sportEX Dynamics Journal Issue 42 - October 2014 by Co-Kinetic

ISSUE 42 Oct 2014 ISSn 1744-9383

promoting

best practice in

highlights

manual therapy

n MyOfascial techniques fOr hip MObility n fascial stretch therapy n shOulder iMpingeMent n biOtensegrity and bOdy architecture

contents oCTobEr 2014 issuE 42

Editorial

publisher TOr DAvIES BSc (Hons) tor@sportex.net art editor DEBBIE ASHEr debbie@sportex.net sub editor ALISON SLEIgH Journal watch BOB BrAMAH subscriptions & advertising support@sportex.net +44 (0)845 652 1906 COMMISSIONINg EDITOrS Brad Hiskins - Australia & NZ Whitney Lowe - USA & Canada Humphrey Bacchus - UK & Europe glenn Withers - Worldwide Dr Marco Cardinale - Worldwide Dr Thien Dang Tan - USA & Canada Dr Joseph Brence, DPT, COMT, FAAOMPT, DAC TECHNICAL ADvISOrS

Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds rob granter Michael Nichol Joan Watt Dr greg Whyte

oct 2014

So soft tissue therapists, bodyworkers, manual therapists, sports massage practitioners, massage therapists...you’re going to love this issue I hope! Lots and lots of content around fascia and structural integration which is becoming a very hot international topic indeed and a sign of things to come for sportEX dynamics in terms of content. However it does raise both a national and international issue around terminology and naming conventions. The Aussies continue to struggle with this as you’ll read in the next issue. They asked their mailing list to vote for their preferred profession name with results as follows: remedial massage (25.6%), massage therapy (20.9%), myotherapy (2.3%), soft tissue therapy (44.2%) and musculoskeletal therapy (7%). The athletic therapists struggle in Canada because they often work with other ‘physical’ therapists like chiropractors who refer to them for the rehab aspects but ‘non sporty’ clients can be reluctant to see the athletic therapist because they don’t consider themselves ‘athletic’. I even get it with the journals. Often our content isn’t sports-specific but the brand ‘sportEX’ puts off people who don’t work in sport because perfectly reasonably they think the content won’t be relevant to them (I’m on it!). Naming and professional identification is incredbily important and we need to think it through carefully and urgently.

BSc (BASraT), MSc MCSP, MSMA MSc, FA Dip, Mast STT Dip SST Dip SST BSc (BASraT) MCSP, MSMA PhD, BSc (Hons)

Tor Davies, physio-turned publisher and sportEX founder is published by Centor publishing Ltd 88 nelson road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 fax: ax: +44 (0)845 652 1907 www.sportex.net oTHEr TiTLEs in THE sporTEX rangE

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ng exceotille n in

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medicin sportEX medicine - ISSN e 1471-8138. Written specifically for professionals working in the field of soft-tissue injury diagnosis, treatment and rehabilitation - personal subscription £54, practice subscription £94, library subscription £175

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sportEX is printed in the UK by Cambrian Printers Ltd, award-winning colour printing specialists, independently audited to ISO 14001 and EMAS environmental standards. sportEX is printed on paper from FSC certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

ConTEnTs 4 Journal watch 8 Hip mobility 13 fascial stretching This quarter’s latest soft tissue research

Find out why improving hip mobility can reduce low back pain Part 2 describes how to improve faulty squat patterning with stretches for the knee, ankle and foot

shoulder impingement

Understand the anatomy of the shoulder to optimise shoulder function and learn techniques to manage shoulder problems

29 biotensegrity 34 social watch

Fascia and the science of body architecture

Some useful resources on Twitter

To finD ouT morE abouT sporTEX visiT

DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

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e eating tWo larger meals a day ((Breakfast and lunCh) is more effeCtive than six smaller meals in a reduCed-energy regimen for redu patients With type 2 diaBetes: a randomised Crossover study. kahleova h, Belinova l, et al. diabetologia 2014;doi:10.1007/ s00125-014-3253-5 Fifty-four patients with type 2 diabetes (27 males, 27 females, age 30–70 years, BMI 27–50 kg/m2) followed a diet of either two meals a day (breakfast and lunch) or six meals a day for 12 weeks. Both regimes consumed the same amount macronutrients and calories. The diet in both regimens had the same macronutrient and energy content. Body weight, hepatic fat content, fasting plasma glucose and C-peptide levels decreased in both regimens but more so in the two meals a day group. No adverse events were observed for either regimen.

leisure-time running reduCes all-Cause and CardiovasCular mortality risk. lee dC, pate rr, et al. Journal of the american College of Cardiology 2014;64(5):472–481 This massive study used a medical history questionnaire to examine the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, 18 to 100 years of age (mean age 44 years). It found that during a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately 24% of adults participated in running in this population. Compared with non-runners, the runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit. In dose-response analyses, the mortality benefits in runners were similar across quintiles of running time, distance, frequency, amount, and speed, compared with non-runners. The least active fifth of runners spent less than 51min a week jogging, covering less than 6 miles. Yet their risk of dying of heart disease or any other cause during the study was no different to the fifth who ran for more than 176min, covering more than 20 miles a week over at least six runs,

sportEX comment It would be interesting to see if these results correlated with a nondiabetic population. While we wait for that we will have a bacon butty for breakfast and a long lunch!!!

sportEX comment Runners Rule. Even as little as 5–10min a day at slow speed reduced deaths. Jog on.

Coa CoaChes’ and players’ perCeptions of training dose: not a perfeCt matCh. Brink sm, frencken Wgp, et al. international Journal of sports physiology and performance 2014;9:497–502 The participants were 33 professional soccer players from an under-19 and under-17 squad. Before training, coaches filled in the session rating of intended exertion (RIE) and duration (min) for each player. After the session players rated perceived exertion (RPE) and training duration and a comparison between the coach’s plan and the player’s perception made. Players perceived their intensity and training load (2446 sessions in total) as significantly harder than what was intended by their coaches. The correlations between coaches’ and players’ intensity, duration and load were weak. On the sessions that coaches intended easy and intermediate training days, players reported higher intensity and training load. For hard days as intended by the coach, players reported lower intensity, duration and training load. Finally, first-year players from the under-17 squad perceived training sessions as harder than second-year players.

sportEX comment Young players believe they are working harder than the coaches intend them to. The big question is does this lead to over training. Maybe this should be monitored by the clubs.

