fault pattern of the foot or ankle? Are there inherent strength changes that are going to last for a while? Maybe they are weak and that is why they had this injury.

I always like to say we need to think of the why of an injury, not just that the injury is there. Why did it happen? Was it just that somebody hit them, and they fell? That happens sometimes. Or more importantly, was there a weakness there? Or was there a fault, what I like to call a fault pattern there, or a range of motion loss, that predisposed them to injury? We need to think about all these things as we dive into this area of the body and start having some fun with it.

Let us understand that the function begins with the structure.  If the structure is altered, the function is going to be altered and vice versa. The function is altered, the structure is the same but it adapts and changes. It tries to get these what we call compensatory pathways that start to form. If we really think of the foot and those 26 bones and 33 joints, we must understand how many things must happen to walk normally. Just in the foot and ankle, before we even get up to the mid-calf and the knee and the hip and the low back, how many things must transpire before we have a normal gait pattern? We really understand again how important it is for us to really own the foot and the ankle assessment and treatment and be able to pick up on these nuances. How do these changes impact performance? What is going to happen if somebody does not have good plantar flexion? What is going to happen to their ability to jump vertically or their forward propulsion? It really affects the entire kinetic chain when we do not have good foot and ankle motion at all.

Remember, too, we have to think about all the layers in the region of the foot and ankle. It is not just the bones, ligaments, tendons, and muscles. It is everything, like what I like to call a pot of soup.  We think about taking to somebody, and I like to look at them in layers. As I evaluate somebody, I first consider the bony structures, then the ligament structures, then the tendon structures, then the muscle. We are layering them as we are doing an evaluation.

When we talk today, we are going to go forward, and as we do our evaluation, we are going to be building an evaluation protocol. I will show you my evaluation a little later. I videotaped it. You can look at it and review it time and again just so that you can get this concept, and then you do not forget about any structures as you evaluate them. You just roll right in and evaluate all the structures.

We think about the foot and ankle. Let us look at just some, and these are at the top of my head. A list of the things that we need to make sure we tick off the box in evaluating when someone has a foot or ankle injury. Do not be so quick to just jump into one injury. Let us say, I think that it is a medial ankle sprain. Do not kid yourself to think that there is going to be a myriad of injuries there. It is very rare that someone just gets one particular thing injured. We have to think about, when you go through a mechanism of injury, other structures are there. There are tendons there, there are ligaments there, there are bones there. We need to think about, do not stop until you are truly satisfied evaluating that ankle, that you have evaluated all the structures.

Here is a list of things that could potentially be injured as we think about foot and ankle injuries. Again, this is not a comprehensive list. These are just some things that I make sure I tick off every time I do an evaluation of an ankle. We always talk about the layers of Tom, Dick, and Harry, or the anterior ankle, and then the side of the ankle, Tom, Harry, and Dick. We think about the tendons of the medial ankle that come off the medial side here. It is tibialis posterior, and that is the Tom, Dick, and Harry.  Tibialis posterior, flexor digitorum, and flexor hallucis. That is off the medial side. Then we think about tendons in the anterior ankle here, Tom, Harry, and Dick.  We have anterior tibialis, extensor hallucis, and extensor digitorum longus. Knowing that it is not all about the ligaments in a sprain; we need to understand there are tendons there, too. Do not forget about those. It is not too difficult to memorize these. I know we have all done it in chiropractic school. But really own them and know what structure is injured because do not you think we should know if it is anterior tibialis or if it is extensor hallucis? These two things do very different things.

Let us pretend we are using a soccer player and he has an anterior tibialis strain. I might treat that differently than an extensor hallucis strain.  For extensor hallucis, I would consider maybe taping or supporting the toe. For anterior tibialis, I am not going to do that. Really understanding where these tendons lie helps guide your treatment, and your treatment will be much more effective and the athlete will be much more successful. Because we can figure out what to do to help that athlete get further faster.

I get texts of injuries to me all the time. This was one that I got sent to me that said, “Hey, what is wrong with my ankle?” I do not know how many of you get these, but I love them because I think they are funny. I can actually assess that as they are up on their bathroom sink there. But one thing that we must think about is, again, going back to “How did you injure it?” That is my first question. Were you able to bear weight and walk after you injured it? Could you complete playing if you were playing a game? In other words, could you complete the game? Or did you have to stop playing the game? Those are important questions. Also, looking at this pattern of edema. This is very strange for an ankle injury. As we go through today, you will see by the end, you will understand what I mean. This is not your typical ankle sprain pattern of edema, so this is a little worrisome for me when we see this.

We think about stability of the ankle. We think about these four ligaments right here. Your anterior talofibular ligament which lies right in the sinus tarsi right up here. It goes obviously from your fibula to your talus. Your calcaneofibular ligament is sitting on the lateral ankle right here from the calcaneus to the fibula. The posterior talofibular ligament, again, same as the anterior talofibular, but on the posterior to the lateral malleolus, and the deltoid ligament which provides stability to the medial ankle.

We must really grasp the function of each of those ligaments and understand how to assess them and how they might be injured. If we are thinking about an inversion ankle sprain here, and that is where you roll your ankle, we understand that we are going to injure these lateral structures. That would be your anterior talofibular ligament here, your calcaneofibular ligament, and your posterior talofibular ligament. Those would be the ligaments that you’d be worried about in an inversion ankle sprain.

If you are talking about an eversion ankle sprain here, you are going to be looking at the deltoid ligament. That is your medial ankle. It is actually in three sections. A very thick ligament there on the inside. Good support. We most times see this lateral ankle sprain.  That is much more familiar to us, but they do happen to these deltoids. A lot of times in younger athletes, avulsions happen in the deltoid so you need to watch out for that. Here is our normal. Really understanding how it happened starts formulating your diagnosis, your differentials of what potential structures could be injured.  Again, we are going to ask, did you have a previous injury to this area, and were you able to keep playing?


We are going to go through ligament testing, and we are going to hit each of these. I just wanted to put up the acronyms so that you understood anterior talofibular, calcaneofibular, posterior talofibular, tib-fib, that is your distal syndesmotic between the tibia and the fibula, your classic high ankle sprain, and your deltoid. That is how I am going to refer to them as we move on.

Let us look at how we might test the anterior talofibular ligament if we were concerned about sprain to that injury. That is the one that is sitting right up here. Someone’s going to have swelling right in the sinus tarsi region, so they are going to get inflammation and tenderness right in this area here. We are going to test that with just 20 degrees of plantar flexion and inversion. This test right here is called the drawer test. I do two different tests for my ATF sprain. You can do the drawer. A lot of times you are not going to get this forward motion, so this is not unlike the drawer test of the knee. But we are really taking that calcaneus and we are pulling it forward to try to see if we get a joint gapping here in this talar region. We are stabilizing with this hand here. You are stabilizing that tib-fib and trying to lift this superiorly, so to speak. You are trying to look for gapping here in this area. If we really have a big ATF or an avulsion or rupture, you are going to really get a good amount of movement.

I like to also test the anterior talofibular ligament by doing a Talar Tilt, and we will go through that in a minute. Here’s that Talar Tilt. A classic Talar Tilt is where your ankle is more towards the 90-degree mark, here, like this picture on the left. We are actually testing the calcaneofibular ligament. This is a test question, a test answer. In the Talar Tilt test, you are testing the calcaneofibular ligament. So, when you do a Talar Tilt, you are truly testing the calcaneofibular ligament.

Real-life test? In real life, we do this at 90 for your calcaneofibular ligament. Then, I like to do a little bit of plantar flexion, so I also can get another look at my anterior talofibular ligament. It is just another little way to see how much motion you get on that ATF, because remember, you are going to try to grade these sprains. Remember an injury of a ligament is a sprain, an injury of the muscle is a strain. These are sprains. Is it a grade 1? A grade 2? Or a grade 3? You are going to grade that by the amount of joint gapping you see or motion on these tests.

I just want to stop here to say it is very important that you always test the good side first. If her injury here’s on her left leg, I am going to test the right leg. In this way, it gives you a benchmark to the amount of mobility that is normal for that person.  We have got to know if their ankle is loose to begin with or is it tight to begin with? I like to do the other side first. The other reason to is if this is an acute injury, it is very important that they know you are not going to grab their injured leg and rip it off. What we do is we get the good side, do their range of motion, do their special tests, then you have a benchmark to compare to. Then, the athlete also knows and knows what to expect, and they are less guarded. When they are less guarded, you can get more accurate reading on your test, particularly, ortho tests.

This is the valgus stress test. Here is a bird’s eye view. We are testing the deltoid ligament, which is the medial ankle, so like valgus stress. We have to understand that the deltoid ligament is not injured as frequently as the lateral ankle.  Like the anterior talofib, most commonly injured ligament of the ankle. We have to understand that it is a much thicker ligament, too, so it is harder to injure that area but also a better overall recovery for the long-term stability of the ankle.

This is the squeeze test. The squeeze test is for that syndemostic injury or that distal tib-fib sprain, or high ankle sprain, all the same. The high ankle sprain tends to last a lot longer than your regular ATF sprain. Because that ligament is so much thicker than your ATF ligament, it has more swelling that comes along with it, more disability that comes along with it, more pain. One thing that I like to do for this distal tib-fib high ankle sprain has put them in a boot for a week. They just get better so much faster. They are in a lot of pain in the beginning. I noticed in a week; I make a month’s worth of progress when I just put them in a boot. At the end of the week, I get them out of the boot and then I start my rehab.

This is called the Anvil test. The Anvil test is for gross fracture. Pretty much, I just hold them at 90 degrees and you just take your fist and hit the bottom. It is like a percussion test here. If they have a fracture, that is going to also be positive for pain.

We are going back to our foot up in the bathroom, and we think about what your protocol is. We want to make sure for an acute injury that we understand the history and the mechanism, we look at the range of motion, we look at the strength. We must rule out a fracture before you do a whole bunch of orthopedic tests. That would be your palpatory findings. You are going to palpate that distal fibula, distal tibia, your tarsals, your metatarsals, just making sure we do not have any gross fracture before we start cranking on the foot and putting it in different directions.

We are going to look at those patterns of edema. If we see that ecchymosis very quickly, and that is the same day, then I am worried that there might be a fracture. That is like the fracture warning sign, so watch out for that black and blue or that ecchymosis to happen very quickly. Also, take note of where the edema is happening early on because that is going to speak to the structures that are inflamed. Later on, we have what we call dependent edema. Everything goes along with gravity. All bets are off once that has set in because the edema is just everywhere at that point.

Then we are going to evaluate the ligament stability of the ankle and then we are also going to talk about their ability to ambulate. Can they walk normally? Can they put weight on it? Can they continue to play? All these are very important aspects of overall injury in our diagnosis as well.

Here are our grades of ankle sprains. This picture, I think, makes it easy to get the concept. We have normal; grade 1, just stretching and some small tears in the substance of the ligament itself. Grade 2 is up to 50% of the fiber itself is torn, and grade 3 is a complete rupture. Understand, with a Grade 3, when you do your ortho test, we are going to have serious joint gapping and a lot of motion in that area. As you are evaluating, pay attention to how much motion you get that maybe you do not get on the other side, and barring previous injury, that is going to be how you grade your ankle sprain.

