Chuck Wolf: Discovering the “Whys” of Injury
Pain is a very complex issue, and it’s likely some of your clients are dealing with it even as they continue to train with you.
In the study by Dr. Jan Schroeder and Shawn Dolan for IDEA called Personal Training and Equipment Trends1, there were some interesting statistics:
85 percent of personal trainers work with seniors, and looking at clients as a whole:
33 percent were between the ages of 45 and 54—(the baby boomers are getting older,)
25 percent were between 55 and 64, and
21 percent were 65 or older.
Among that group, we’re seeing certain injuries. Degenerative joint disease keeps cropping up and sedentary behavior is definitely a factor . . . but here’s the big one:
84 percent of the people working with personal trainers have chronic injury.
Those are often overuse issues, and rehab may or may not have helped. Rehabilitation in the physical therapy world only has a certain number of visits because of the way the insurance industry is regulated. With that limited capitation, the physical therapy world needs the fitness professionals . . . and the fitness pros need the physical therapy world.
We need to bridge the gap.
The problem is, the fitness professionals do well with the “what, when and how” in program design. But many of us, including many in the physical therapy world, sometimes don’t understand the “why.”
We have to start appreciating how the body moves from the ground up to understand the “whys,” because the site of the injury usually isn’t the problem. Often the problem is a joint level (or two) above or below the site of the pain. When an area becomes limited in motion, the injury often occurs at the site of the compensation.
Step back from the knee
Here’s an example. Step back . . . don’t zero in on that shoulder. Instead, start addressing the knee and the shoulder might start to feel better. We have to look deeper to discover why the body has compensated and what has become limited in motion to create a compensation.
Think of it this way: The knee is stuck between the foot, ankle and hip. If we can get the foot mobile, if we can get the ankle mobile—especially in dorsiflexion—and if we can get the hip mobile, the knee doesn’t have to make up the difference. When we can achieve this, a lot of the pain problems go away.
The back, knee and shoulder regions are three big pain areas for our clients. Often, it seems like what we do just doesn’t seem to be doing the trick for these people. We’ll certainly have more success if we can get these major regions moving better.
The back is stuck between the hip and the thoracic cage, and if we can get the hips mobile and if we get the thoracic cage more mobile, we’ll see a lot less rotation going through the lumbar spine. The shoulder is really directed by what goes on in the thoracic cage, but also, surprisingly, the hips and the foot. If we can get their bodies moving in those regions, in all three planes of motion, we will be able to create an environment for our clients to become successful.
Ankle and great toe dorsiflexion
Let’s take a deeper look. Ankle dorsiflexion sets up the system. If we can’t set up the system properly with good ankle dorsiflexion, we’re going to see all kinds of compensations.
We need to pay more attention to mobility of the great toe. If a person has had a toe injury, we must bring that mobility back.
Consider this: Does the client have good mobility through the great toe? Is the person able to dorsiflex through the toes, through the metatarsal heads? Here we would be seeing greater, prolonged knee flexion and there won’t be as much ankle dorsiflexion or hip extension. When we don’t have good ankle or great toe dorsiflexion, we see a lot more frontal plane loading.
All forces from the top down and the bottom up go through the lumbar spine. When you don’t have as much hip extension, what’s happened to your lumbar lordosis? You don’t have as much to propel you through. Your shock absorption has been reduced. We see a lot more frontal-plane loading of the back and we see less loading of the hips.
Does the person have enough ankle dorsiflexion?
Is there enough motion through the hip in all three planes of motion?
Do we see frontal plane loading of the hip?
Do we see good internal rotation of the hip?
What’s going on at the thoracic cage?
The relationship of the thoracic cage and the pelvis
The two most mobile regions of the body are the thoracic cage and the pelvis. If we lose quality motion there, we’re going to see excessive rotation at the lumbar spine. When people have back pain, you will see one of three (if not all three) characteristics: lack of ankle dorsiflexion, lack of tri-plane loading of the hip and lack of thoracic rotation.
The common limitations we often see are limited forefoot dorsiflexion and tight hip flexors and calf on the same side. When you have limited dorsiflexion, you don’t have much hip extension. Or if you have a tight hip flexor, your ankle dorsiflexors become tight. A tight calf will turn off the hip and a tight hip can tighten up the calf or an opposite shoulder. In that case, we need to stretch with the same-side calf and the same-side hip together. Together!
When we walk, ideally, we want to have the pelvis move one way and the shoulder girdle the other way. We wind up with opposite hip and opposite shoulder—these are both lengthened. Yet on the back side, we’ve got the opposite lat and opposite glute lengthened. It’s a spiral effect that allows proficiency, efficiency and economy. When we lose this, we become sagittal-plane dominant. We’ve become too frontal-plane dominant and we lose power.