sportEX dynamics 2014;42(October):4-7

JOURNAL WATCH

Journal Watch reproduCiBility of and sex differenCes in Common orthopaediC ankle and foot tests in runners. van der Worp mp, de Wijer a, et al. BmC musculoskeletal disorders 2014;15:171 This study starts with the premise that it is important to identify whether (hyper)pronation of the foot, decreased ankle joint dorsiflexion (AJD) and the degree of the extension of the first metatarsophalangeal joint (MTP1) are risk factors for running injuries. These are tested by the navicular drop test (NDT) stance and single limb-stance, the AJD test, and the extension MTP1test. The three orthopaedic tests were administered by two sports physios on a group of 42 (22 male and 20 female) recreational runners. Females had a significantly lower navicular drop score and higher range of motion in extension of the MTP1, but no sex differences were found for ankle dorsiflexion. The reproducibility for the AJD test in runners is good, whereas that of the NDT and extension MTP1 was moderate or low.

sportEX comment These tests have a good inter and intrarater reliability, so the tests can be applied to a large cohort study in order to determine risk factors. Bring on the study!

Cardiovas CardiovasCular pre-partiCipation sCreening praCtiCes of College team s physiCians. asplund Ca, asif im. Clinical Journal of sport medicine 2014;24(4):275â&#x20AC;&#x201C;279 Two hundred and twenty-four USA college team physicians responded to a survey about cardiovascular pre-participation screening practices including non-invasive cardiac screening (NICS) such as electrocardiogram (ECG) or echocardiogram. The majority (78%) of schools conducted the American Heart Association (AHA) 12-element history and physical examination. The top (Division I) institutions were more likely to add an ECG and/or echocardiogram (30%) to their pre-participation examination (PPE) compared with lower divisions schools.

sportEX comment Studies looking at sudden death in young athletes have shown that 12 fit and healthy people under 35 die in the UK every week. Around 4 out of 5 of them have never shown symptoms before the event. Screening can go a long way to identifying those at risk. In the USA the AHA recognised that an ECG is expensive so they came up with a 12-point screening protocol based on personal and family history and a physical examination that includes checking for a heart murmur, taking a femoral pulses, checking physical appearance of Marfan syndrome and finally taking the brachial artery blood pressure in sitting. What is your club doing?

t aCtute effeCt of Whole Body viBration training on flexiBility and explosive strength of young gymnasts. the dallas g, paschalis k, mellos v. Biology of sport 2014;31(3):233â&#x20AC;&#x201C;237 Thirty-two young competitive gymnasts were allocated to either a vibration group or traditional body weight training. The vibration intervention (VG) consisted of a single bout of eccentric and concentric squatting movements on a vibration platform. The traditional body weight group performed the same training protocol whilst standing on the vibration machine but without it being switched on (NVG). Flexibility as determined by a sit-and-reach test (S&R) and explosive strength tests determined by a squat jump (SJ), counter movement jump (CMJ), and single-leg squat of the right leg (RL) and left leg (LL) were performed pre-test, immediately post-test, and 15min after the end of the intervention www.sportEX.net

programme (post-test 15). The results were that a significant interaction between group and time was found with respect to SJ. However, no significant interaction between group and time was found with respect to flexibility, CMJ, RL and LL after the end of the intervention programme. Further, the percentage improvement of the VG was significantly greater in all examined variables compared to the NVG. This study concluded that whole-body vibration training improves flexibility and explosive strength of lower limbs in young trained artistic gymnasts and maintains the initial level of performance for

at least 15 minutes after the WBV intervention programme.

sportEX comment Everything improves using the vibration plate which suggests that it may serve as a usual bit of kit for a warm-up in sports where flexibility and explosive speed are required. It would be nice to know why.

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immunologiCal effeCts of massage after exerCise: a systematiC revieW. tejero-fernández v, membrilla-mesa m, et al. physical therapy in sport 2014;doi:10.1016/j. ptsp.2014.07.001 The objective of this review was to determine whether immune parameters can be modulated by massage after intense physical activity. looking for controlled studies published between 1970 and 2012, this systematic review searched the usual databases using the key words ‘massage’, ‘myofascial release’, ‘acupressure’, ‘recovery’, and ‘warm up’ combined with ‘exercise’, ‘exercise-induced muscle damage’, ‘sport’, ‘immunology’ and lymphocytes’. The CONSORT Declaration was applied to assess the quality of the selected studies. The initial search identified 739 publications in the databases, of which only 5 met the review inclusion criteria. A positive relationship between immunological recovery and postexercise massage was reported by some of these studies but not by others. Overall there is preliminary evidence that massage may modulate immune parameters when applied after exercise, but more research is needed to confirm this possibility.

sportEX comment The first thing to learn from this is that there are a lot of research papers out there. The second is that much of it is not up to much and the third is that despite this there are indications that massage has a place in immunological recovery. Bring on some more research please.

e effeCtiveness of soft tissue massage and exerCise for the treatment of non-speCifiC shoulder pain: a systematiC non-spe revieW With meta-analysis. van den dolder pa, ferreira ph, refshauge km. British Journal of sports medicine 2014;48:1216– 1226 This systematic review searched articles from 1966 to December 2011 to find studies that involves ‘hands on’ soft tissue massage performed locally to the shoulder or exercises aimed at improving strength, range-of-motion or coordination. Participants were aged 18–80 years and outcomes measured included pain, disability, range of motion, quality of life, work status, global perceived effect, adverse events or recurrence. Twenty-three papers met the selection criteria representing 20 individual trials. There was low-quality evidence that soft tissue massage was effective for producing moderate improvements in active ﬂexion and abduction range of motion, pain and functional scores compared with no treatment. Exercise was shown by meta-analysis to produce greater improvements than placebo, minimal or no treatment in reported pain but these changes were of a magnitude that was less than that considered clinically worthwhile. Exercise did not produce greater improvements in shoulder function than placebo, minimal or no treatment.

sportEX comment Shout it from the roof tops. Soft tissue therapy is effective. So get the range–of-motion with it and then send your patients home with an exercise regime to maintain it.

short term effeCts of ClassiC massage Compared to ConneCtive tissue massage on pressure pain threshold and musCle relaxation response in Women With ChroniC neCk pain: a preliminary study. Bakar y, sertel m, et al. Journal of manipulative and physiological therapeutics 2014;37(6):415–421 Forty-five female volunteers (ages between 25 and 45) with chronic neck pain lasting 3–6 months were randomly assigned to either to a group receiving one session of either classical massage (CM) or connective tissue massage (CTM) to the thoracic spine and neck. Each treatment was carried out for 1 session. Pressure pain threshold (PPT) was measured with an algometer and muscle relaxation with electromyography biofeedback (EMG-BF). The results were that PPT of the sternocleidomastoid muscle was significantly different for the CM group. The EMG-BF values were significantly different for the CTM group 6