A little key for the foot and ankle is the amount of swelling, and that is actually true for all the injuries. The more swelling, the more edema, usually the more severe. A grade 1, little to no swelling and that is an easy one, too. Then, we also know when we grade them, we also can predict the return to sport duration. How long will they be out of play? That is really important.

We talked about structures affected by function. Since we are also talking about functional assessment of the ankle today as well as structural assessment of the ankle, we need to consider that the most important part of an ankle injury and a foot injury is that we really think about how that motion needs to happen, how many things need to happen normally for that athlete to go back to where they were pre-injury? I want you to get that in your brain as you visualize all the different views, medial-lateral, superior-inferior of the ankle, on the talus and the calcaneus, and this whole articulation. It is very important to understand we have got to get full function back before we get somebody back into the sport.

When we understand the functional component of it, we really can get the anatomy. What is the anatomy doing in a good way or doing in a bad way? What does it need to do? What is the chain of command? What has happened here? What is fallen away from normal and why? What are the compensatory mechanisms? What are they doing to limp or to walk normally? What other muscles are working that aren’t supposed to be working? We want to not rule out footwear, particularly when they are injured, advising them on what they should and shouldn’t be doing, and the anatomical variance.  If somebody has extra bones of some type in the foot, we have accessory navicular, or what have you, we need to understand that, too. A lot of those sometimes are diagnosed as fractures, which is funny, and their goals, that is an important thing to think about. We need to align your goals with the athlete’s goals. That is an important thing to happen early on. We have to think about if their ankle looks like this. This is somebody coming to me the second day after an ankle sprain. If their ankle looks like this, what is the likelihood that they are going to be able to give 100% full out that day in competition? With learning this stuff and becoming comfortable and working with more and more athletes, you will be able to understand you have got to align your goals early and set realistic goals. Your goals need to be with the safety of the athlete in mind. We do not want to put them out where they can get another more severe injury. Consider all these things as we start thinking because an athlete is like, “I want to play today. I got to play today.” We need to really think about that return to sport strategy and aligning what you think is realistic and what your athlete thinks is realistic together.

Of course, we cannot forget about all the motions of the foot. Pronation, supination. Inversion, eversion, plantar and dorsiflexion. We need to understand that all these movements come with, not only structural considerations but also functional considerations. Muscles, tendons, joints, and ligaments. As we are putting somebody through an assessment, we need to really understand these layers and how they interact with each other. How is an injury of the anterior talofibular ligament going to affect the talus? How is an injury of the peroneal tendon going to affect the cuboid? These things are very important facts that we need to understand.

Here we are looking at the medial side and I want you to really appreciate this deltoid ligament. Usually, we cannot see it too good in this picture, but it is more broken up into three sections, but thick, strong. Then now, we jump over and compare it to this lateral ankle view here. Look at that anterior talofibular ligament, thin. Here is your distal tib-fib or that high ankle sprain. Can you really understand now why these takes longer to get better than this one? There is just more substance there. A lot more significant injury, more edema, more swelling. Plus, when they stand up, and this is sprained, the tib and the fib separate, so it is like a wedge with the talus, slides up between, and it creates constant pain. That is why it is good to get it in a boot where we keep that tib-fib nice and stable, squeezed together, so that does not keep separating and it takes longer for that ligament to get better.

We said distal tib-fib, anterior talofib. Here is a calcaneal fib right down here, and then posterior talofib is here. Get that anatomy and appreciating how the ligaments are not all created equal, is important. This anterior talofib is very different than the deltoid. Therefore, different swelling, different functional differences, and different return to sport durations. We are going to consider our movement, and when we get an ankle injury, how do we think about getting somebody back to sport, post-ankle sprain? What do we need to think about as far as overall motion when we are evaluating somebody? Particularly for injuries of the ankle and foot, we really need to appreciate these phases of gait. I know you went through this in your biomechanics section. I am just going to glaze through it quickly as a quick review for you because it is just so important. Understanding this stance phase of gait.

Let us look at our really high-tech picture here. When your foot touches the ground, until it comes off the ground in the back, that is considered your stance phase. That is 60% of the gait cycle and the thing that is important to understand with that stance phase is that that is when all your major muscle groups are really working hard. That is when most of the big muscle groups are working the hardest during that stance phase. We are getting our forward motion or energy from that stance phase.


The swing phase is a smaller component. When your foot swings through in gait. There is no weight on it. We have more of the foot intrinsic muscles, anterior tibialis, just getting that foot; not as much as the big muscle. We look at that 60% of your gait cycle. That stance phase has an important part to consider when we are looking at injuries. Thinking about that, too. I have a gait analysis thing on my Instagram. We will be doing that regularly so that you can truly understand this gait and how to take a foot injury, maybe it is a little bit older or not getting better and figure out where it is coming from. Again, it is not always the obvious answer.  We understand that this stance phase is divided into four different phases. I said from the time your foot hits the ground till the time it comes off the ground, that is your stance phase. That is the easiest way to remember it. Here is a little better view. We just looked at the stance phase. From contact to propulsion. Here, we think about how much energy needs to happen in that amount of time. I want you to just think about that for a minute. Then let us just push that to the side because we are going to come back to this concept later. This midstance is most of your energy. But you need to gather a lot of energy from this propulsion stage.

If we think about all these things that need to happen in this midstance, you have to think about, boy, that is a lot of stuff that needs to happen. Now when you have somebody with an injury that is cheating the system or limping or not walking properly, or maybe they have developed a limp and not able to get rid of it, you have got to go back and break that chain. You have to understand these phases of gait so that you can figure out what is missing. Is it that the ankle is not going into pronation, so I am not getting any oblique access plantar aponeurosis motion? Or is there a problem with the midtarsal joint? Maybe that is the problem, post-injury.

If you think about an ankle sprain, and let us pretend somebody was booted or they were braced, they lose motion in all those joints of the foot. It is not just the injured area that loses motion. Then you have to work to get all that back, and who better than us to go ahead and adjust all the bones and mobilize all the bones and joints in that area of the foot, and they will come back quicker? I think a very nice addition to rehab is to get a little bit of chiropractic in there as they start getting better.

When we think about gait just a little bit more, it really is just control of a fall. You are controlling the fall of your foot down. When we talk about running, more has to happen in a shorter amount of time, you are really controlling that fall. If your walk is not without a limp or without falls, all hell breaks loose once you run because now we have lost control. What we really need to make sure is we are bringing somebody back post ankle, that we’d get them to walk without a limp. That is your first stage.  

Let us look at what happens with this gait here. With your foot dorsiflexion, the tibia internally rotates, the talus everts, and the foot pronates. That is an important component. I want you to think about that for a minute. As you start to dorsiflex, your tibia must roll in so that you can begin the pronation portion. Pronation is not always bad. We need to be able to pronate so that you have normal motion. It is just hyper pronation is the bad part. Then let us look at plantar flexion, and that is more of your propulsion phase when you are pushing off on your gait. We have plantar flexion, your tibia is going to externally rotate, your talus is going to invert, and you are going to supinate. When you push off, you supinate. When you step down, you pronate. Makes sense, but we have to understand as we are bringing somebody back, we need to gather these motions also. This talus and this tibia are often forgotten about. We cannot forget that we need motion from them too, so watch those gait faults as you are bringing somebody back post-injury.

This is an interesting case, which we will get to later in this lesson, but we have to think about what happens when we start to have a cadence or your cadence improves or increases. You go from walking to a slow jog to a run. What are the things that happen? Now you have a very short stance phase. When your foot is down, it is for a shorter amount of time. You need those same muscles to gather more energy, to go through a greater range of motion in a shorter amount of time. They need to become more efficient with a greater range of motion, up to 50% more range of motion from walking. If you do not have a normal range of motion, post-injury, for foot and ankle, you are not going to be able to run normally. Very important are those early stages, and we are going to talk about it as we go forward. Getting that range of motion is important for any athlete that is not sitting down, which is most athletes. We have got to get that range of motion because we know we need a little more than normal for you to be able to run.  You need 50% more than you need, just walking. You will have vertical forces that are changed too when you run. We need to understand the shock to the area and how’s that going to affect your injury. Then, there is going to be a change in that basic activity of the muscles of the lower extremity, when they work and when they do not work, that short bursts of activity.

We are going to go back to that case and I am going to show you him a little bit later. I do not want to spoil it now. Let us look at when you are evaluating an ankle. Do not get too myopic and get stuck in the ligaments. We must do that too. That is an important part, but it is not the only part. We need to look at their gait. We need to look at their shoes. We need to look at their posture, the practice surface, how frequently they are practicing, hip and knee function. We are going to go back. You have got to get your laser diagnosis and then you must be able to pan back and look at everything as we are returning them to sport.

We cannot forget about that. Just do not patch up the problem and send them back. We have got to be able to scope out and look at everything and send them back in a safe way. We need to pull it all together in the end as we start bringing somebody back from injury. How are we going to do that? How are we going to take somebody that is on crutches and get them back to run a marathon? This is a marathoner here that we are going to look at. What are we going to do about that? How are we going to put it all together? I am just going to play this video here, and then we are going to talk about his case a little bit later. I want you to just watch his gait pattern and see if you can pick up what is there. I am going to play the sounds, so you can hear his steps.


I am not going to tell you the answer now. Let us see how good you are. Hopefully, by the end of this lecture, you guys are all great, and see if you were able to pick up the problem that this marathoner came in for. We are going to come back to that later. A little bit of a challenge for you as we are moving through the lesson.

This was another one that I got. A text to me, which I got, which I want to highlight. This was a patient of mine that was mowing his lawn and the lawn mower went over the hill. He tried to pull it back towards him and it ran over his foot and chopped off his toe, so we needed to have it amputated. Very interesting. He developed that phantom pain and needed to have a TENS unit implanted into his spine to stop the pain that he was feeling from the toe that wasn’t there anymore. But what we think about is the importance and significance of the great toe. My brain always goes to, oh boy, how are we going to make up for his gait pattern without a portion of his toe? How do I have to cheat the system to get that very important motion back? The big toe is so critical with our normal gait.

Here is him walking post-amputation here. He is really supinating, only walking on his back outside. He will not use the front toe. This was a couple months after his amputation, too much pain. We think about there is no way that that person is going to have normal motion. What happens to the kinetic chain? I am going to shut the sound off so you can see and focus. What happens to the kinetic chain when he loses all this motion? Let us talk about the knee and the hip and the back. What is going to fail next? You certainly can see that his affect or his whole psyche is different. As we move forward we will continue to talk about that.  That is something we cannot forget about with athletes, is how they are emotionally responding to injury. This picture on the right is of my grandparents. I try to include them when I can. They were married for seventy-five years. They landed on a slide deck by accident one day. I figured that was a sign and I had to keep them. That is grandma and pop there.