We need the frontal-plane motion to allow transverse-plane motion of the hip. If we become limited in the frontal plane, we’re going to limit the transverse plane and vice versa.
We have to regain frontal-plane motion of the hip. We have to get the pelvis involved with the thoracic spine. We need a relative position of anterior pelvic tilt to the lumbar spine to help retract the scapula. Historically, we’ve treated kyphosis as a thoracic problem, when in fact it’s probably both a thoracic and a pelvic problem.
Scapular motion drives the shoulder
A tight shoulder girdle is another common limitation. Due thoracic mobility limitations, the scapula can become immobile and resistant to gliding over the thoracic cage as well as it should.
When you start seeing shoulder joint problems, think of this idea: Where the scapula goes, the humerus will follow.
We need to see how much scapular motion our clients have. Let’s see what kind of thoracic motion they have. If the motion isn’t there, take a look at their range of pelvic motion and foot function.
To create an environment for our clients to become successful, we’ve got to think of pre-positioning. This means regression before progression. If they don’t have the necessary mobility somewhere, it’s going to be compensated elsewhere.
When we look at the movement away from the spine, we define it as the distal bone in relation the proximal bone. In the spine, it’s the reverse; it’s considered the proximal bone in relation to the distal bone.
ACL injuries abound in those with flatfoot
All muscles and all joints work in three planes of motion. Let’s say we see someone who can’t jump or land very well. Some people would blame that on a lack of a jumping program where they’re quad-dominant. I don’t doubt that, but that’s telling us the “what.”
We still have to understand the “why.”
We also have to discover if the person has ankle dorsiflexion and tibial internal rotation. When there’s a flat foot, there is an increased risk of ACL injury; in 80 percent of the ACLs I’ve worked with, there’s been a flatfoot.
The foot and ankle have to do certain movements to activate the glutes. When there’s a problem, we have to figure out why it’s deactivated. What is it that’s not working?
We need to have the calcaneous go through eversion, dorsiflexion, tibial internal rotation and forefoot abduction. The foot is on the ground, and as the foot goes through pronation, that calcaneous everts and the rearfoot drops farther and faster than the forefoot. There is no real movement of the forefoot, but the relative position of the rearfoot to the forefoot—or the distal bone in relation to proximal bone—creates forefoot abduction. If any one of these gets gunked up, all four get gunked up and we start seeing glute deactivation.
Discover the “whys”
Now we’re getting to the “whys.”
We’ll often see IT band problems; we’ll see tight hamstrings; we’ll see piriformis issues. We’ve got to figure out the “whys,” beyond just what we’re seeing.
When we talk about kyphosis, it’s both a thoracic and a pelvic problem—we address the pelvis also. If we don’t, we’re doing our clients a disservice and not really creating an environment for them to become successful.
The thoracic spine moves in primarily two patterns. It will rotate one way and laterally flex the other. It’s a type 1 movement. In fact, most of our motions are type 1 thoracic spine. This is where we laterally flex one way and we rotate the other.
In type 2, we have the lateral flexion and rotation in the same direction. Any time you laterally flex and rotate posteriorly or reach around posteriorly, you’re getting type 2 thoracic motion. Get the thoracic spine mobile in all three planes of motion; let the pelvis help and you’ll see that the lumbar spine isn’t going to take the hit quite as much.
All of this will be determined by the threshold of the capabilities, limitations, compensations and idiosyncrasies of our clients.
How do we figure that out?
We do some type of movement assessment. We have to do a tri-plane movement assessment—use the Functional Movement Screen—or your preferred method. They all have good content, so become eclectic in your approach. You’ll glean good information.
The Flexibility Highways
Then we get to the six Flexibility Highways.
The Anterior Flexibility Highway enhances extension movements. I’m not concerned about stretching muscle tissue. I’m more concerned in thinking of where the connections are in the fascia, not only from a longitudinal but also latitudinal and in-depth approach in how fascia connects to fascia.
The structure of the fascia—the integrity of the fascia, the mobility or pliability the fascia—is what really predicates posture. Not the muscles—the fascia.
If we know that the anterior tibialis comes north and connects to the distal quadriceps, and the distal quadriceps goes into the hip flexor; the hip flexor goes into the abdominals, the abdominals into the pec and the cervical flexors, that’s going to allow greater extension movements.
Changing an arm position could even get the pec involved; we can get into a staggered stance and then reach to involve the Anterior X Factor to help develop greater extension.
Do most fitness programs take the client into extension? The answer is no. We do too much flexion.