(P<0.05). Comparing the results of CM and CTM, EMG-BF averages favoured the CTM group.

sportEX comment Do them both then. Sadly like much massage research this study is unrepeatable. The actual treatment is only minimally described. CM was 20min using ‘Swedish technique’ comprising of included ‘3 strokes, 3 kneads, and 3 strokes’. The CTM is only described as massage that focuses on stretching connective tissue layers. It was done in sitting on 4 sections of the back for about 20 to 25min. sportEX dynamics 2014;42(October):4-7

JOURNAL WATCH

effiCaCy of a massage roller ComBined With Cooling lotion in the prevention of Calf musCle Cramps. schmidt fp, körber k. phlebologie hlebologie 2014;43(2):78–83 As a prevention strategy, 208 patients with a recent history of muscle cramps had a massage roller applied to the legs for at least 5min daily, starting at the big toe and progressing to the groin, using moderate to medium pressure. Marked improvement was reported in 151 patients in whom the frequency of calf muscle cramps either fell by more than half or in whom no further calf muscle cramps occurred. Cramp duration was also reduced when the massage roller was used to treat an acute calf muscle cramp. Pregnant women, younger patients, patients with venous disease, men of all ages and middle-aged women benefited most from using the massage roller.

sportEX comment Did you know that cramps can be divided into three types: (1) occasional spontaneous calf muscle cramps (similar to hiccups), (2) due to physical exertion with heat, and fluid loss (sweating, vomiting, diarrhoea), and (3) as warning signs of a primary disease. Unfortunately the actual cause is still a mystery, but this study shows that mechanical force into the tissue can have an effect.

emerging evidenCe on footstrike patterns in running. kirby ka. podiatry today 2014;27(6) This looks at the current fad for barefoot running. It quotes some good studies including one in which runners who underwent a 10-week transition period of running in Vibram Five-fingers shoes showed significant increases in foot bone marrow oedema versus those runners who trained only in traditional thick-soled running shoes. It reviews the most popular studies on foot-strike patterns and the controversy surrounding differences but concludes that as 97% of runners choose a rearfoot pattern as opposed to the forefoot, this may be the most metabolically efficient running form at recreational running speeds. Finally, the claims made by the barefoot/minimalist shoe advocates about foot-strike patterns in running have little if any support within the scientific research literature.

sportEX comment Therapists who treat runners need to be able to offer their patients thorough information and advice based on scientific fact, not the latest fad. myofasCial treatment for patients With aCetaBular laBral tears: a single-suBJeCt researCh design study. Cashman ge, mortenson WB, gilbart mk. Journal of orthopaedic & sports physical therapy 2014;44(8):604–614 Four patients were treated for 6 to 8 weeks, using a combination of soft tissue therapy, stretching, and strengthening for the hip abductors, external rotators, and tensor fasciae latae. Data were assessed visually, statistically, and by comparing mean differences before and after intervention. All four patients experienced both statistically significant and clinically meaningful improvement in posterolateral hip pain and hiprelated function. Three patients also experienced reduction in antero-medial hip pain.

sportEX comment Not all patients with acetabular labral tears complain of pain. When they do the pain commonly presents anteriorly but may also present posteriorly and laterally. The treatment is arthroscopic repair but not all patients respond to this. It is possible that some of them have myofascial pain in addition to anything happening inside the joint. This is a very small study but it proves that the soft tissue approach is worth a try before surgery.

deep tissue massage and non-steroidal anti-inflammatory drugs for loW BaCk pain: a prospeCtive randomized trial. majchrzycki m, kocur p, kotwicki t. scientific World Journal. 2014; doi:10.1155/2014/287597 Fifty-nine patients, age 51.8 ± 9.0 years, with chronic low back pain were given either 2 weeks of deep tissue massage or the same with the addition of anti-inflammatory pills. The outcome measures were a visual analogue pain scale, an Oswestry disability index, and a Roland-Morris questionnaire. In both groups there was a significant pain reduction and function improvement. All pre- and post-treatment differences were significant; however, there was no significant difference between the groups.

sportEX comment Yet more evidence that soft tissue massage works and for good measure this study shows that you can save yourself the cost and the side effects of the medication.

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Myofascial D techniques for hip Mobility

BY Til luchau Ba, NcTMB cMP

This article cites evidence linking low back pain and limited hip mobility, and then clearly explains three hands-on techniques for applying this information in clinical practice. The techniques described are safe, simple and clear enough to be employed by practitioners of all modalities and experience levels. Contraindications and cautions, including hip replacement and femoroacetabular impingement syndrome, are discussed.

Ischiofemoral ligament

r Ida Rolf and the Structural Integration approach that she originated (also known as ‘Rolfing®’) have had a significant impact on our understanding of the body and change, both during her lifetime (1898–1979) and in the years since. Many who studied her work (such as Thomas Myers, the author of Anatomy Trains, and fascial researcher Robert Schleip) have gone on to become influential thought leaders in the fields of physical therapy, manual medicine, movement, and sports training. When I was a student at the Rolf Institute of Structural Integration in the 1980s, I heard a story about Dr Rolf, which underlined the importance of pelvic mobility in her work. According to the story, Dr Rolf would regularly quiz her trainees about the aims of each of her ten ‘hours’ or sessions. She reportedly asked her classes questions such as, “What is the goal of the fifth hour?” As a demanding teacher, very few answers would satisfy her; but even though each session was different, she reportedly accepted the answer “Free the pelvis” as a correct one, no matter which session she would ask about. While this story probably has an element of folklore to it (since her death in 1979, many ‘Ida stories’ have Pubofemoral ligament

Iliofemoral ligament © Primal Pictures Ltd 2014

Figure 1: The iliofemoral, pubofemoral and ischiofemoral ligaments limit hip motion.

sportEX dynamics 2014;42(October):8-12

Manual therapy

assumed the status of legend in the structural integration community), it illustrates the key role that pelvic adaptability at the hip joints played in her vision of an integrated body (Fig. 1). Dr Rolf referred to the hips and pelvis as “the joint that determines symmetry” (1). She was not alone in emphasising the key role of the hips; balanced hip-joint mobility is important in fields as diverse as athletics, dance, geriatrics and back pain management. I became even more curious about the relationship of the low back to hipjoint mobility when I travelled to Japan to teach and practice manual therapy, a few years after graduating from the Rolf Institute. I noticed challenges to my own hip mobility as I adjusted to the Japanese practice of sitting on floor cushions more often than chairs. I noticed considerably more hip mobility (especially external rotation) in my Japanese clientele than I had seen in my American and European clients. My Japanese clients also seemed to have generally flatter spinal curves. Was this also related to their hip mobility? In utero, humans develop with flexed hips and no secondary lumbar curve (Fig. 2). It is only once they begin to crawl (Fig. 3) and extend their hips that they develop a lumbar curve. Conventional wisdom maintains that freer hips mean happier backs, and research both in Japan (2) and in the

Figure 2: Infants have more hip flexion as a result of their position in utero.