Here is his toe, post-amputation. If we look at the research on how important that big toe is, it really plays a large role in your performance, not only on your stance leg, for sure, and you lose the ability to control directional changes with your body. Forward and back, switching weight, turning, and pivoting. Your balance is significantly different when you are not using that big toe. We are just using this as an extreme example.

What about when somebody just has a toe injury or toe stiffness or loss of range of motion of the toe? The same thing happens. We lose balance. We lose the ability to transfer weight and change directions efficiently, so do not negate looking at the great toe. I have had several athletes that were just having trouble doing skills, and it came down to the big toe had just lost a lot of motion and had inflammation. They did not think it was anything significant. Once we improve that, lo and behold, everything comes back. That small little area of your body really has a large impact on the movement, all the way up the kinetic chain.

When we think about evaluating an ankle, we also need to think about the functionality. That is why for this module, we put the two together because I have a very hard time just doing an eval and not looking at the functionality of it, too.

Let us move forward and let us look at the talus. The talus is this bone right here. Here’s your tibia, here’s your fibula. This was a patient of mine that had a trimalleolar fracture, so a fracture here and here. Here’s the talus in here. It is a very important bone.  If we think about that talus and that talocrural joint. This is your tibia and fibula. Come down, and here is your talus sitting in there. The importance of that ankle rocker mechanism. As you are walking, that ability to rock on that is super important. The motion through this joint and this fluidity is very important post ankle sprain.

We have to also think that the talus has no muscular attachments to it at all. What are the series of effects on a faulty talar pattern? This is something that is so overlooked with ankle injuries. We really need to get in there. Once the acute phase is over, make sure that the talus is motioning normally. Super important. You are going to see your ankle sprains, as they are getting better, improve a little bit quicker once you get that talar motion.

Let us look a little closer at the talus and how it sits in that calcaneus. Here is your calcaneus and here is your talus. It is a very odd-shaped bone. This sits right here and it contributes to that rocking motion. We need to understand as we are adjusting that, we want to think about traction, but also its ability to roll on your calcaneus. It is important. If we look at the top, the facet here and on the sides, it is such an important aspect. Then, look at the facet here that articulates with the navicular. Can you understand when this is not articulating, it is not moving? Your whole ankle is locked up. Again, as somebody gets better, the long axis tractions, a little bit of rolling, and a talar glide adjustment are super effective with speeding up recovery once the ligament structure is somewhat healing.

Talking about the talus too, we will explore and understand what happens when somebody injures their anterior talofibular ligament. We said that was the most commonly injured ligament in the ankle. A lmost 87 to 90 something percent injured of this ATF. If somebody injures this ligament here, that is an inversion ankle sprain, and the ankle is rolling this way. Can you understand how that happens? The talus can hit up against the tibia and cause what we call a talar dome lesion or an osteochondritis of the talar dome.

There are many different types of these osteochondral defects, but what happens in a severe ankle sprain is that the talus will butt up against the tibia and cause a compression fracture or microfracture of the area here. This is how it looks on MRI. On plain X-Ray, you might miss this. Not all these are visible and even a type 1 is not even visible. My point in showing this to you is, as you are evaluating your ankles, if it is a more severe ankle sprain or someone has a lot of motion of their ankle, they have injured it lots of times before, they may have a talar dome lesion, so make sure you put that foot in a little bit of plantar flexion and you make sure you palpate the talar dome for pain up in this area. It is an important part of the ankle assessment.

The most common site of an osteochondral defect is the talus, so it is super important not to forget about looking at this. It is on the medial aspect, so understand that is usually because of a lateral ankle sprain and that is why we see it their most commonly.

Here is another view of that talar dome lesion. They can progress not only from like a microfracture to forming like an osteonecrotic area where this breaks off the bone. You can get it where it completely breaks off and floats around the joint or it can just sit there and be stable. This is a stable defect here. This would be something that becomes more unstable that would need a surgical repair. It is important for you to really make sure we are not forgetting to assess that.

If you can see the location of this one, this is probably not from an ankle sprain. It is not on that medial side. It is right in the middle. That is more from repetitive stress. You can tell what it is from by the location.

This is an osteochondral defect. We talked about several types. This is a talar dome lesion. We have to understand the sport where the person is at. This is a stable one. I see no fragments floating around. Sometimes these correct themselves over a period of time. We keep an eye on them. We just decrease impact if they are having pain there for a little bit, and then try to figure out the why. Is it that we have a vascular area of the talus? It is a poorly perfused area with blood. Or is it that there is so much repetitive trauma? Or do I have another issue, a metabolic issue? We should consider all these things when we start looking at injuries and then going forward like that.

We are going to take a minute and look at these Ottawa Ankle Rules. The Ottawa Ankle Rules tell us when we need to get an x-ray for an ankle injury. It is very important to consider you will need to get an x-ray when these things happen. When there is any bone tenderness, you want to think about the lateral malleolus here. The base of the fifth metatarsal here when you have any bony tenderness, or they cannot bear weight. Those are the times that are your red flags, called your Ottawa Ankle Rules, and that you need to make sure that you order an X-ray or send out for an x-ray.

Let us go backwards. Here, the Ottawa Ankle Rules also pertain for the medial side of the ankles. The same thing. Medial tibia or fibula for the lateral side, and the navicular here. Okay. We need to understand bony tenderness, distal fib or distal tib or base of the fifth metatarsal or navicular or they cannot bear weight. These are the times we send out for an X-ray. Good.

This is called Thompson Test. Thompson Test is to rule out Achilles tendon rupture. Notice here that when I squeeze her calf, I get a mild plantar flexion. When I let go of her calf, it goes back into dorsiflexion. That is a negative test. That tells me that the Achilles is intact. When somebody has ruptured and you squeeze the calf, it will not move; it will stay just like that. That would be a positive Thompson test. Understand, this here is a negative Thompson test. When I squeeze the calf, the foot will mildly plantar flex. That rules out an Achilles tendon rupture.

Let us then start getting your brain going a little bit as we move further through this lecture. We want to think about what is going on with this athlete. I want you to start putting your brain into case studies as we dive a little bit deeper and get you working on what do you think? I want you to look at this picture on the left and I want you to think about and jot down a couple of thoughts. This is an athlete, a gymnast, post Achilles tendon rupture on the right side. Never really rehabbed properly, sent back into sport, and re-ruptured again. How could you send this person back into athletic activity? That is my point. We can do better than that. We can rehab somebody completely and correct all these million faults I see all the way up to her hip that are going to just predispose her to injury again.

If we take her lateral view, we can see the genu recurvatum here. She’s just waiting to happen, and other injuries waiting to happen. Consider the whole chain that we have got to correct in order for her to be able to get back, not just looking at the Achilles and stopping there. That is not going to do us much good. We need to be able to move forward and really understand that we have got to look at the whole kinetic chain. You need to correct everything or they are walking into a lion’s den, and they are just going to get injured again. That is what happened with this athlete.

Here is a closer look. Here is the scar here, post this Achilles tendon repair. She needed to have it surgically repaired. Lots of research on Achilles tendon and thinking about, do I surgically repair it or not? It is a mixed bag. It depends on where it is ruptured, number one, the age, and the activity level of the person. I am going to leave it to you to do some reading on your own on these Achilles tendons.

She had a musculotendinous junction tear here, surgically repaired, re-ruptured because they were doing a lot of deep scar tissue release. For this particular musculotendinous junction injury, you need that scar tissue to heal. It re-ruptured because they broke down the scar tissue. They did Blood Flow Restriction PT on her, but the problem with the rehab of Blood Flow Restriction, particularly for an Achilles tendon and your gastric. We have this interesting nuance with these gastroc injuries, these Achilles tendon ruptures. The gastroc muscle wastes very quickly. Within 7 days we see a big change. But then it gets something called metabolic resistance. The number of mitochondria down-regulates, and we lose the ability to gain muscle, to become anabolic again. If you do blood flow resistance training, our mitochondria needs that blood flow to grow and proliferate. You are precluding the problem from getting better. The treatment regime was just incorrect for this problem to allow the anabolic nature of that gastroc to come back with the blood flow restriction.

If we are going to do this a little bit better, we are going to get a better strategy. We are going to give homework to the athlete at home to speed up recovery. We are going to look at the gait. We are going to look at the whole kinetic chain.  We are going to correct everything, her genu recurvatum, her core strength, her shoulder rounded forward. We need to fix everything and push reset on her and then see how that progresses. That is your plan.

When we think about an ankle that you will see acutely, we need to know what is your plan? Are you going to wrap or tape them? Are you going to brace them? Is there an imaging issue? Do we need to refer them out? When you get your assessment skills together, you need to have a plan there. Let us talk about that for a minute. What I did for you was I videotaped an ankle assessment. This is my order of events here. I thought it would be better for you to see what a full ankle assessment might look like, and then you can practice over and over again. It is very important for you to practice your assessment in an order that allows you to not forget structures. I have been doing this a very long time and I still do the same order all the time, and that way, I make sure I hit everything. Sometimes you are surprised. Sometimes you have something there that you did not think was going to be there, so it is really important to consider all of that.

We are going to observe the area for ecchymosis and deformity. You are going to look for the patterns of edema, comparing good to bad. You are going to compare active and passive range of motions from the good side to the bad side. You are going to palpate all regions for tenderness. We talked about those Ottawa Ankle Rules. We are going to look at the distal tibia, the distal fibula. We are going to look at the navicular, the base of the fifth metatarsal, all the tarsals, and all the metatarsals. You are going to do a manual muscle test in all planes. You are going to do your anterior Talar Tilt. I said I do that in a little bit of plantar flexion and at 90. Your anterior drawer test and that is for your ATF also. We are going to do a valgus or eversion stress for your deltoid ligament. The Squeeze Test for your high ankle sprain. You can also use your wedge test for your high ankle sprain as well. You are going to check the talus for those talar dome lesions. You are going to do the Anvil test for fracture, Thompson test for gastroc. Always check vascular, neuro assessment as well.

Let us watch an evaluation. I am going to talk you through it a little bit. This starts with our active range of motion here. I do this for every single patient. Once they do an active range of motion, then I will start with a passive range of motion. Here is a manual muscle test in all four planes. Then here is my passive range of motion in all four planes. Palpating distal fibula all the way down, looking around that malleoli, palpating distal tibia all the way down to the medial malleoli. Then, I am palpating the navicular, base of the fifth, the talar dome. There is your palpation there. Then, all of your tarsals. Metatarsals, too. Make sure you are spending some extra time on the base of the fifth metatarsal. It is super important for lots of injuries to that area. We will talk about that. Looking at your peroneal tendons, here’s Anvil test. Palpating anterior talofibular ligament there, calcaneofibular ligament there, posterior talofibular ligament there. You are looking for tenderness. Palpating the deltoid ligament on the medial ankle. I always check the Achilles tendon for tenderness and edema, peroneal tendons, too. Then I start muscle testing for peroneal tendons, posterior tibialis tendon, and then we do peroneus brevis and tertius, and then extensor hallucis, anterior tibialis, extensor digitorum.