If we can gain more mobility through the Anterior Flexibility Highway, we’ll have greater extension—not just in posture, but in gait. This will allow the calf and the hip of the same side to excursion farther, and a bit more internal rotation.
The Posterior Flexibility Highway goes from the plantar surface of the foot into the calcaneous, into the Achilles tendon and into the calf. The calf goes north—the gastroc goes over and attaches at the femoral condyles. The hamstrings come down and attach around the knee. They don’t attach behind the knee. We do not flex our knees as if in a curl machine when we walk. They decelerate motion. They control rotation. Think of the hamstrings as the reins of a horse that controls and decelerates rotation.
The hamstrings go north to the ischial tuberosity via the sacraltuberous ligament to the sacrum, conjoins with the lumbar fascia to the erector spinae and the occiput, going across and over the cranium to the epicranial fascia. If we have good motion in the Posterior Flexibility Highway, it’s going to allow better flexion through the full distance of the body.
A lot of people are very sagittal-plane dominant—the senior population, cyclists, runners, swimmers and triathletes are examples.
They’re taught to move that way because their coaches think it’s more effective and more efficient—that they’ll go straighter. But guess what? The abdominals are saying, “Please lengthen me.” The glutes and the lumbar fascia are saying, “Please lengthen me.” That lumbar fascia can act as a slingshot to help propel the hips forward when we lengthen it through the Posterior X-Factor. Train your clients like sprinters—get them to move!
The Lateral Flexibility Highway goes from the peroneals to the iliotibial band to the tensor fascia latea, glute minimus, glute medius, QL, intercostals, obliques, ties into the lat and into the rotator cuff, and, depending which way you hold your arm, goes into the triceps and forearm flexors. If we have good motion there, we’re going to have good frontal-plane loading of the entire chain . . . the entire system.
Do you have clients who have iliotibial band issues—what people commonly think are tight iliotibial bands? What do we typically do for that? We foam roll it. But the iliotibial band is connected to the lateral epicondyle and tensor fascia latea—30 percent of those fibers go into the glute. It ties into the lateral glute complex.
What happens if you’ve got somebody with a flat foot? Where is the tibia going to go? It’s going to internally rotate. What does that do to the iliotibial band? It puts pressure on it, and some transverse torsion too.
Now let’s assume your client has a weak butt, an anterior pelvic tilt and a flat foot. What would that do to the iliotibial band? It makes it even longer. Are the iliotibial band and hamstrings short and tight, or long and taut? Those are now long and taut, but what’s the sensation going to feel like? It’s going to feel tight.
And what do we do? We stretch it. Do long and taut muscles need stretching? No. We might put it into a position to shorten it and then we might work it, but we’d work in the transverse plane.
The X-Factor Highways
Then we have two X-Factor Highways: the Anterior X-Factor and the Posterior X-Factor, where we’re looking at extension and rotation.
Throwers get in the Anterior X-Factor position, or golfers in the backswing or follow-through or tennis players; any time you reach for anything behind you, you’re into the Anterior X-Factor Highway. These structures need to be worked and stretched together.
The Posterior X-Factor needs even more attention. The lateral insertion of the glute ties into the lumbar fascia and the opposite lat. They run parallel.
Any time we have flexion and rotation, we need to stretch the structures together. If we’ve used up that usable amount of motion and then reach, where is that excessive rotation going to come from? It’s going to be made up by the lumbar spine, which doesn’t like it.
And then we have the Turnpike, another X-Factor that represents lateral flexion and rotation in the opposite direction or the same direction.
We need to work the opposite posterior neck through the rhomboids into the opposite scapula to the serratus interior to the oblique and the same side hip. We need to do these motions and movement patterns and mobility work together because that’s what connects the head to the hip.
Considering limitations, compensations and idiosyncrasies
You have to consider the limitations, compensations and idiosyncrasies of your client and maybe recognize that progression isn’t a fit for your client. There are no bad exercises. Sometimes our options are bad based on the limitations, compensations and idiosyncrasies of our clients.
We’ve got to use movement patterns from a regressive and a progressive approach. If we gain mobility, especially in the sedentary population, but we don’t give a matching exercise, we may be setting up an increased risk of injury. When we don’t have the ability to proprioceptively respond or don’t have the eccentric capability to control an increased range of motion, we’re not ready for the movement, speed or load. We are essentially looking for a capability to control that increased range of motion.
I go into great depth about tri-plane motion, the Flexibility Highways and regression exercise suggestions in my new book, Insights into Functional Training. I hope you’ll take a look.
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- 1. http://www.ideafit.com/fitness-library/2010-fitness-programs-equipment-trends