Figure 3: It is only once babies begin to crawl and extend their hips that they develop a lumbar curve. (AdvancedTrainings.com, used by permission)

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USA (3) generally supports this. In this article, I will describe three techniques from our Advanced Myofascial Techniques seminar and DVD series that are useful when assessing and balancing hip-joint mobility, and which can be used when working not only with hip mobility issues directly, but as a way to ameliorate low back pain and other hiprelated issues.

TechNiques Push Broom ‘a’ The ‘Push Broom’ series is an effective way to increase hip-joint mobility without undue effort or strain by the practitioner. Using gravity, we will take the hip through three positional techniques that will release all of the structures in the hip joint: from the deep iliofemoral ligaments, to the iliopsoas, hamstrings, hip abductors and adductors, rotators, sartorius, quadriceps and their enveloping fascias, superficial and deep. The term ‘push broom’ refers to the starting grip: hold your prone client’s leg at the ankle and knee as if holding the handle of a push broom (Fig. 4a). Swing the knee outwards as you walk the leg up into full hip flexion, bringing the knee as far towards the head as comfortably possible. Rolling the pelvis away from you as you bring the knee up will make it easier to flex the hip past the 90° point. Almost all clients will be more comfortable if you take the leg past this 90° position so that the femur is close to the side of the body, rather than perpendicular to it. Simply being put into this ‘baby crawling’ or ’bullfrog’ position often gives a therapeutic stretch to the hip joints; however, while we are here, we can increase hip mobility by evoking a reduction in resting tone of the gluteal muscles. While stabilising your client’s leg with your own, use the flat of your forearm to gently lean into the medial attachments of the gluteus maximus just below the iliac crest (Fig. 4b, Fig. 5). Tendinous attachments have concentrations of Golgi tendon organs. These are thought to respond to sustained, firm pressure, so you will get the best results by waiting with slow, nearly static pressure here, rather than sliding or moving your touch (4). Use

PElVIC ADAPTABIlITy AT ThE hIP JoInTS PlAyED A kEy RolE In IDA RolF’S VISIon oF An InTEGRATED BoDy moderate pressure, with a slight vector of pressure towards yourself, in order to ease or nudge the gluteus away from its bony attachments on the ilium. Gently sustain this pressure until you feel the tissue respond with a subtle softening or easing; then, release your pressure and move to the next segment of gluteal attachments.

Push Broom ‘B’ (external rotation) While still in the leg-up position of the Push Broom ‘A’ technique, drop your client’s lower leg off the table, as shown (a)

(b)

Figure 4: The ‘A’ variation of the Push Broom technique. Hold your prone client’s leg at the ankle and knee as if holding the handle of a push broom (a). Once the hip is flexed with the lower leg on the table, use your forearms to release the medial attachments of the gluteal muscles (b). (AdvancedTrainings.com, used by permission)

Figure 5: The medial attachments of the gluteus maximus are just below the iliac crest.

BAlAnCED hIP-JoInT MoBIlITy IS IMPoRTAnT In FIElDS AS DIVERSE AS AThlETICS, DAnCE, GERIATRICS AnD BACk PAIn MAnAGEMEnT Figure 6: The ‘B’ (external rotation) variation of the Push Broom technique. (AdvancedTrainings.com, used by permission)

BOx 1: KeY POiNTs fOr The hiP MOBiliTY TechNiques indications n limited hip mobility. n Balance or gait issues. n Back, sacroiliac or sciatic pain. Purpose n Restore mobility and refine proprioception at the iliofemoral (hip) joint. instructions n Without causing any pain, gently bring leg into flexed, abducted and rotated positions as described in text. Add static pressure on muscle attachments. n Wait in each position for a response to the stretch. n Repeat with other hip. Movements employed n Passive hip flexion, abduction, internal rotation and external rotation. in Figure 6. Roll the femur into external rotation by lifting the adductors towards you with both hands. This also allows you to prevent any pressure that the edge of the table might otherwise put behind your client’s knee. At the same time, use your leg under the table to augment the femoral rotation by gently pressing your client’s foot towards the head of the table. your client should feel no strain on the knee or anywhere else – only a stretch and release around the hip joint (Fig. 7). omit the pressure on your client’s foot if it produces any discomfort. Stay comfortable and upright in your own body. Invite your client to breathe easily and relax into the stretch. Sustain this positional technique until you feel a response – softening, easing, or relaxing. Usually this takes at least three to five breaths.

Push Broom ‘c’ (internal rotation) Figure 7: Viewing the hip joint from below helps visualise how external rotation can open the anterior hip joint (Primal Pictures reproduced with permission). Figure 8: The ‘C’ (internal rotation) variation of the Push Broom technique. (AdvancedTrainings.com, used by permission)

Specific kinds of hip mobility have been correlated with low back health. Internal hip rotation, hip flexion and hip extension in both sexes, and hamstring flexibility in men, all have a negative correlation with back pain (that is, people with those types of mobility generally have less back pain) (5). The ‘C’ variation of the Push Broom technique combines several of these important motions: internal femoral rotation, hip flexion, and hamstring stretch. From the external rotation ‘B’ variation, go right into internal rotation with Push Broom ‘C’. Instead of dropping the lower leg below the level of the table as in ‘B’, rotate the femur so that the lower leg is high. By using the grip

and position shown in Figure 8, gently take the femur to its soft end-range of internal rotation; hold, and wait for tissue response. Remember to keep the hip flexed at least 90° (that is, keep the femur perpendicular to the body, or even a little past this position toward the head). As in the ‘B’ variation, be mindful to avoid strain or discomfort on the knee. once you have completed these three Push Broom variations on one leg, return the leg to its anatomical position. Clients will often comment that this leg feels significantly longer and freer than the one you have not yet worked on. Repeat these techniques with the other side to balance the left and right sides.

