Sports injuries; what’s in an assessment?

For many of us, sports injuries are a common part of our practice. We regularly see people who depend on their bodies to perform to a certain standard, who have higher than average physical expectations, and who regularly test and increase their limits. Our assessments protocol assumes too many universal beliefs; it needs more flexibility to better reflect the commonality of “outliers”. It lacks context.

In my mind, there’s a simple rule that all of our assessments need to follow: they should be meaningful. This means that they’re relevant to the stressors our patients encounter.

Before getting to that; however, I’d like to touch on some generally accepted concepts.

A couple of established norms:

• Hypermobility is a pathology.
• Misalignment is abnormal, and leads to injuries.
• Asymmetry is an example of poor posture, which is abnormal, and leads to injuries.
• If something is torn, worn, or narrowed, it’s anatomically abnormal, which is a pathology, and is probably going to hurt.

So what is normal?

Look at yourself. Are you in alignment? Are you in pain because of your current lack of alignment?

During daily movement, we rarely if ever maintain alignment. Seriously, just watch anybody walking around and see how often their knees valgate, or they hunch or rotate through their trunk. Misalignment is normal. You may be thinking “well duh”, but that’s just the little bit that you can casually observe. What’s fascinating is when we take into account outlier variables, and extreme forces, such as in sports-specific movements.

When assessing sports injuries, we need to be aware that altered mobility and alignment may be normal. Among high school baseball players, for example, pitchers demonstrate a general shift to greater external rotation range through the glenohumeral joint (up 10 degrees external, and less 15 degrees internal).^{1, 2} In sports like basketball and volleyball, athletes regularly demonstrate a significantly higher than average peak knee valgus angle on landing.³

Our provocative tests need to be modified to reflect that these altered limits may be normal.

Sports-specific training often results in greater tolerance to misalignments such as knee valgus. Certainly we want to aim for alignment in training, especially at load and at velocity, but given these increased tolerances, our measure for a positive special test needs to be adjusted to reflect those increases in order to more accurately reflect patient norms.

What about symmetry?

While discussing alignment, we should cover symmetry. We have this whole narrative based on the idea that people should be symmetrical: front to back, side to side, we’re supposed to be balanced. I’ve been given different explanations for this, ranging from irregularities in joint changes over time, to excess stress to maintain vertical posture. I don’t know what universal truth there may be there, but I remember learning that asymmetry is a bad thing.

One of my go-to tests used to be the Adams forward bend test: a standing, forward-bending test to look for evidence of scoliosis (manifesting as pseudohypertrophy, or unevenness in the paraspinal region from right to left). It’s reasonably simple, plainly visible, and doesn’t require any special tools. It’s by no means a perfect test, but it’s accessible and easy to monitor over time.

But how uncommon is asymmetry? An often quoted study by William P. Bunnell tested one thousand high school students for spinal symmetry, and found that less than 2% actually demonstrated it, with 80% of them demonstrating 3 degrees of rotation or greater in forward bend.⁴ So here I was, using this special test that I thought was great, but the numbers just didn’t justify it; I had to reconsider my approach.

Okay, so asymmetry is a thing, and it’s common, whereas normal ranges of motion are commonly abnormal, and safe limits to alignment are incredibly variable. This is giving me a headache.

Let’s consider structural norms

Probably the most common complaints I see in my office involve shoulder pain. I’ve classically followed textbook assessments protocols, including looking for structural dysfunction under the assumption that structural changes are pathological. But what if they’re not?

In a study of volleyball players from the US Women’s and Men’s national indoor teams, 26 players underwent MRI imaging of their dominant shoulders. About 2⁄3 of them presented with tears of their rotator cuff muscles, and almost half of them presented with labral tears or labral fraying.⁵ Every player was asymptomatic, and all were performing at a high level, with extreme demand on range of motion, speed and strength. These athletes were high functioning, explosive movers, and yet the majority of them are injured according to our assessment criteria.

Maybe these injuries aren’t actually injuries, but are instead adaptations to training demands. We can clearly consider a soft rule that no stress is too much, so long as it stays within reasonable anatomical limits and we allow for adaptation. Over time, this results in structural adaptation (yes, even tearing) and neurological optimization. This fills a functional niche, but isn’t necessarily pathological.

Anatomical irregularities may not be injurious; they may be adaptive.