We want to make sure that we are looking at everything. Here is your Talar Tilt at 90 for calcaneal fib, plantar flexion, Talar Tilt for anterior talofib. Here is your drawer test for anterior talofibular. Eversion stress test for deltoid. Again, I always check that posterior calcaneal area for retrocalcaneal bursitis. That is your ankle assessment. Just take that, videotape it, play it over and over again, and practice that. You will be awesome at evaluating an ankle if you just do those things.

We think about our treatment progression. We have an ankle sprain. You have diagnosed your ankle sprain. What is your plan? We need to talk about that too because you need to have that nailed down. Number one, foremost, always is you have got to get rid of the edema first. If we do not get rid of the edema, we really do not start healing. The range of motion will always be in a stuck position. They will always have pain and the tissues really do not start healing until we get all those inflammatory modulators out of the way. Once we get edema reduced, the range of motion will come. We are going to be working on that. Then, we are going to begin our strength and proprioception. Do not forget about proprioception. It is the most critical part of any rehab protocol for someone that is returning to sport. And then we are going to begin our strengthening and our return to sport plan in straight planes, in other words, running forward and backward first. Then we are going to go to lateral motions last. That way, we understand the difference.

This is an interesting athlete with a left peroneal tendon rupture. Really notice how he stopped using his toes. Can you see how his toes just is not active? We do not see them pushing down on the floor and holding it steady like this. They become a bit flaccid. What happens is when you are not activating your toes, you cannot stiffen up your lateral ankle here, your cuboid, and you cannot activate your peroneal tendon, so the body was super smart and figured out how to shut off this peroneal tendon when it ruptured if he just did not use his toes. But the problem becomes that we need to reintegrate normal motion in someone that is had this for a year in order to return him. We have got to reteach his toes to work because they have shut off. They are out to lunch. We have to consider all these things as we come back. It is not just the one problem.

We have your acute ankle sprain. What are you doing that day in your office? What is your plan? Are you going to ice? You are going to do compression. You are going to do elevation. I always find that E-stim on the area, the day of an injury really speeds up my overall recovery, so that is the thing I like to do. There are lots of controversies with ice. I still use ice in the first 24 to 48 hours with somebody. I just find I can get to where I want to go faster. Elevate. Now, I like to wrap. I did not wrap this patient. I typically will take pre-wrap and wrap up between the toes and all the way up to the mid-calf, because you do not want to allow the swelling to drop down into the foot because then you have to get rid of it all. The more swelling you can prevent, the faster the person will get better. That is why you are going to keep it up. This is an Air cast that she has on here. That will prevent medial and lateral roll. This would not be for a high ankle sprain. I said, for a high ankle sprain, I put them in a boot. This is more for an anterior talofibular or calcaneofibular sprain or even a deltoid sprain up to a grade 3. I can put them in this. Grade 3, actually, I might put in a boot, but a healthy grade 2 would be in here.

If they need crutches, they are on crutches for the day. Home instructions are very important. Take time to tell them what you are going to do. You are going to ice it every two hours. You are going to elevate it. You are going to wiggle your toes. Wiggling those toes obviously helps move that swelling down. Keep it elevated. What I like to tell people is take a blanket, roll it up, put it under your whole mattress, and that way, all night, your feet are slightly elevated. Just a little bit. It does not need to be a lot. And then you want to see them the next day. You always want to check these injuries the next day so that you can just double-check yourself, do another reassessment, see if anything’s changed or different or if you need to plan a referral.

As your rehab starts to progress, we want to think about, we did the range of motion, we are doing passive and active range of motion first. They are wiggling their toes. They are going to spell the alphabet with their foot. So, that is what I tell them. When they are home, I want your foot up three times a day. I want you to spell the alphabet with your foot, so this is an a, this is a b, as your foot is elevated, because what happens is that movement will pump the swelling down out of the ankle. We want to make sure that we have gravity and the movement to go ahead and pump down. Then we are going to bring them to the office and elevate them. And then I do passive range of motion in the office. Just nice and gentle. Nothing painful.

As they progress, then I will start doing some resistance bands. You are not going to start strength too soon. You do not want to start strength the first day or two or three. Maybe by day four, if it is a very mild ankle sprain and they can do it, but you have got to watch that you are not doing it too soon. When you are ready to incorporate your strengthening, you can use TheraBand. Here is an example here. This would be an inversion, e-version, plantar dorsiflexion.  So, here is plantar flexion, dorsiflexion here. This here would be inversion, and this would be eversion. I like to stabilize the leg with my other hand. If they just do small motions, you could start with a very light resistance band and then gradually increase that. You also can start with just a couple of repetitions. Maybe the first day you are just going to do five repetitions on a very light band, and then you will increase that till they do maybe 12 to 15 three times in each plane. Then you can even teach them as you progress to do that at home if they are able to.


The other thing I also like to do is toe raises. I tell them to do this when they are brushing their teeth. We do it also in the office. We do three sets of 15, toe straightforward. Here. Then toes turned out, and then, toes turned in. Making sure they are doing those toe raises to help keep that foot control, that gastroc strength. We want to do them with a straight leg and a bent leg so that we get the gastroc and the soleus complex. It is super important to include and not forget about the soleus. That is really our powerhouse muscle. It is very underrated in the past but we are really finding out with the newer research that it is really all about the soleus.

Then, as we progress, this is the BAPS Board. It is a nice thing you can use early on, seated, when they cannot put all their weight on. Again, we are going to work from non-weight-bearing to weight-bearing activities. This will help with range of motion as well as starting our proprioception.

Sensory motor stimulation or proprioception is a very important part of rehab. We cannot forget it. With injury, our brain forgets to adapt for where your body is in space. The kinesthetic awareness, when we do not rehab that part, you send them back without the ability to make corrections. Then they are running on a field and maybe the field was a little off or they step in a hole, they are not going to be able to make that correction to prevent injury. It is a very important component of your rehab.

We will do the BAPS Board here. They sit and they try to tap each edge of the board down without moving their knee so that their foot is rolling the board. They do it seated in the beginning. And then, when they can weight bear, they stand on two feet, and then when they get good, they hold on to something, they do it on one foot. That is the progression of the BAPS board.

You can also use a wobble board, which is very nice. It does not go all around the circle, but you have forward-back motion and side-to-side motion. This might be a good progression before you do the BAPS Board if somebody’s too unstable for the BAPS Board. It is very important that they start learning how to control in multiple planes. It also speaks to foot intrinsic muscle strength. Super important for recovery.

We need to think about our return to sports plan. What is the measure of readiness? When do I know somebody can go back and start participating in sport? How do I progress them back? What is my first step? What is my second step? That is what we are going to talk about next. We are going to talk about how you work somebody back into sport. I will tell you I really want them back better than before. We saw the gymnast that was sent back worse than before, so she was set up to fail. Let us not emulate that. Let us make sure that we can take them to the next level.

The first thing we need to think about is for you to start rehabbing them in more sports-specific drills, which is something we need to do as we are progressing them. We need to think about, what does their sport need them to do, and what type of strength and rehab can I incorporate to promote those motions or those muscles? In the beginning, you might need to tape or brace them for rehab, or as they return to sport, and maybe just do drills non-contact or just do some light exercise, you might want to tape or brace them. What I did was I just videotaped a taping procedure. This is a regular rigid tape, so this would be a post-injury, more of a rigid stabilization type taping. It is called an ankle Gibney tape. Basically, it just prevents you from rolling in or rolling out depending on how you pull the tape. Let us watch this. If you want to record this, watch it over and over again. Please, please, please practice taping. When we see you for Hands-On modules, we will be practicing this, so I am going to know who practiced and who did not. Let us just watch this here. I will turn the sound off.


These are Heel and Lace pads. The Heel and Lace pads prevent friction in the tendons in the front and back of the ankle so that you do not get a blister. This is called pre-wrap here, and the pre-wrap also, same things. It protects the skin. When we are really taping somebody, I like for them to shave the leg so that you can tape on the skin, and that way you have less sliding of the tape. It is actually a little more stable. You are going to begin your tape right where their gastroc comes in to meet the leg, so higher up.  I would have liked this tape a little higher. It is a little low for my taste. But two ankle stabilization foundation straps, and then another one down distally. These are your proximal and distal markers. Making sure that the furthest down you are going to come is just behind the base of the malleoli because you do not want to compress that.

This is called a horseshoe. It goes from medial to lateral for lateral ankle sprain. You are going to pull up on the lateral side so that you push them into eversion and lock that ankle in. This is a C-strap here and this is called an open basket weave. We are going to alternate between this horseshoe and the C-strap. You are going to overlap the tape by half, moving forward on your horseshoes, and by half moving up on your C-straps. That way, slowly you are moving up and forward in your tapes. You are going to see how I keep slowly inching forward and up. Again, a series of three of each alternating or basket weaving them together and really pulling the tape up on the lateral side so that I lock them into eversion. That is really important.

I would like this tape to come a little higher on the calf. Here’s another C-strap, and then you see that little area in the front of his leg that is open with pre-wrap. We call this closing the window. Then we do our C-straps around and we slowly work our way all the way up the leg here to your foundational straps, where we close that window. Again, we always want to alternate or overlap the tape by half and making sure you do not have a bunch of wrinkles. If they have wrinkles, they are going to get blisters, and they are not going to want you to tape them again. That is why you have got to really practice. Again, overlapping by half, so you will work all the way up. Then we are going to begin our figure 8s and heel locks where you are going to go behind that heel under the foot and up and behind the heel under the foot and really pull out early to lock them into eversion. That is the important part of this tape, is that you lock them in eversion. Do not lock them in inversion. They will sprain again.

Then we are going to do the heel lock in the opposite direction. Again, pulling into eversion and then doing a figure 8 wrapping around the ankle. I hope you have all that. So, lots of practice. These are open C-straps very gently laid over the foot on the top and bottom not connected so that the foot can spread out when it steps. That is why it is so important you start that tape behind the base of the fifth metatarsal so that the foot can spread out when they stand. Lots of research on that last strip that comes forward has shown that when you put that piece of tape on the dorsum of the foot here and you put that last little strip here, that little half strip you saw me put, it is a stimulation to the brain to get it to dorsiflex. We have noticed in research that if we have that little piece of tape, they tend to not plantar flex as much. When they are in dorsiflexion, it is a more protective position for the ankle.  Dorsiflexion, eversion. They are not going to sprain again. We want that little half strip again not too tight. Do not compress.

When we think about tape, there are lots of different ways to tape. It is only limited by your creativity. But you must understand, it must make sense and it has to be doing what you want it to do. I will tape lots of different ways depending on the athlete, what is practical for that athlete in that sport, and what I want the tape to do. But it cannot just be some wonky tape that you made up that does not do what it is supposed to do. So, make sure that you are proficient in what you are doing, and it makes sense, and not just laying tape on there because you need to lay tape on there. You must understand what type of footwear the athlete is wearing or are they barefoot? If this is a gymnast that is on a balance beam, is this going to work? Or is she going to be able to turn in her toes? Or she is going to slide off the beam? You need to understand, is it functional for that athlete? Is it safe for that athlete, and is it doing what I needed to do? This is a dynamic tape procedure. It is wonderful for lots of athletes for propulsion. It helps create that windlass mechanism. We will be doing a lot of the dynamic tape in the hands-on module, having lots of fun with it. I love that product too. Do not worry, we will get to all that.