OTher cONsiDeraTiONs Although we have described these three variations above as hip-joint techniques, they also affect the ligamentous adaptability of the pelvic girdle itself, mobilising the sacroiliac joints by addressing sacrotuberous, sacrospinous and sacroiliac ligament restrictions, and balancing the torsion and flaring movements of the ilia on the sacrum. This makes them useful in addressing appendicular sciatic pain, sacrotuberous ligament pain, sacroiliac joint pain and other conditions of the pelvis. See Box 1 for a summary of the key points for the hip mobility techniques. If your client or patient is unclothed or minimally clothed, you can drape these techniques by simply grasping the leg through the top sheet in variation ‘A’, and move the sheet together with the leg. Alternatively, especially for the ‘B’ and ‘C’ variations, sportEX dynamics 2014;42(October):8-12

Manual therapy

the leg can be out from under the edge of the drape, with the sheet gathered around the thigh so as to give a sense of security and privacy to the client. When applying the techniques described here, it is important that they do not cause pain. In addition to soft-tissue restrictions to mobility, there can be bony restrictions as well, such as the shape or orientation of the acetabula or femoral heads. These can cause pain or irritation when pushed to their physiologic limit. Femoroacetabular impingement (FAI) syndrome is a painful restriction of hip movement caused by abnormal contact between the femur and the rim of the acetabulum, probably due to both genetic and usage factors. Although often addressed surgically, techniques that increase mobility are also effective in managing FAI pain – though pushing a stretch too aggressively can aggravate this condition, so use caution at the end ranges of motion, especially if there is discomfort right deep in the hip joint itself.

WhaT aBOuT hiP rePlaceMeNTs? Although the prevention of difficulties is more difficult to measure or study than the difficulties themselves, it is reasonable to assume that maintaining balanced hip mobility can help prevent or ameliorate the joint pain, degeneration or arthritic conditions that if otherwise unaddressed, can lead to hip replacement or resurfacing. If your client has already had hip replacement surgery (Fig. 9), special considerations may apply when using

Figure 9: X-ray of a total hip replacement (total hip arthroplasty).

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these techniques. hip replacement surgery involves cutting through tissues and dislocating the joint being replaced, either posteriorly or anteriorly, depending on the type of surgery. This can leave the hip with less support in the direction of the surgical dislocation, at least during recovery (6). Different types of hip surgeries have different movement restrictions associated with their recovery period. Surgeons also differ widely in their recommended movement restrictions after surgery. In 2010, an informal survey of hip surgeons’ recommendations to yoga teachers found that a third of responding surgeons did not require any movement restrictions whatsoever after an anterior hip replacement (7). however, the most conservative recommendations say that for 6 months to 1 year after surgery, hip replacement patients should avoid: n adduction, internal rotation, and hip flexion past 90° for posterior hip replacements; or, n abduction, external rotation and hip extension for anterior replacements. Given these variables, the best practice for manual therapists is to inquire about any movements your client’s surgeon or rehabilitation therapist has recommended that the client avoid during the recovery period. Many hip replacement patients continue to experience soft-tissuebased movement restrictions long after their surgeries have fully healed. For these older, healed hip replacements (approximately 1 year or more after surgery), these techniques can be a great help with longer-term recovery and maintenance of mobility. however, given that we are not trying to stretch or alter the artificial materials of the prosthesis itself, go easy on the endrange stretch of any stretching applied to the replaced hip. Think about keeping the tissues around the joint long, easy and mobile, rather than trying to deeply stretch the artificial joint itself. Finally, do not hesitate to adapt these techniques for senior or physically challenged clients. By being sensitive and staying in communication about their comfort, you will often be surprised as to how comfortable and

ThE ‘PUSh BRooM’ SERIES oF TEChnIqUES IS An EFFECTIVE WAy To InCREASE hIP-JoInT MoBIlITy WIThoUT UnDUE EFFoRT oR STRAIn By ThE PRACTITIonER effective these releases are, even for those with limited active hip mobility.

suMMarY With practice, these techniques will become indispensable parts of your technique toolbox, enabling you to assess and release many hip restrictions within the context of your regular work. your clients of all ages and activity levels will appreciate this: whether we have lower back pain or not (and 80% of people experience back pain at some point in their lives), most of us will benefit from increased hip adaptability, as it makes our sitting, walking, and moving easier, more efficient and more comfortable.

acKNOWleDgMeNT This article was excerpted from Til luchau’s upcoming book, Advanced Myofascial Techniques, and reproduced here with permission from handspring Press. Volume I is scheduled to be published by handspring Press in late 2014. References 1. Rolf I.Rolfing: integration of human structures. harpercollins 1987. ISBn 978-0064650960 (£140.90). Buy from Amazon http://spxj.nl/1vEo36g 2. horikawa k, kasai y, et al. Prevalence of osteoarthritis, osteoporotic vertebral fractures, and spondylolisthesis among the elderly in a Japanese village. Journal of orthopaedic surgery 2006;14(1):9–12 3. harris-hayes M, Sahrmann SA, Van Dillen lR. Relationship between the hip and low back pain in athletes who participate in rotationrelated sports. Journal of sport rehabilitation 2009;18(1):60–75 4. Schleip R. Fascial plasticity – a new neurobiological explanation: part 1. Journal of bodywork and Movement therapies 2003;7(1):11–19 5. Mellin G. Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. spine 1988;13(6):668–670 6. To learn more about the procedures involved in a posterior replacement, I recommend checking out the interactive hip surgery simulator at www.edheads.org/activities/hip/. The squeamish need not be concerned – the animated procedures keep it neat and tidy, unlike real posterior hip surgeries, which can appear downright gory and brutal to the uninitiated. Accessed 5/2014 7. Jones M. yoga after a hip replacement. 2010; http://spxj.nl/yTX2B5. Accessed 5/2014.

furTher resOurces 1. For more information about Til luchau and Advanced Myofascial Techniques, visit www.Advanced-Trainings.com or Advanced-Trainings.com’s FaceBook page (http://spxj.nl/1ruD64o). 2. Til luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars in the Uk and abroad. he is also a Certified Advanced Rolfer™ and taught for the Rolf Institute® of Structural Integration for 22 years.