Let’s stop and step back…

Why is your patient here? They’re experiencing a thing: pain, weakness, decreased range of motion or tightness, the list goes on. That doesn’t automatically mean that their body is damaged, nor does it mean that it’s not, it just means that they’re experiencing a thing and that they want to change that experience.

Trying to accurately determine what’s happening in a patient’s body is daunting. We rely on our experience, their precedent/health history, and protocol and special tests to create an index of suspicion. Our special tests depend largely on the assumptions that the anatomy is consistent (it isn’t) and that perception of dysfunction is accurate (it isn’t) as their basis for reliability. In a systematic review of orthopaedic tests for the spine by Simpson and Gemmell, most single tests demonstrated either poor specificity, poor sensitivity, or both.⁶ We can offset single test unreliability with test clusters, but it’s far from perfect: false positives and negatives can still skew the entire index of suspicion. This isn’t to say that we shouldn’t perform special tests, but it is to say that overreliance on them can be detrimental.

We have to consider that a person’s lifestyle and experiences contribute to what they perceive as normal, both neurologically and physically. Stressors such as valgus deviation, hypermobility, or tears may be normalized to them, and may not be the cause for either alarm or pain.

Coming back to context…

A person’s complaint is often obvious (pain/tightness, etc), and we focus our assessment on that; it represents the “foreground” of the assessment. Their general movement capacity not including dysfunction represents the “background”. Putting the foreground and background together gives us a complete trackable assessment, and the basis for our treatment plan to calm the warnings and build tolerances. I personally like to break down my movement and injury assessments in terms of 3R’s (range, resistance, and rate of movement), including my tests. The following descriptions are simplified, but the concept is sound:

• Range is the available range of motion required for the movement to occur. This is active range, and includes mechanical factors, as well as neurological.
• Resistance refers to the idea that we can generate enough muscle energy to perform our task. This includes sufficient motor unit recruitment, and perceived safety to allow for that.
• Rate takes into consideration time to apply muscle energy, to start, stop and control our movements with appropriate timing.

This may sound needlessly complex, but it actually simplifies things a lot. The movement portion of the assessment can cover one or multiple joints, and many of the simple and combined movements overlap with our special tests. We have to have enough movement, strength, and speed in order to perform a task, and if dysfunction is present, we can break it down along these lines.

Consider reaching for a cup of coffee. You require sufficient range of motion through your joints, sufficient muscle energy to lift your arm against gravity, and finally sufficient control over timing and accuracy so as not to spill your drink. Your nervous system needs to decide that the movement is safe enough so as not to require a warning, in order to succeed painlessly.

When we assess our patients for injuries (sport or mundane), we are essentially questioning what is impacting their ability to perform a task. The cause may be mechanical (like a broken bone) or perceived risk (like kinesiophobia).

Your patient has a complaint, but that doesn’t mean that they’re necessarily injured. It just means that challenging those movement variables in some way or other is causing them to experience dysfunction. Breaking down our general range of motion testing, and asking what feels apprehensive/painful/meaningful to them will give us a much more complete picture of what they’re experiencing.

For consideration:

A couple of years back I was treating one of my circus performers, the primary complaint was right-sided shoulder pain in performance (cyr wheel, hand balancing, and tumbling). Full range, full resistance, full rate control with no positive special tests. According to most testing criteria, he was pain free and perfectly functional, and it wasn’t until we tested his hand balancing while walking up stairs, down stairs, and in static single arm holds that we found meaningful symptoms. My standard testing criteria was all but useless, so we had to get creative and find a testing method that was meaningful to him. Walking into an assessment with unquestioning confidence in our dogma is just us setting our own narrative; assessments are about discovering the narrative. It’s all about context.

Footnotes

As an EDS patient, I rely greatly on regular full-range movement exploration to manage my pain/physical capacity. It made sense to use a combination of movements that I find helpful for myself, and for my patients to create a simple daily regimen of “movement snacks”. Just about every movement demonstrated is scalable, and can be modified to suit your needs in terms of your own capacity.

*Please note, my form isn’t perfect, nor is it meant to be. I’m not trying to focus on a perfect repetition so much as a movement that feels good for me.