Moving on with our progression of rehab here, we want to think about, now we are talking about return to sport. We have somebody getting better. What are some of the things that I can do not only in rehab and in therapy but as they start returning. Really important. This ankle hopping progression is super important. It prevents a ton of ankle sprains. This is even something that they can always do in their warm-up after their injury, and you will see several ankle sprains not happening because of this. Really, we start them forward and back hopping. Real simple. Making sure that they feel safe, and their ankle feels stable. And then as they progress, they are going to move side to side. Again, a little more challenging because we have lateral motion here. We are going to do just 30 seconds of each motion in the beginning. And then as we work through the progression, we are going to go ahead and we are going to go to single leg hops, forward-back. The goal is to get her to work up to a minute, hopping on the injured side for strength. We can look at this one here. This will just be single leg forward and back and single leg side to side.

Again, this would be our next progression. The more advanced would be this one here where they are doing a triangle, obviously. And then, side to side. They are going to be nervous doing this side-to-side pattern, particularly if they have a lateral ankle sprain stepping back to that side. We can really measure readiness by not only their confidence in doing this and their ability to do this but their ability to do well, also. Not limping, not jumping, not stopping early. These are great activities and some ideas.

Then we want to think about, how do I keep progressing them past that. When they can walk without a limp, they can start progressing. We have got to get them to walk without a limp, and then when they can run without a limp, we can begin short distance running stuff. We want to begin those sport specific exercises as soon as possible so we can increase function.

I want to just take a minute to talk about that. We need to be able to cross-train them too. Because they have an ankle sprain does not mean they cannot do handstands or press handstands or cast handstands on the bar, or for another athlete, something with upper body or swim, cross-training. We do not want them to lose their global strength. We need to be a little creative in protecting the injury but keeping them active in a safe way. Beginning with those straightforward motions, forward and back. The proprioception is super-important. It strengthens the region globally. Everything. And then we want to slowly add time and intensity on. If we just start with 10 minutes of activity, then we are going to do 20, then we are going to do 30, and we are slowly going to add to it. They are almost doing a practice. You are going to have them continue that strengthening plan.

We are going to talk about medial tibial stress syndrome. A lot of you are familiar with this more so than you think because these are our stress fractures. These are those stress fractures that we might see more commonly in women than men, more commonly with women that have a lower BMI, metabolically challenged. They are not eating enough food to sustain their metabolic rate and therefore adequately turnover bone. Somebody that maybe has Vitamin D deficiency, so metabolic issues as well. It is due to repetitive trauma of the area. We also know that it is predictable for somebody that has a narrow tibial width and hip external rotation. That is an interesting thing to think about.  Somebody that continues to get shin splints, we need to see, are their tibias narrow. Do they have that hip external rotation? Or let us look at the shoes.  Are they running on poor shoes, so are they pronating too much? Are they in a barefoot shoe, and maybe they cannot be in a barefoot shoe? They do not have the intrinsic muscle strength for that of the foot? Looking at all these things for tibial stress syndrome, and then, of course, the tibia, hence, the name medial tibial stress syndrome, is the most common site for stress fractures in the lower extremity of all. And then followed by the fibula. We are going to go ahead and we are going to go through that. Just a little more detail.

Let us look at shin splints. We are going to see that we have a very common sight in this medial tibial border. Here. We also are going to look at the distal fibula and then be wary of the pain in this anterior tibialis region because sometimes that can turn into chronic exertional compartment syndrome. That is something completely different and something that is more prodromal or lasts for a long time. The most common site for tibial stress fractures is 12 to 15 cm above the medial malleoli, so in this area here. What you will do is you are going to palpate down the tibias. I like to go to both sides at once. You can feel the periosteum lift in the area of pain, and they will have exquisite tenderness in that spot. That is your idea that either you have a pre-stress injury or a stress fracture. You might have to order imaging or decrease load and get them off their feet and cross-train for a little bit. The mid-shaft stress fractures and medial tibial syndrome are the ones that have a high incidence of nonunion or they do not heal well, so we need to be a little more conservative with having them return to sport until that is really fully healed.

Here are the stages of medial tibial stress syndrome. We have a grade 0. This is normal. Your grade 1, you are going to have mild edema. That is periosteal edema here, so your periosteum lifts, which is actually quite painful. Lots of neurovascular input in the periosteum, so this is a very painful structure. Here in grade 2, we have marrow edema. We can see this on a T2-weighted MRI. But then we also start having these bony changes that we see, and that is how we can grade the difference. We really see that difference on MRI and we really understand how we can better differentiate the two. And then we are going to look at grade 3 with more bony reactions. Grade 4 is where we start to see bony changes in multiple areas of the bone, and then, grade 4, we just have a linear fracture line.

This is the high incidence of non-union in that mid-tibial shaft, medial tibial stress syndrome. We need to be careful of these because these turn into those long-term injuries. We also need to be careful of these for chronic exertional compartment syndrome because that is a huge part of it. It actually starts with medial tibial stress syndrome and turns into a long-standing compartment syndrome. Good.

Understanding the foot structure. You can cheat sometimes by looking at the wear pattern on your athlete’s feet and in their shoes, and their callus formation on their foot. Understand the difference between the severe pronation and take a look at their feet. See what muscles are more developed. See where their calluses are formed. Then look at their shoes. See the wear pattern of their shoes. Then you can really understand what type of foot strike they have and how they are using their foot. That also helps you make corrections, but it also helps you understand what is happening. If I am a supinator here, can you really appreciate how I am using my peroneal tendons way too much? Somebody like that is more prone to a peroneal tendinopathy or peroneal tendon rupture. I know if I have my supinator, I have got to try to get them more to that mid foot stance here. That way, I do not really stress that peroneal tendon now. Looking at those callus formation and the shoe wear pattern is a very important way of getting somebody better.

How do we understand the cascade of events that happen for injury? This is an avulsion of the growth plate of the great toe right here. This needed a surgical repair to get that growth plate back in. We worry about the growth plate of the toe, particularly in these youth athletes. What is the overall prognosis for that? If we start with this injury here, what is going to happen up the chain of command as they are growing? What is going to make up for the motion that they lose there? That is an interesting concept. As years go on, down the road, we can trace these injuries back to the first injury that created the faulty pattern.

For this particular athlete here, they had this injury early and developed chronic exertional compartment syndrome in the fascia. This is a cadaver. I work in the cadaver lab doing a lecture once a year, and I am always interested in compartment syndrome. It is one of the things that I do a lot of research in and reading on because it is one of those real stubborn things that a lot of people do not know a ton about. It does not get better. I am always looking at this fascia. This deep investing fascia that traps the nerves, the blood flow, the muscles, do not let things glide past each other. But if we look at the imaging capabilities, we really cannot see fascia very well. It is too thin, so it is under appreciated. I think we need to understand where the problem comes from and what are the long-term ramifications all the way up that kinetic chain even with something as simple as fascia.

As we are considering injuries and evaluating, we cannot go through this lecture without at least mentioning parental concerns. You need to be able to meet and consult with parents for youth athletes and explain the injury to them. Explain home care or explain referrals. If you need to get them to the emergency room or to a doctor, you need to be able to effectively communicate with parents. The best bet is always to just be honest and put your athletes’ best interest first. That is an important component if you are working with youth athletes.

If you are going to be working on the field, be prepared for trauma. You might be in your office 99.9% of the time, but if you are asked to work in event, please be prepared. Understand what you need to do if someone gets injured on the field because you might see an injury that you do not typically see. As sports chiropractors, we need to be prepared for everything and we need to be equipped to handle everything, have the supplies necessary that you need, have an EMS emergency squad back up if you feel that you need that for that particular sport, make sure that the EMS is on alert or you have an idea how to get them there. A great example of that is I worked at a track event and we had a thermal injury, so someone with a heat injury and heat exhaustion. Basically, if I had not google-mapped the entrance to the track, which was not the address of the track ahead of time, the emergency squad wouldn’t have gotten there in time. Because I had prepared and had told them that they needed to go through a different entrance on a different street, I would have not gotten them there. Make sure you are prepared with little things like that sometimes. Sometimes that makes a big deal.

This is an injury that I saw when I worked at a football event. You can see that his ankle is on sideways. This speaks to being prepared. What do you do in this scenario? What do I do if they have asked me to cover an event, and now this happens? You have got to go back to your basics. You have got to check for blood flow. You have got to check for sensation. Start with the basics. We always go airway, breathing, circulation. Well, we are going to go with, do we have circulation? Can you wiggle your toes? Can you move your toes? Great. Stabilized transport. Let us just be efficient and let us make sure we are doing the right thing for the athletes. Here’s another view also of him. Once we got into the hospital, we took everything off and he has an open dislocation fracture of tibia and a fracture of the talus, so he required seven surgeries to get this ankle better.

I want you to also be aware of the patterns of edema. Always looking at this tells a story. Our typical ankle sprain will have this, dropping of this, a little bit of ecchymosis down here laterally. The injuries to the anterior talofibular ligament or calcaneofibular ligament, we will see this dependent edema for a typical ankle sprain, and it dropped down here. I worry about this little bubble here though and I want to look at the base of the fifth metatarsal there. Just making sure we do not have an injury there. We talked about that earlier. However, when this athlete flipped their foot over, I saw this. This does not worry me; this is run-of-the-mill stuff. I saw this. We have got to think about that because we know that the posterior tibialis tendon runs down here, and I have a little edema here. But the thing about the posterior tibialis tendon, it loves to shear vertically. It likes to start with a little tiny tear, and if you ignore it, it just keeps tearing up and up and up until you need surgery. Once I saw this, I am like, “We are going to put you in a boot and we are going to get you first an imaging just to make sure nothing else is going on before we start progressing.” Just knowing those little nuances and taking the time to look at the athlete in all different directions and those patterns of edema is really important.

The way they tie their shoes is very important. I am the shoe Nazi of my office, but if we have lateral stability or we pronate a lot, if you use the top hole in the shoe and do what we call a runner’s knot, they get a better control of their ankle. If we have good control of the calcaneus, the foot cannot pronate and supinate too much. We need to think about that. Good calcaneal control. Making sure that they are untying their shoes when they take them off and they are not just sliding them on and off because that will stretch out the top of the shoe and they will lose support. Here’s an example of how I make all my athletes tie their shoes. This is called a runner’s knot. You use this extra little hole at the top that nobody likes to use, look right here. You leave the loop there and then you cross the edges into the loops, there you go. Once you do this and someone walks around, they are like, “Oh, that is so much better.” We do this. They are not going to come loose. It gives good support. It helps that calcaneus with support and helps you prevent a little bit of pronation. Of course, I always double tie the boat for them, so it does not come untied. Just like a little trick if you are working with somebody and you are seeing a little too much motion when you are looking at their gait, this helps control that a little bit.