online if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access. Video 1: Watch Til luchau demonstrate the Push Broom techniques (http://goo.gl/wv9OZi). (excerpted from the ‘Pelvis, hip, & sacrum’ advanced Myofascial Techniques training DVD set, with Til luchau, certified advanced rolfer, advanced-Trainings.com 2009)

Th AuThOR ThE TIl luChAu BA, NCTMB CMP T Til is the director of Advanced-Trainings.com. As a Certified Advanced Rolfer®, he was a faculty member and coordinator of the Rolf Institute’s Foundations of Rolfing Structural Integration programme for over 20 years, where he originated Skillful Touch Bodywork (the Rolf Institute’s own training and practice modality). his articles have been published in magazines and peer-reviewed technical journals in Australia, Canada and the uSA. Formerly a resident practitioner at the Esalen Institute, Chair of the Rolf Institute’s Teacher Training Committee, and adjunct faculty member of Naropa university’s Somatic Psychology Department, he has trained thousands of practitioners in his popular courses at schools and clinics in over a dozen countries on five continents.

KeY POiNTs

DISCUSSIONS

n Which types of hip mobility have been correlated with low back health in both men and women? n As stated in the text, conservative recommendations say that for 6 months to 1 year, posterior hip replacements patients should avoid what types of motions? n The author states that the Golgi tendon organs located in the tendinous attachments respond best to which type of pressure? n how long does the text suggest you should hold the position of the Push Broom ‘B’ technique?

continuing education Multiple choice questions This article also has a certificated elearning test which can be found under the elearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

this quiz is accessible

free

with a subscription that includes online access to this Journal.

n Certain types of hip mobility are negatively correlated to low back pain, and these types vary slightly between men and women. n There appear to be cross-cultural differences in hip mobility, but there is evidence that the low back pain/hip mobility correlation has been observed in both Japan and the USA. n Ida Rolf, the originator of Rolfing structural integration, placed a high degree of importance on pelvis and hip mobility. n hip mobility can be addressed through a series of techniques combining positional strategies, passive stretching, and direct pressure. n The ‘Push Broom’ series is an effective way to increase hip-joint mobility without undue effort or strain by the practitioner. n Practitioners can leverage the Golgi tendon organ response when working with hip mobility. n When applying the techniques described here, it is important that they do not cause pain. In addition to soft-tissue restrictions to mobility, there can be bony restrictions as well, such as the shape or orientation of the acetabula or femoral heads. n Recommendations from surgeons about movement restrictions post-hip replacement vary greatly, and these recommendations differ according to the type of surgery that was performed.

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Improve squat patternI patternIng wIth FascI FascIal stretch therapy™ BY CHRIS FREDERICK PT KMI

InTRoDuCTIon The focus of this article is to introduce you to how to use Fascial Stretch Therapy (FST) techniques to correct faulty movement patterns in the squat. Then functional training can progress safely and not be interrupted or slowed down by pain, weakness or imbalances caused by movement restrictions. A consequence of this is better, faster, more complete results with greater confidence gained from both therapist/ trainer and client.

WHaT IS FST? FST is a modified proprioceptive neuromuscular facilitation (PNF)-based, client-assisted flexibility system. The therapist/trainer uses hands-on, direct techniques on a table with stabilisation straps to assess and remove restrictions to movement in joints, muscles and fascia (Fig. 1). Results are quicker and more thorough than traditional, isolated stretching because of the 10 Principles [described in Part 1 (1)] that make up the system.

Stretch to Win – Fascial Stretch Therapy® (STW-FST) offers sport manual and movement therapists and trainers a quick, effective and logical system to improve function. STW-FST combines innovative passive, active, resisted and assisted mobility and stretching movement patterns that can be used to remove the restrictions that are the barriers to good mobility. The squat is used as an example where we are focusing on the hip, knee and ankle. In Part 1, a full description of the STW-FST system with a focus on the hip was presented. In this article, Part 2, we will discuss common problems that occur in the knee, foot and ankle to complete a comprehensive discussion of correcting faulty patterns in the squat movement. of-motion (ROM) tests n New motor pattern learning ability, speed and style.

Figure 1: Stretch to Win. Fascial Stretch Therapy (FST) follows a set of 10 Priniciples, described in Part 1 (1). (Photo credit: C. Coons, 2013)

THE KnEE It is important to note that the knee is often the ‘victim’ that may become painful, weak or unstable. This is on account of it being ‘caught’ between the ‘criminals’ of the hip and ankle/ foot. It is advised that any problems of imbalances identified in the hip and/or ankle/foot be addressed first before correcting the knee in isolation. Consequently, the entire kinetic chain should be taken into account when conducting the following tests for a more accurate assessment: n Motor sequencing assessment and www.sportEX.net

Note: not all items are necessarily done at the same time. Some items are done only when indicated with an accurate and proper screening. Even with the best of assessments/tests, corrective training and then reassessments, there will be clients

correction n Key muscle strength testing for nerve function n Functional movement, strength and flexibility tests n Passive and active range-

The Superficial Front Line can be traced through the: n Sternocleidomastoid n Sternalis/ sternochondral fascia n Rectus abdominis n Rectus femoris/ quadriceps n Patellar ligament n Toe extensors/tibialis anterior.

FIRST ASSESS ANd AddRESS ThE SqUAT TEChNIqUE IN ThE ‘FULL bOdy’ CONTExT bEFORE LOOKING AT ONE bOdy PART with continued knee pain or other discomfort, mobility and/or motor pattern faults and some with excessive muscle tension or over-recruitment problems. These are the problems that respond best to FST.

Two common problems, two FST solutions for faulty squat technique

Figure 2: Superficial Front Line. [Primal Pictures, adapted from Myers (2)]

Figure 3: Superficial Front Line stretch – anterior knee fascia focus. [Photo credit: M. McNutt, 2011 (5), reproduced with permission from Handspring Publishing]

The FST solution for many knee problems seen in the squat is to first assess and address it in the ‘full body’ context before looking at one body part. We say, “Go global before local”. One common example is anterior kneecap pain. Even when hip imbalances, knee position and/or ankle mobility are corrected, pain may still be present. Whereas some clients with this symptom may have some degree of patellofemoral joint degeneration without knowing it until they started squatting, many can still be helped with FST techniques. The second example to be discussed is posterior knee issues. One may have pain posteriorly for a variety of reasons. For instance, an athlete may have suboptimal power generation in triple extension coming up out of the squat. One aspect of this that is often ignored is a tight posterior knee joint capsule and/or popliteus muscle. Another is ‘glued down’ tendons of the hamstrings and gastrocnemii that block full knee joint extension and inhibit full quadriceps activation. Together this decreases knee joint stability, making it prone to further injury. Those knee problems and FST solutions are discussed in detail below but first contraindications and FST tips must be reviewed before attempting the technique.