Hip Girdle

I don’t think I need to state the prevalence of lower back and sacroiliac pain we see in our clinics day to day. Whether you’re working in a relaxing spa environment or with elite athletes in a competitive setting, lower back pain is practically ubiquitous. The effects of daily stress on low back pain are well documented, and regular movement is one of the best ways we can try to manage that. I’ve found hip girdle based exercises incredibly helpful for this.

The following link begins with some femoroacetabular movement and gradually grows from there to greater complexity and difficulty:

Training the hip girdle for strength and mobility

Shoulder Girdle

Headaches, neck pain, shoulder stiffness. We were taught that a quintessential intervention is the good old fashioned doorway (pec) stretch. Get up, stretch, lather, rinse, repeat. It gets old fast, and loses efficacy even faster.

For my own rehab, overhead range of motion has always been a focus, as well as addressing ongoing issues with thoracic outlet syndrome and management of chronic dislocations. End range exploration and competence is key.

The following link features scapulo-costal movement, glenohumeral movement, resistance and coordination to tie it all together:

Training the shoulder girdle for strength and mobility 

Spine and Trunk

I find a commonly overlooked area of core training is mobility, rather than flexibility (with flexibility being how far you can be moved through a range, and mobility being your ability to control that flexibility). We’re often taught about core strengthening, and diaphragmatic breathing and the like, but I regularly find that core mobility to end ranges is a great daily intervention.

The following link opens with some basic control and builds up in terms of simple to complex ranges of motion,and mild to moderate resistance.

Training the trunk for strength and mobility

*DISCLAIMER*
These videos are intended as demonstrations of movement exploration only, not interventions for existing pathologies. If you’re uncertain about any movement, consult with a professional.

References:

Chadi C Abdallah, and Paul Geha “Chronic Pain and Chronic Stress: Two Sides of the Same Coin?” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546756/

Eric Bowman, “Low Back Pain: What Are We Doing Wrong and What Can We Do Better?”
https://ericbowman03.blogspot.com/2017/09/low-back-pain-what-are-we-doing-wrong.html?fbclid=IwAR0CNUTRUZ31BTGYx4GJ647d_O_erVIAUWfGnNOusNfBJ3dFk4BQp6xibpg

Bronwyn Thompson, PhD, “BACK TO BASICS ABOUT PSYCHOSOCIAL FACTORS IN PAIN”
https://healthskills.wordpress.com/2017/09/04/back-to-basics-about-psychosocial-factors-in-pain-i/?fbclid=IwAR2BWNo27PXXnTJKsGvZgSxzGyKcjhhuoGP2EO92PWVkDUwBEI6YoYEbDFU

This is an older article (almost a decade at the point of this edit) and is no longer in keeping with my belief system.
Pain is complex, and the following is not at all representative of that complexity.
Our sense of pain and dysfunction is highly influenced by biopsychosocial factors, and our own perceptions.

The reason I still keep this article up and others from a similar time are that I believe it’s important to be transparent about the fact that we in this industry are all fallible, and that there is no shame in admitting that you were previously speaking from a place of lesser knowledge.

The links between core “weakness” and “instability” and back pain are tenuous at best. When I wrote this my education had solidly adhered to the idea that a weak core and tight hip flexors were your recipe for back pain – they are not.

That being said, thank you, and I hope you enjoy a chuckle as you read

You’re at the gym doing your second set of squats, a personal trainer asks if they can offer you some advice… Engage your core.

Do you have any idea what they’re talking about?  Do they?

In the 5 years I have been working with athletes, personal trainers, AT’s and RMT’s I have actually met very few who actually knew what the core was, much less how to make it work for you.

To most people (health care professionals included) the core is this vague sense of your abdominal muscles, and it’s important… but they don’t really know why.

What is it?

The term core actually refers to a series of muscles in your low back, abdominal area, pelvis and ribcage.  For the purposes of this article I will stick to the internal core muscles (if you want to go by fascial connections to the core, almost any muscle in the trunk or upper legs could be considered a core augmenting muscle).  Here I will list the muscles of the core and how they work to help in workouts and pain control.

Abdominal Diaphragm – Yes, your breathing muscle.  This muscle attaches to your lumbar spine and the inside of your ribcage and acts as a sort of ceiling to the core itself.

Quadratus Lumborum – This short powerful back muscle attaches superiorly from your lower rib down inferiorly to the upper crest of your pelvis and medially to the sides of your lumbar vertebrae.  This becomes a major part of the posterior wall of your core.