Then being able to understand your x-rays, what is normal? This is an extra bone right here in the back, a flabella. This basically was read as a fracture, and this athlete was put in a boot for a period of four weeks. This is not a fracture at all. This was just an accessory bone. That is a normal variant for this patient. That was just inappropriate care on the part of the physician. After four weeks, how much atrophy do we have of a calf? That is now our big project to bring back. Whereas we had a mild injury, that would have been easy to bring back, now we have a complex injury. I have got to get a gait pattern back. I have got to get all the motions in the foot and ankle. All those 26 bones, 33 joints. I have got to get everything moving again in the ankle and I have got to get the muscular weakness. I have got to get the foot intrinsic muscle strength back. I have got to get proprioception back, gastroc and soleus back. It would have been easy. But after four weeks of immobilization, not so easy anymore.

Again, looking at these patterns of edema. This is a little higher. I am more worried about a high ankle sprain. When we see a regular anterior talofibular sprain, it sits in the sinus tarsi area here. When it is a little higher, I am going to make sure I am looking at the fibula for any fracture, but I am going to do that squeeze test, we talked about the squeeze test, to see if they have a high ankle sprain. That is really important.

I want you to look at these lateral views of this here. This is a ruptured Achilles tendon here. You see, there is no Achilles tone anymore and we can see that here’s the Achilles tone. You can also compare that to this side here. That would be the big difference from side to side. That is an acute that just happened. About an hour before this exam, they came right to me.

Here’s another trick. You can see when the Achilles is intact, we get that plantar flexion. We talked about the Thompson test where you squeeze the calf, and you get that passive plantar flexion. Well, when it is ruptured, you just do not have that. So now, they are sitting in a little bit of dorsiflexion, and that Achilles tendon is just ruptured. That is a good way to diagnose it, too.


Again, we talked about this case earlier. Here’s that healed Achilles tendon surgery. We have to think about what everything is we need to fix as we bring somebody back to sport? Particularly if it is something of that nature. How many things do I have to correct?

Sever’s disease is inflammation of the growth plate in the back of the heel and the calcaneus. As they have their calcaneus, you are going to palpate medial and lateral and they will have pain back there. It’ll be pain more from repetitive trauma of landing on the heels. Our gymnast is huge and a youth gymnast, so obviously somebody with an open growth plate. We need to be able to manage issues like Sever’s disease and wearing a heel cup or something that absorbs the shock or landing on soft surfaces or decreasing the number of repetitions that they do. These are all things we need to consider with Sever’s disease. That is an active Sever’s MRI right there with a lot of inflammation.

We need to consider the sesamoid bones too. The two bones are in the flexor tendon here, the toe. We need to think about inflammation in that area and pain. What type of footwear you wearing? Are you wearing enough cushion underneath your feet or are the sesamoids inflamed? That sesamoiditis is a very big deal because what happens is you lose great toe extension because the sesamoid bone here is inflamed, so therefore the great toe is not going to extend. Again, we talk about that great toe earlier, and how important that is to get that normal range of motion. If I do not have 55 degrees of extension of the great toe, I am not going to have a good running gait. If I have sesamoiditis, I have got to shut them down and pull them back from running and calm it down. Get a good cushion or donut around the sesamoids so that they can heal.

We have to think about how important that area is, and then as we look at somebody’s feet, take the time to look at the callus formation here. How is she using her two feet differently? What is happening that she’s pushing off of her toe? Is she pronating too much on the side? If she’s everting and pronating on this side, is she pushing off more on this side, and that is why she has sesamoiditis? Really understanding the effects. What actually happens? What are the long-term effects?

We cannot look at the foot and ankle without looking at plantar fascia, plantar fasciitis particularly. We all are very familiar with this, where the plantar fascia comes down and attaches. Here they have pain on the medial calcaneal area inferiorly. They have an area of point tenderness. They can get little tearing or micro-tears or inflammation of the area. Best to have them in a more sturdy shoe, so not so much motion. They can do tennis balls rolls on the bottom of the foot, icing the bottom of the foot. We need to do some laser treatments and some massage. I do a lot of stretching of the extensor hallucis in that area. They tend to get better quickly. Just being diligent and making sure they are not walking without shoes in the house and that they are not too flexible with their shoes. This used to be a very common injury post-illness. They were in bed for a long period of time and they get out and start walking around and they develop plantar fasciitis.

A Lisfranc Ligament is the ligament that sits right here from the medial cuneiform to the base of the second metatarsal. With a Lisfranc injury, that is torn and they have a separation of the first and second metatarsal. That is a surgical repair. They need to have that surgically fixed. They can have a sprain where it is very mild in that area there. You will have the whole point tenderness there from that cuneiform to the base of the second met, but they can also have a rupture. And then that slides those two apart and that just creates a biomechanical disaster so they need to have that repaired. Here’s a picture of a Lisfranc foot right here, post repair, years later. We can see what happens to the rest of the bones. Here was her injury. Here’s the Lisfranc injury. We can see the rupture of that Lisfranc ligament and how that is going to change the separation. They will go in and they will repair that and pull that second met back over again. But just thinking about how that changes the biomechanics, and we have got to consider that with athletes as we try to return them to the sport.


We think about age and gender. Later on in your modules, you will have one module that is dedicated to the age and gender of athletes. But I thought it would be important to just mention. These are important considerations. What injuries are more predisposed in females versus males? We tend to see more trauma with males. They are a little rougher. They play a little rougher. They go a little further and harder out when they are in competition. We think about what injuries am I going to see different? What about age? I am going to see more Sever’s diseases or more growth plate injuries than younger. In the Masters, I might see more fractures. Or I might see other types of injuries. A lot of soft tissue injuries. We are going to go over that in a later module, but I just thought we’d glanced over.

This is a master’s track event that I worked on. We need to be able to be equipped for the older athlete, as well as the younger athlete.  Not everybody is that perfect age. We need to be able to work with all ages and understand how I would treat somebody differently that is a different age.

Again, we talked a little bit about footwear. We need to make sure if we are seeing problems. This was an athlete that came to me with a long history of foot pain. Just watch this running gait. That is painful to even watch. There are so many things going on with this gait that I was looking at it for a period of time. Let us look at her side view before we give you the answer. I want you to see if you can figure out what is going on there. She is hyper-flexing her elbows. Her feet are rolling out. Her hips are tight. Her glute med is not working, peroneal tendons are overworking, she has valgus deformity. I could list ten things at least just to start with when we are looking at this gait. But I looked at her and there is just too much to add up with her complaint, so I just had a gut instinct. I looked at her shoes. We took her shoes off, measured her feet. She was wearing shoes, a size and a half too small for her. Once we got her a pair of shoes that were her size, all that cleared out. Sometimes it is not the obvious thing. It does not add up, again, going back to earlier in this lecture, we talked about the mechanism of injury. She had no mechanism of injury. It is just gradually over the years, it got worse and worse and worse. Well, her eval was not matching her gait so we just try something different. Think outside the box sometimes. Checking the footwear saved a ton of treatment and she was better immediately with a much nicer run.

This is an interesting one. A twelve-year-old gymnast reports with left ankle pain. Cutie patootie here. I look at patients statically from the side and from the front. I look at them actively, either I walk them on the treadmill if there is somebody that does that type of activity or run them. Or for a gymnast, I might have her do some skills for me and tell me when it hurts the most. But, this case was pretty interesting. She just got back from Disney, walked for seven days without pain in her foot in Disney. When they got home, the doctor called the mom and said she had stress fractures all in her feet, her left ankle, and she had to go in a boot. Well, the story is she just came out of a boot for the other side, the right side. She was in a boot for four weeks on her right side. She goes to Disney, walks without pain, she comes home, the doctor says, “The left side has stress fractures in it or stress injuries in it. We need to boot her for four weeks on the left side.” They came in to see me, and I said, “Let us look at her. Let us look and see what is going on. Let us look at the whole kinetic chain.” She’s certainly off in multiple areas. We can see the pelvic un-leveling here a little bit and rotation of shoulder here. Hip internal rotation here. We can see pronation on that side. A lot is going on there.

Here is a closer look at her feet. You can see she pronates more on this foot here, but see, she puts more weight on your toes.  She really shoots her weight forward on her foot, we look at how much they grab the floor with their toes sometimes. We will have a clue there. Remember, she came with left foot pain. Here’s the MRI of her right foot. She has all this micro-fracturing of medial malleolus, remodeling chronic fracture, the edema, posterior tib contusion, and now her left MRI has the same.


We talked about trauma and everything mechanism of injury. When did it happen? She could not name a time or date. There is nothing new that she was doing in training. Guess what? It is time to think outside the box. You must go back and look at everything. You have got to look at everything when you look at a patient like that, that it is not adding up. She just walked in Disney without pain. We need to look at both and understand that now, she was booted on the right and sent back to activity. Now, she got the same pain on the left and they want to pull her activity again. The boot we talked about, the ramifications, muscular-wise, proprioceptive-wise, kinesthetic awareness-wise, and then repairing that. How long it takes for that.

But we need to understand that we have to look at the whole persona. What are the coaching issues? How many hours is she practicing a day? Tell me about her eating habits. Tell me about her sleeping habits. It turns out, which is very interesting with her, she had a very severe vitamin D deficiency. This was a long period of time that she went, and nobody looked at the obvious. I asked about her training, and she actually got to the gym at 8:00 a.m., practiced till 12:00, was able to home-school in the gym without leaving the gym for two hours. Then at 2 o’clock, she was back in the gym till 6:00. Well, there was no outside time. There was no sunlight time. There were no vitamins, so she was in severe vitamin D deficiency. Once we brought that on board, guess what, everything started to clear out. Do not be so laser-focused on the injury. We need to treat the injury, but sometimes you must back up and say, “Wait a minute. Why?” That is my big thing. We want to know the whys, not only just the injury. It is important to get that diagnosis right, but the why is the thing that I want to know. We can keep treating her for the next 10 years or we can give her vitamin D and get her better. Think outside the box sometimes and look at the big picture.

We saw this picture earlier, but I wanted to come back and go with the patterns of edema again. As we are getting further in this lecture, I want you to understand where those patterns sit and why. We had it wrapped tight and we can see where he did not have it wrapped and where he did have it wrapped because of those patterns of edema. Just knowing where their injuries are. Here’s the medial ankle. No deltoid injury there.  We certainly had an ATF injury here. Everything dropped down. But I am wondering about this edema up here. I am going to be looking to make sure there is no fracture there. Look at that and it tells you the story of what is going on. I find it quite interesting. Here is just a different view. I am looking at that distal tibia. Why is that color there? Mechanism of injury, history of previous injury, going back to what we said earlier. Where are they tender? Where are they sore? Can they bear weight on it?