FST contraindications

Figure 4: Fig. 3 Stretch to Win – Fascial Stretch Therapy: The Scorpion Stretch™. (Photo credit: C. Coons, 2013)

Please follow any contraindications and precautions as dictated by your intake form and your training/experience. Others peculiar to certain stretches will be noted.

FST tips Follow the tips listed below to get the most out of FST: n A good example of what not to do: a client says, “Stretch me more” or “I don’t feel anything, so go further”. If you feel tissue being stretched, it is being stretched even if the client doesn’t feel it. Under-stretching is better than over-stretching. One can always progress it in the next session but one may lose a client if one over-stretches and injures them. n Experience shows better results when full global or entire fascial lines are engaged during FST. Example: if one has a client with tightness or anterior knee pain, instead of merely doing a quadriceps stretch, work the entire Superficial Front Line (SFL), which the quadriceps are part of, for more of a functional stretch effect. See first example below to explain this particular example. n Review Part 1 for optimal understanding and full application (1).

FST TECHnIquES FoR THE KnEE 1. Superficial Front Line stretch: anterior knee fascia focus The difference between an isolated assisted quadriceps stretch and an SFL stretch to affect the muscles and joint of the knee is huge. If one attempts this stretch with a client in the sidelying position, and one performs a traditional, isolated stretch by flexing the knee in the sagittal plane, one will only stretch mostly the distal portion of the rectus femoris and some of the rest of the distal, anterior quadriceps attachments. Adding hip extension adds more stretch to the rectus femoris, leaving out the rest of the quadriceps that cross only the knee joint. In contrast, if you expand your concept of the anatomy and include short and long lines of fascial connections, then your eyes open to see many more factors that play a role sportEX dynamics 2014;42(October):13-20

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in function that can also affect the knee. If you look at Figure 2 and note the fascial connections from, literally, head to toe, you will see a larger part that the knee serves in just one of many full body fascial lines. With many common knee problems, the fascia of the SFL is often ‘tacked down’ and/or shifted in a specific direction. This can affect the entire kinetic chain or have dominance in one region, as it often does at the knee. For example, if the SFL is shifted up then the patella may appear in a higher position than normal. Or it may be shifted down in the opposite direction. both can lead to knee pain and/or instability/weakness during the squat. FST can correct both quickly and restore the squat to normal if this is the cause of the aberrant squat pattern. however, doing a traditional isolated, rectus femoris or quadriceps stretch will more often not do the job. Problems to treat with this stretch The following problems often benefit from this stretch: n Anterior superficial knee cap pain n Anterior deep knee pain (in patellofemoral joint) n Old but stable anterior cruciate ligament (ACL) surgeries leaving restricted ROM n General knee joint stiffness n General muscle tightness around knee. Contraindications do not use this stretch if the patient suffers with any of the following: n Acute injuries or any inflammatory condition n Old ACL tears n Old meniscal tears n Unstable knee n Severe osteoarthritis. Tips For optimal performance of the stretch: n Avoid twisting the ankle into eversion n If medial knee pain occurs, abduct the knee a little higher. Technique (Fig. 3) The points below provide a step-bystep guide to this stretch: 1. Place client in side lying position with leg you are working on top. www.sportEX.net

2. It is best to traction the hip joint capsule and stretch the hip flexor first [which sits in the deep Front Line (dFL)] with extended or slightly flexed knee [see Part 1 (1)]. 3. Progress to rectus femoris/ quadriceps by lining up the thigh with the torso before bending the knee slightly. 4. Some clients feel a quadriceps stretch with the thigh in neutral, others don’t. Clients whose knees can be bent so that the heels touch their bottom and they either feel a small stretch or nothing at all, need to be brought back to knee extension then add more hip extension before adding more knee flexion. 5. Progress to slightly more hip extension to engage more rectus femoris before flexing the knee. 6. do passive ROM first for 3 reps then PNF for 3 reps to increase ROM. 7. Progress with increased hip extension and knee flexion until no further gains are made within client tolerance. 8. Alternate reps of both ROM and PNF between proximal attachments and distal ones to get better, faster response. 9. To increase the stretch along entire fascial line: a. Add overhead arm position for upper body b. Add ankle–foot plantarflexion for lower body c. Figure 4 shows our advanced Scorpion Stretch™ full fascial movement (not described in this article) of the SFL and dFL. 10. Re-test squat and check symptoms. 11. If pain is relieved and/or movement improved, progress ROM from session to session. 12. If pain is worse, refer to physician to rule out patellofemoral syndrome or other; continue training but avoiding pain.

2. Deep Front Line/Superficial Back Line stretch: posterior knee fascia focus As stated previously, the pain may be in the posterior knee for a variety of reasons. Some common examples are repaired ACL or posterior cruciate

ligament (PCL), and some other knee surgeries. Many clients never got full extension of the knee after rehab and most never get full, normal hyperextension (up to about –3°). Coming up out of a squat without fault may be a problem for these clients, as the full extension lockout position at the knee may be inhibited and/or painful. It is the author’s opinion that even if one does not fully lock the knee during some triple extension functional movements, it is essential to train. It enforces full neuromuscular activation, joint stability and proprioceptive training for all activities involving triple extension. The squat is one exercise that can effectively train this movement, with a focus on knee lockout, if indicated. Although scar tissue may still be the cause of pain for many, the FST solution for this problem is quite effective, often eliminating scar tissue in the process. This is because the technique targets the deepest fascia in this region – the posterior capsule. It also targets the deepest muscle of the knee, the elusive popliteus (Fig. 5). The popliteus sits in the dFL because of its initial anterior position in embryonic development. In addition to or separate from a tight joint capsule, a tight popliteus may be unable to lengthen enough to allow the knee to fully extend and lock out. It may also act to prematurely contract from a stretch reflex thus causing early buckling of the knees inward upon initial descent. In any event, a ‘glued up’ popliteus will interfere with proper sequencing of motor patterning and needs to be addressed.