Psoas – 2 muscles on each side, the major and minor.  These hip flexors run from the front of the lumbar vertebrae, and run down to attach to the upper thigh bone.  They act as part of the posterior wall of the core adding congruency to the wall.

Transverse Abdominus – A muscle that runs laterally from the back around the side of the abdominal cavity and attaches into the other abdominal muscles in the front.  It acts like a lateral wall to the sides of the core.

Obliques – External and Internal obliques act to add congruency to the lateral core again, and generate force from the ribs down the the front of the pelvis, and from the front of the ribs down to the lateral side of the pelvis.

Rectus Abdominus – Everybody’s favourite abdominal muscle (the 6-pack!) and it’s surprisingly overlooked as a core muscle.  Everybody trains the upper portion (the part you see as your 6-pack) and neglects the lower portion as it attaches down to the front of the pelvis on the pubic bones.  As you can guess this muscle makes the front of the core and pulls the ribcage towards the pelvis.

Pelvic Floor muscles – This series of muscles by far the most overlooked part of the core, and by far the most important.  The pelvic floor muscles literally act as a floor to the core as well as helping stabilize the pelvis and the joints therein.  If these muscles are firing when they need to the pelvis will be properly supported and less dysfunction will be experienced.

How do they work?

When the abdominal and back muscles of the core are engaged (tensing), they form a sort of circular wall going around from the spine to the navel on each side, and from the pelvis to the ribs on the front, sides and back (picture it like the wall of a popcan).  This will act to contain the abdominal organs (like a back support belt, but more complete).  The Diaphragm on the top acts like the lid of the pop can pressing down on the abdominal organs, and the pelvic floor engages last to push up on the abdominal and pelvic organs.  This compression in all 3 plains acts to squeeze the contents of the abdominal pelvic cavity, which pushes out on the spine and serves to support the lumbar spine (creating a sort of fluid ball within the abdomino-pelvic cavity.  This also reduces the fluid like dynamics of the contents of the abdomen and makes it act more like a solid, so force is transferred up from the legs to the ribs or vice versa through the pelvis and abdomen much more quickly and smoothly.

What does this mean?

By training your core, you can decrease the frequency and intensity of back pain, and for athletes you can increase your performance.  More stability means less injuries, and the increased efficiency essentially means more power and balance.

Be sure to follow my video series on youtube under haddowmassagetherapy for more information on the core muscles, how to use them and how to train them.

Edit:

This is an older article (almost a decade at the point of this edit) and is no longer in keeping with my belief system.
Pain is complex, and the following is not at all representative of that complexity.
Our sense of pain and dysfunction is highly influenced by biopsychosocial factors, and our own perceptions.

The reason I still keep this article up and others from a similar time are that I believe it’s important to be transparent about the fact that we in this industry are all fallible, and that there is no shame in admitting that you were previously speaking from a place of lesser knowledge.

Thank you, and I hope you enjoy a chuckle as you read

This is the joint between the sacrum (a large triangular bone at the bottom of the spine) and the ilium (the biggest part of the pelvis). The sacroiliac (SI) joint is important in all motions involved in weight transfer, and any motion where force is transferred through the pelvis. When the SI joint is weakened, excessively mobile or immobile we can experience pain. Most commonly regarding pain in the knee we will see a lack of mobility in the SI joint above the knee.

Why is this?

If the SI joint doesn’t move, the muscles that act on the pelvis from the thigh when we walk will have to work harder to transfer movement through the pelvis. Those muscles also act on the knee joint by pulling the tibia (shinbone) forwards and backwards. Take the quadriceps (thigh) muscle group for example: when the quadriceps straightens the knee, they use the patella as a fulcrum to help them. If the quadriceps has to exert too much force to straighten the knee, they will compress the patella and femur more than normal and will essentially grind them together. This is now a case of PFS even though the pain is caused by a pelvis that isn’t allowing for smooth weight transfer from the thigh to the knee.

The SI joint is a surprisingly complicated joint, it allows the pelvis to flare in or out, allows each half to partially rotate independently and to flex forwards and backwards (known as counternutation and nutation). These motions are key in allowing the entire complex of the leg to function properly.