Let us move past that. We cannot forget in this lecture about the posterior ankle. We talked a lot about the Achilles. You see this space in here, lots of room for swelling to sit. When someone has a regular ankle sprain, they are going to get that pseudo Achilles tendinopathy because the Achilles tendon is bathed in those inflammatory materials because that is where there is room to go.  You have got to get that swelling out from behind the ankle as well because they will have that Achilles tendon pain.

Notice that retrocalcaneal bursa here. Here is a patient with acute Achilles tendinopathy. She has all the swelling in that Achilles area here, and all that swelling is sitting across there. Why? For this patient, you have got to go back to it was not an activity, she did not do anything different, she did not go on a vacation and walk anywhere, she is not wearing different footwear. What else do you think you can think of? I want you to just think about it for a minute.


This is medication-induced. We know about the antibiotics, levothyroxine class action suit for acute Achilles tendon rupture. I asked her about antibiotics and she was not on antibiotics but what she is on is chemotherapeutic drugs as she was a cancer patient. We know that certain chemotherapeutic drugs attack some of the tendons. Making sure that if you cannot figure it out, ask the next question. Are you on any medication? Let us try to get to the bottom of the why, and then she understands, oh, now I know it is from my chemo. We just have to figure out how to manage that when she is on her chemotherapeutic.

As we start getting towards the end of our lesson, I promised you we would talk about this marathon runner. I will let you watch and see if you can figure out what it was. We are going to watch it one more time now that we went through the whole lecture and now you know a lot about ankles. We will watch him walk. Remember, I said when I put somebody on a treadmill in the office, I like to see them walk first, then a slow jog, and then their race pace or your normal training pace. I put them through different cadences, and I watch everything. If the pain is when they are striking their foot down, I am going to look from the foot up. If their pain is when they are swinging through, I am going to look from top to bottom. Asking when they are having pain is important.

Let us look at a different cadence here. We are going to listen to the sounds the foot makes. I want to see if you can pick up the problem. It is right lateral foot pain. I do every cadence set 30 seconds. I like to see them 30 seconds from the back and 30 seconds from the side. There were no differences on the sides, so I did not include it in this slide deck. But I assume as I put them on, I said, oh I see it. You see how he’s drifting to the left side of that treadmill? I am going to play this one again. You see how he everts his foot with every step. You see his right foot everts.  Now he is lateral loading. He is going to peroneal tendinopathy, lateral calf, and then he’s going to develop IT band. But you see how that is so powerful, that it pushes him to the left side of the treadmill, and he must work his way back, and then it pushes him again to the left side of the treadmill, and then he works his way back. You can see that little peroneal tendon acting up there.

We need to look at all those different speeds and we need to think about what is the kingpin? What I call the kingpin is what started the process. Again, we see with runners in particular, a lot of tendon pain and tendinopathy, in general, tend to crop up when you have a big change in regime. You are loading more, more repetitions, more intensity, different training, when things are changing rapidly. We can change their training slowly and not get as much tendon issues, unless we jump too quickly, that is when we tend to see the tendon problem. He did a nice job at training, so there was no change in footwear, there was no history of injury. It just really was a technique issue.

For him, his lateral foot, let us look at the next slide. Here is his right foot. Look at that peroneal tendon and let us look at the left foot. Not there. What I can do is I can treat him for peroneal tendonitis or tendinosis, probably at this point. Tendinosis is a poorly healed tendonitis. I can grasp them, I can stretch them, but if I do not fix his technique, and every time he steps, he everts. 2500 steps for every mile and he is a marathoner which is why I am never going to fix that. My treatment a couple times a week is not going to fix a technique for a marathon, so we have to go back and get him on a treadmill, and we have got to get him to correct this technique so that we can untrain the problem. Thinking about, why is this overactive? Is the posterior tibialis underactive? We think about these agonist-antagonist muscle relationships. We retrained him so he was not everting, and then while we treated the problem, we just kept cuing them and retraining them and the problem goes away. But again, do not just stop at that cheap diagnosis. Why?

We are going to look at foot and ankle injuries. Understand sometimes for injuries, emotional component is huge with a physical injury. I like to include a little bit of this with almost every lecture I do because I think we forget about it, that there is an emotional component with every injury that is left behind. Do not forget to be there to guide and to inspire and to give control to athletes. Athletes like control. Let them be an active part in their care. It’ll be great for their overall emotion.

This is an athlete here with chronic exertional compartment syndrome, had to leave her sport of gymnastics, couldn’t wear tight pants because her legs turned blue, couldn’t stand, couldn’t walk, couldn’t participate with friends. Very bad scenario. That was surgically released and not corrected. We did some fascial treatment in the office and got her back, not to sport, but back to be a normal child. Not good enough for sport. It was just too many years. But my point with this is the cascade of events that happened with an injury also are inclusive of emotional component. Please be able to unpeel that and refer the athlete if they need it for someone to talk to, if you do not feel comfortable talking, or at least encourage them to seek out some help. We do not want somebody like this. You can certainly see her affect. She’s just not in a good place. We need to make sure not only are we treating the injury, but we are unpeeling a cascade of events that happen with the whole injury.

One of the last cases we are going to look at today is a stress fracture of the base of the fifth metatarsal. Here is a runner. He was a triathlete that had chronic right lateral hip pain that had cleared up years and years earlier and never returned again. Then he came in with this base of the fifth metatarsal pain. He had a stress fracture that repeated for approximately two years. I put him on the treadmill. Well, why does the stress fracture keep coming back? He says, “I do not know. Everybody’s treated, I have done physical therapy, I have seen an orthopedist, I have taken time off. Every time I start again, the base of the fifth just gets injured again.”

Here he is running, and we are looking at his gait pattern. As I am looking at him, I already had it figured out at this point, what was going on. But we still want to ask the question of mechanism of injury, terrain, change in training, footwear, what is his gait, what are his personal goals, what are your goals? If we look at his regime, let me see if I can just stop this and bring it back. You can see the problem here. Why he has this base of the fifth. I do not know if anyone can see it, but he is not using that right hip like the left. The right hip is a little everted. The foot is a little more everted than the left. Once I look on the treadmill and I get an idea of what else I want to look at, I take them off the treadmill, re-put them on the table, and re-evaluate them, I might take them on and off the treadmill several times as I am getting an idea.

I took him off and I looked at his hip because he said he had a history of hip years earlier but it never bothered him again. He had a severe loss of internal rotation of his hip. Once we corrected the hip, we changed his gait, and the fifth metatarsal stress fracture stopped happening. Again, thinking outside the box and really watching your gait makes a big deal. But also understanding this base of the fifth metatarsal. Where is the stress fracture? Are we at Zone 1 here? This is more for the youth athlete. This is more Salter-Harris fractures or avulsion injuries, somebody with growth plates that are open. If we have a Zone 2, this is our metaphyseal region. Our non-union risk is 15 to 30%. These are more of our acute injuries. But in this Zone 3, that is where a stress fracture happens. That is where they happen in athletes. I want to know first, well, where does your foot fracture all the time? Is it in the stress fracture area or is it in Zone 2? He’s not really a candidate for Zone 1 as much from his age. But again, there is a high non-union risk here. But we need to look at our hind foot position because your hind foot position dictates how much weight goes on to your fifth metatarsal, and understanding these. Maybe think, geez, this is a gait issue, so let us look up the kinetic chain and see if we can figure out why. I could laser this. I could treat it but I am not going to correct the problem unless I travel up the chain and evaluate. As we get to understand that, we really come full circle with their whole ankle evaluation.

I hope you have gained some confidence in this lecture and having to evaluate the ankle and diagnose it and think about the functional component of the anatomy and the functionality that the athlete needs to return to sport, what your deficiencies are, and what corrections you need to make to get them back to sport-healthy.

I thank you for listening to me with this lesson and look forward to meeting you at some of the hands-on modules or seeing some of you guys in some events, hopefully working together side by side. Good luck. Looking forward to seeing you in the future.



3.2-ICSC05_ Running Injuries

English Direct Download PDF ICSC05-3.2-VIEW Running Injuries with Luke Nelson & Pete Garbutt

ICSC Lower Extremity Module 5
Section 2.1_ICSC05
Instructors: Luke Nelson and Pete Garbutt
Video Lesson: 21:17

Luke Nelson: Welcome to this FICS module which is on the assessment of the running athlete. Very privileged to present for FICS, both myself, Luke Nelson, and Pete Garbutt all the way from Australia. We are both sports and exercise chiropractors involved with FICS and Sports Chiropractor Australia for several years, and we look forward to talking about a particular passion of both of ours, and that is running. Just to quote the great man himself from his book, The Running Machine. I would recommend having a read of that.

“Running is born out of our inner need to move and breathe and experience all that we are capable of. It is the true expression of life in motion.” I love that quote because it pretty much sums up what running means to me as well. As a runner and someone that sees a lot of runners, I think that quote is quite fitting.

Pete Garbutt: Injuries in runners is a fascinating area because we consider running as, by and large, a non-contact sport but we see high injury rates. Studies that are out there show variance between 19% and 92%, and generally the acceptance falls somewhere halfway in between. Fifty percent of runners are likely to get injured and of that, 25% of runners will be injured at any one time. Now, that is a lot of people, that is a lot of people injured. Particularly considering how many people run. Then when you consider that those that are injured are then 50% more likely to be reinjured, we start to see patterns occurring within running, which initially a lot of people take up for health. It starts to put quite a shadow over this sport or this activity that is designed to be health related.

Let us have a look at some of the things that might lead to that. We say running is a non-contact sport but each time your foot hits the ground, it’s absorbing about two and a half times your body weight. If you are an average 70-kilo athlete, that is 175 kilograms every time the foot hits the ground. Now, if you consider somebody running several kilometers, the average is always going to make 1,000-foot strikes per kilometer. 10,000-foot impacts per 10 kilometers. Start to do the math and you see that it may be a non-contact on other bodies, but we are making a lot of contact with the ground and absorbing a lot of force through there.

Luke Nelson: Going on from that load that Pete mentioned, this is a term that I have learned from Pete Garubutt, rather than classifying injuries as overuse, which implies that something’s being used more, “which is overload injuries”. The vast majority of injuries that you are going to see in runners are overload injuries. There are very few acute injuries that you’ll see, such as an ankle sprain, a soft tissue in the calf or hamstring. The vast majority of them are going to be an accumulation of load over a period of time, an overload on a particular structure. By far and away, the biggest injury area that you’ll see in runners is at the knee. That is up to 50% of injuries around the knee. Then, some are scattered throughout the lower limb: the ankle, the feet, and the lower leg, and some proximally, a few injuries up around through the hip, the thigh, and the back.

When you are dealing with runners, most of the injuries you are going to see are from the knee down. This is where you need to be good at your management of these conditions. Then if we go through and break this down by types of injuries, again, we see the biggest injury. The biggest type of injury that you’ll see in runners is patellofemoral pain, and that is almost 50% of running injuries. Unfortunately, females get the short end of the stick there. They are more prone to developing this condition, at 62% in miles of 38. Then if we have a look at some of the other common injuries, you’ll see medial tibial stress syndrome or sometimes classified as shin splints, plantar heel pain, and Achilles tendinopathy, which tend to be tendon-related pains. Tibial stress fractures are always a nasty one to deal with, and females, again, being at the short end of the stick are more prone to 70% of tibial stress fractures. With ITB, again, females are more prone to those injuries there.