The SI joint can become immobilized in neutral position, or in a position of nutation or counternutation; this further exacerbates the discomfort in the knee by tilting the pelvis and effectively shortening anterior or posterior muscles attaching to the pelvis. Muscles being shortened anterior to posterior leads to the standard inappropriate force coupling experienced about the knee joint with shortened muscles; short quadriceps experience more tension across the patella and short hamstrings create a posterior translation of the tibia on the femur effectively compressing the meniscus and/or irritating the bursae in/around the patella.

If one or both SI joints experience pathologies resulting in an inflare/outflare, the main effect on the knee will be experienced in the inward or outward femoral rotation and resultant tilt of the knee in compensation (this is known as genu valgus or genu varus) to balance out the effective tilting in or out of the hip joint. Besides simple discomfort, the valgation from an inflare can increase vulnerability of the medial collateral ligament as well as increasing iliotibial band friction. The varation from an outflare causes less immediate pain as the dysfunction focuses more around the medial meniscus but does cause more wear on the meniscus and can increase tendency to tear.

Other deviations of sacroiliac joint function affect the knee in much the same way, or a variation of these ways.

What Can Massage Therapy Do?

A skilled massage therapist can assess the angles of these joints during both movement and static stance to determine if there is contribution to any knee discomfort. Simply stretching and/or strengthening the proper muscles and increasing mobility through the joint may be enough to eliminate knee discomfort.

For injuries at the SI joint such as ligament strains leading to discomfort in the knee the therapist will be able to determine the original cause of the discomfort and by treating the injury recover will speed, and pain will greatly decrease.

For any questions on this article, please contact me at the email address listed on my website.  I will answer whatever questions I can and we can set up a meeting to assess the causes of the knee pain if necessary.

This is an older article (almost a decade at the point of this edit) and is no longer in keeping with my belief system.
Pain is complex, and the following is not at all representative of that complexity.
Our sense of pain and dysfunction is highly influenced by biopsychosocial factors, and our own perceptions.

The reason I still keep this article up and others from a similar time are that I believe it’s important to be transparent about the fact that we in this industry are all fallible, and that there is no shame in admitting that you were previously speaking from a place of lesser knowledge.

Descriptions of the knee as easily damaged are inaccurate, and acting as a hinge are reductive. It’s actually a remarkably robust joint, in which structural abnormalities are common and often completely asymptomatic, with multiaxial function.

Thank you for looking, and I hope you enjoy a chuckle as you read

Many people experience knee pain, and through a variety of methods try to cope with that pain. They will do everything from applying ice to the knee to numb the pain, to ‘playing through the pain’ until it fades into the background. They rest or they work more, whatever seems to reduce the discomfort for that day or week. Then they finally seek help from a professional, they go to a doctor or a physiotherapist or a massage therapist; the practitioner examines the knee telling them that it seems fine and it’s probably just some sort of patello-femoral pain syndrome and they can’t do anything about it.

What is Patello-Femoral Pain Syndrome (PFS)?

Specifically, this condition occurs when the patella (kneecap) interacts with the femur (thighbone) in such a way that irritation results. The experience is generally a dull ache of varying intensity that can be affected by levels and types of activity. More generally speaking though, PFS is a condition that is commonly greatly over diagnosed or over assessed. Most often PFS is a symptom of some other dysfunction and not a direct pathology in and of itself.

What is it about the knee that makes it so tricky?

The knee is a joint made up of three bones, the patella (kneecap), the femur (thighbone), and the tibia (shinbone). The knee acts as a hinge swinging front to back with very little rotation or side to side flexion (known as valgation or varation), and bears a great deal of weight; that large but specific range of motion coupled with the stress on it makes the knee an especially vulnerable joint. It can be injured very easily and

due to its limited blood supply it heals VERY slowly, as well as the fact that it’s subject to wear through repetition (yes runners, this especially means you). The knee’s very specific range of extension and flexion means that it depends on the joints above and below to allow for side to side give, tilt, and rotation; this limited range of motion also means that any inwards or outwards deviation can cause great dysfunction at the knee. Any dysfunction in the joints above or below the knee along the movement chain can GREATLY affect the mechanics of the knee and result in pain.

What is it that causes one runner to experience PFS whereas another with a similar training and rehabilitation regimen doesn’t?

Why does it happen more often to street runners than to trail runners?

In the following series of articles I’ll be explaining some possibilities that are widely overlooked and how they can affect the knee.  I will also be looking into possible treatment methods as well as alterations to training that may mitigate the return of such problems.