Pete Garbutt: When we look at the cause of injury, and when you have got stats like that and the numbers that we have already spoken about, we want to know where they are coming from. The trouble is when we are dealing with the human body and its interaction with the world around it, we are not dealing with the same contact injuries you might see in other sports. We have got quite a multivariate area of ideology for these injuries so we start to look at the genetic structure of the athlete, the mechanics, the way they are moving, their training loads, the tissue qualities, and the psychology, all of these things interact to create a load on this athlete, that is how we get to manage that and see how these loads are affecting the body that might give us a clue into what we might need to look at. If we put it in a seesaw-type relationship, on the one side we see what the stresses are, and on the other side is our capacity meant to manage those stresses. Basically, when this gets out of balance, we believe that injuries start to occur.

Traditionally, a lot of the research starts to look at things such as volume, intensity, and frequency. Other stresses to consider within this side as well, are the recovery. We know that to build any strength, muscle, endurance, or any sort of fitness, we need to have, essentially, insult to the body that we need recovery. The recovery phase is where we do the building. If we are not sleeping properly and nutrition is not up to it, then these stresses become a greater risk for the runner. Psychosocial factors also. Some papers that came out a couple of years ago from the IOC spoke quite specifically about the psychological load that creates stress within the body. This is one that we are just starting to recognize. It’s certainly one. If you guys are coming out of the COVID world, this psychosocial stress is certainly one to consider in the athletes coming back. Our capacity is what we can take, how is our resilience in different areas, how’s our resilience within our mechanics of how we are running, our previous injury profiles, as we have mentioned, wherever we got our training load up to, and how are we able to manage the different stresses. Looking at the runner, not so much as a point of injury, but how are the scales being balanced may help us to manage these runners in a more holistic way.

Luke Nelson: If we have a look at some of the risk factors, and there has been a lot of research that is investigated this, you will see there is some conflicting research that is looked at this, if we have a look at gender firstly, we sort of force that some of those injuries are more prone in females. In terms of other risk factors, consistently females have been shown to have an increased risk of stress fractures throughout the lower limb, but other injuries are not necessarily so, and there is some debate over that.

Age is also debated about being an independent risk factor. We know that a previous injury is an increased risk factor. We have mentioned before that there is a 50% increase there. As you go through age and more running exposure there is more likely to be an injury. You are more prone to have a subsequent injury, but age is not necessarily a risk factor. With age there comes a challenge of sarcopenia, losing muscle masses as we age so that is something that we do need to consider, otherwise, there may or may not be involvement there.

Then, we look at anatomy. This is something that I think a lot of us have been guilty of in the past: Looking at someone’s anatomy and blaming that for their injuries. There is a great infographic here done by Tom Goom, in the Running Physio. He looked at things, looked at all the evidence regarding static lower limb alignment and running injuries. Those are things like your femoral inclination angle, your pelvis width, your Q-angle, your static foot posture, which is another one that quite often gets blamed on having a pronated foot, leg length discrepancy, and hip anteversion. There is no strong evidence to support all of these things in contributing to injury.

The fact that the patient in front of you may possess one of these things does not necessarily increase their risk of injury. Even if they were to possess some of these things, there is not a lot that can be done about that structure anyway, so don’t put a huge emphasis on this. Obviously, in things like leg length discrepancy there can be if there is a very large discrepancy, we are talking about sort of 2 centimeters, there can be some increased injury risk. Static foot posture is not reliable, just to look at the foot posture in a static position. Foot pronation, there is a lot of debate in the podiatry world about what is overpronation, and whether pronation is normal. We do need it as part of normal shock absorption but what is abnormal there? Static lower-limb alignment is not great for determining someone’s injury risk.

Pete Garbutt: let us go on to the extrinsic risk factors.  Those are the factors that are not within your body and things that we may have a greater chance of managing. There has been a lot of study on this. Different training variables such as distance, frequency, duration, and intensity have all been studied heavily. It is interesting because when you have a look at the literature and when you have got a lot of papers, they start to make some nice meta-analyses, which then come together and basically tell you not a great deal. Whilst one paper may have shown things specifically, or trends of one certain way, we see a lot of that dropping out once we start to bring the larger multi-study assessments.

What is starting to come out, we believe, is that there might be more of an impact on the sudden change of load rather than any of these specific variables on their own. Certainly, work at the Australians you support, from the acute chronic workload ratio is one that speaks to that where the various workloads can be incorporated, and it is the change that is the big difference. Stretching or warm-ups have been contested for many years. The research doesn’t give us a lot of clear indication there.

Very much what I tend to do in my clinic, and I think that you might as well, is to look for more of a patient-tailored approach to these things because whilst the research is not particularly clear we know that some people do well with a warm-up, some don’t need a warm-up at all. So, we need to be looking at the patient and how that is managed there because the research does not support one or the other.  BMI gets thrown around a lot. It is a handy measurement but not always a meaningful one. Certainly, in running, one of the things that we see coming through is the BMI, in it on itself, is not one of the extrinsic factors that we can rely upon to determine whether someone is going to have an injury or not.

Extrinsic factors we might look at are shoe wear and orthotics. Here is an interesting one. There is no actual research out there that suggests that any shoe can prevent any injury whatsoever, although it’s quite often why people will be heading to the shoe store. What we do know is that at least from some of the studies, it looks like if you are wearing shoes that are more worn than others, then that may be one of the contributors. Orthotics sway both ways. The Van der Worp study in 2015 demonstrated that there was a greater incidence of injury in those who had orthotics, but whether your orthotic is in there because they had injuries or were the injuries because I had orthotics was very unclear. So, again, we are left without a clear definition. One of these we do know, though, is that there are no specific shoes for any injury, and even shoes with specific foot types do not tend to guard you against injury.  

I have looked at running surfaces. lots of research and lots of different theories on the different surfaces that we are on. Is it safe to be on a soft surface or a hard surface? A hard surface, meaning that the stiffness coefficient is more in favor of the ground, therefore, the body doesn’t need to do as much work. The trend that I believe we see is more about the durability of the surface or very much being prepared for the surface. If you are going to race, prepare for that surface. Do not try it on the beach and expect to run a marathon on the road.

Running technique is an exciting area. It is certainly an area that Luke and I have done a lot of work in over the last nearly 10 years now. We are seeing trending towards running technique having certain commonalities as far as ways that we can help to correct injuries or injuries start to develop. That includes a whole bunch of things from where the foot’s landing in relation to the body, or your cadence to the position of the body, and posture, and so forth. This is a trending area of research rather than an established area. Certainly, the technique is probably one of the more reliable areas.

Impact forces are another one where there has been a lot of discussions around. You better do from ground reaction force to braking forces. Some of these come down to pure physics. We can show an increased load in certain areas. When we look at impact forces, maybe it’s the speed at which they are coming rather than the actual overall force that we are looking at. One of the things that has come into the discussion more recently is vibration. Is that part of the injury force that we are taking? These are areas that we need to watch, we need to do more research on. For your extrinsic factors to be a little bit more noteworthy, I would be looking towards the running technique impact forces as where we want to look for future solutions to running injuries.

Luke Nelson: If we have a look at some going on and discussing a little bit more detail about the training variables that are mentioned before being a risk factor, what we found from Rasmus Nielsen’s 2013 study is they looked at a whole heap of running injuries. We can classify a large percentage of them into either being more running volume-related or running pace-related. What that means is that volume tends to be your weekly mileage or your total weekly amount of what you have done. Whereas the pace tends to be more the speed at which you have run relative to your aerobic pace. What they found was that those injuries that were more related to running volume, large amounts there, are more knee-based injuries, so your ITB, your patellofemoral pain, and your patellar tendinopathies. Whereas those injuries that were more related to running pace were more the lower leg, so your calf, your calf-Achilles complex, and the plantar fascia.

What that means clinically is that when we are seeing someone present with one of these injuries, potentially, in terms of returning them back to running, we can then direct them to one or the other. If we have got someone with patellofemoral pain and we know that it is probably more related to running volume and that can potentially upset that, then we might get them not increasing the volume so much but increasing some speed early. Conversely, on the other side, if we have got someone with an Achilles tendinopathy and we know that it’s more related to running pace then we can work on keeping the pace low, to begin with, nice and slow, but build their volume before adding a pace later on. Pete Garbutt has also an observation on this study as well, on these injuries.

Pete Garbutt: This is a great study. I had the privilege of chatting with a couple of the authors shortly after they published this. At that time, pretty exciting to have something there that we can put in, as you say, with helping a runner stay active. Maintaining that fitness when you are coming through an injury is exciting. If we have a look at the two sides there, what are your thoughts regarding the type of structures we got on each side? On the running volume side, we very much wear around the knee. My thoughts were that they are very much a load-accepting part of the body. The structures where we are looking at the calf, the Achilles tendon, the plantar fascia, I classify the Achilles and plantar fascia as essentially one continuous structure–they are more propulsive. Is this something that might be of use, do you think, when we are starting to look at our athletes in this area of mine?

Luke Nelson: Yes, absolutely. I think as Pete Garbutt pointed out; the calf-Achilles complex is predominantly almost exclusively involved in that propulsion. Whereas, as Pete Garbutt said, the knee-based structures and around the quad are the structures that are involved in that load acceptance phase, that initial ground contact. It is involved in all those things throughout the whole phase of gait. If you look predominantly at what’s involved and where then you may be looking at things like, for the knee, you might be looking at that initial load acceptance phase of their running and potentially analysis of their running technique and see what’s going on there, things such as overstride or increased vertical oscillation, those sort of things, or lower cadence which we know alter that knee load.

On the other side of that, we might look at things in the calf-Achilles complex. Look at the terminal stance phase, anywhere from sort of mid-stance to terminal stance. In that mid-stance phase, are we seeing a lot of sloppy and knee-over-toes type of movement and then poor propulsion out the other backside potentially not coming off, pushing off through that big toe? Maybe they are rolling off through the outside of the foot. I think that is where we can start to marry some of these things together.

Whilst we mentioned before in those risk factors, maybe looking at a population as the whole they are not significant but when you start to get the individual in front of you, then all those things do need to be taken into consideration because that leg length discrepancy may be involved in that runner. I think it’s something that we do look at. That is where I think we, as chiropractors are quite uniquely placed here, that we look at the individual as a whole addressing all these things together to work out why a particular injury has occurred.

Pete Garbutt:  What an exciting area to be involved in right now when we see these different factors coming through in the research. Now, as Luke Nelson pointed out, in the area that we study specifically we can start to bring into looking at the runner areas that we are comfortable with that we start to marry with the new research provided.

Luke Nelson: That brings us to the conclusion of our lesson. I hope you enjoy the remainder of the content on the online FICS portal. Thanks very much, and I hope to hear from you soon.     [END]