WhEN ATTEMPTING TO CORRECT PRONATION dySFUNCTION AS A CAUSATIvE FACTOR WITh AbERRANT MOvEMENT PATTERNS IN ThE SqUAT, ULTIMATELy ALL FASCIAL LINES MUST bE ENGAGEd IN CORRECTIvE TRAINING 15

Finally, fascially glued tendons of the interlocking hamstrings and gastrocnemii will block full knee joint extension and inhibit full quadriceps activation (Fig. 6). Together this decreases triple extension and knee joint stability, making it prone to more injury. The following FST method will address scar tissue, the joint capsule and the myofascia problems just described.

The deep Front Line runs through the: n Fascia of popliteus/ knee capsule n Tibialis posterior/long toe flexors.

Figure 5: Deep Front Line – popliteus/posterior joint capsule. [Primal Pictures, adapted from Myers (2)]

The Superficial back Line can be traced through the: n Galea aponeurotica/ scalp fascia n Sacrolumbar fascia/ erector spinae n Sacrotuberous ligament/sacral fascia n hamstrings n Gastrocnemius/ Achilles tendon n Plantar fascia and short toe flexors.

Figure 6: Superficial Back Line. [Primal Pictures, adapted from Myers (2)]

Problems to treat with this stretch The following problems often benefit from this stretch: n Posterior superficial knee pain n Posterior deep knee pain n Old but stable ACL or PCL surgeries leaving restricted flexion ROM n General knee joint stiffness n Posterior knee joint capsule fascial restrictions n Posterior myofascial tightness around knee, eg. popliteus, hamstring and gastrocnemius. Contraindications do not use this stretch if the patient suffers with any of the following: n Genu recurvatum (excessive knee hyperextension) n Acute injuries or any inflammatory condition n Old ACL or PCL tears n Unstable knee n Severe osteoarthritis n baker’s cyst. Technique (Fig. 7) The points below provide a step-bystep guide to this stretch: 1. Client should wear shoes with minimal heel or go barefoot on a non-slip surface. 2. Client stands facing a wall or stable stand up equipment; feet aligned beneath hips, step forward with one foot about 12–24” from wall. 3. Align both knees facing straight forward, feet follow knee position with both heels down. 4. Practitioner sits on floor behind client; find comfortable position to block back foot from sliding. 5. Practitioner wraps both hands around front of lower leg right below knee joint but high as possible. 6. Practitioner cues client to inhale then exhale with lunge forward until small stretch felt behind knee; trainer leans torso back with straight elbows until client feels slight increase in stretch. 7. do 3 reps slow tempo into/out of ROM followed by 3 PNF with 25–50% heel raise between reps; exhale on stretch. Stretch held only for exhale, release for inhale. 8. Repeat one or both sides as indicated; use a general rule of 2:1 reps tighter to looser side.

Figure 7: Popliteus–posterior capsule–high gastrocnemius stretch (high hand position). (Photo credit: C. Frederick, 2014)

THE anKLE–FooT CoMPLEx Two common problems, two FST solutions The FST solution for many problems of the ankle and/or foot seen in the squat is to first assess and address it full body before looking at one body part. One common problem is a lack of sufficient dorsiflexion in the ankle but if we consider fascial anatomy and kinesiology, the foot also contributes to dorsiflexion. however, the practitioner often notices compensations for lack of dorsiflexion higher up. Forward lean of the trunk is common with bilateral, fairly equally limited ankle– foot dorsiflexion. If only one side is limited then an additional finding, such as an externally rotated foot with an internally rotated knee, may be present. Or a hip shift may be present. Pronation is also usually associated with a unilateral restriction and/or a longer leg condition. The second problem we will discuss is bilateral pronation dysfunction (usually also causing knees to rotate internally), a very common condition affecting a large number of your clients. Pronation dysfunction may be present with or without pain; therefore its presence is not necessarily a cause of pain despite complaints from the client that their feet hurt. Those ankle–foot problems and FST solutions are discussed below but first contraindications and FST tips must be reviewed before attempting the technique. sportEX dynamics 2014;42(October):13-20

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FST contraindications Please follow any contraindications and precautions as dictated by your intake form and your training/experience. Others peculiar to certain stretches will be noted.

FST tips Experience shows better results when full global or entire fascial lines are engaged during FST. Example: if one has a client with tightness or anterior ankle pain, instead of merely doing a calf stretch, work the entire Superficial back Line (SbL), along with the Lateral Line (LL) and dFL in which the calf also sits, for a more functional stretch effect. See the first example below for a further explanation.

FST SoLuTIonS FoR anKLE–FooT MoBILITY RESTRICTIonS 1. FST stretch: posterior ankle fascia focus The difference between an isolated assisted calf stretch and a FST mobilisation stretch to affect the muscles, fascia and joints of the ankle and foot is huge. If one attempts the traditional, isolated stretch by flexing or straightening the knee in the sagittal plane, one will miss opportunities in other planes of functional movement. The motions of ankle–foot supination and pronation are triplanar and the stretches must also be multi-

dimensional. however, the common idea of positioning the lower leg and foot in internal rotation and then in external rotation for the calf stretch is not as effective or efficient as the one that will be discussed a little later below. If one looks at Fig. 2, 5 and 6 and notes the fascial connections from, literally, head to toe, one sees the bigger picture in which the lower leg and ankle–foot functions. With many common ankle–foot problems, the fascia of the lower leg is often glued and shifted in a specific direction. This can affect the entire kinetic chain or cause pain or discomfort in one region, as it often does at the more mobile end of the ankle–foot or the knee. For example, if the SbL is shifted (pulled) up toward the knee or even higher, then dorsiflexion will be limited because tissues cannot slide down. In some cases, this can cause an anterior ankle impingement, resulting in pain at the front of the talus bone that limits the squat depth. Tightness in the outside LL (Fig. 8) and/or the inside dFL just compounds the problem, making it more difficult for the trainer to resolve the ankle restriction. Including all these lines will not only release restrictions directly posterior but also posteriormedial as well as posterior-lateral. Since these lines also cross the foot, central, medial and lateral aspects of the plantar fascia also are addressed. In light of these observations, doing a traditional

The Lateral Line runs through the: n Splenius capitis and cervicis/ sternocleidomastoid n External and internal intercostals n Lateral abdominal obliques n Gluteus maximus n Tensor fasciae latae n Iliotibial tract/abductor muscles n Peroneal muscles.

Figure 8: Lateral Line. Left, dorsal view; right, lateral view. [Primal Pictures, adapted from Myers (2)] www.sportEX.net

isolated, calf stretch is certainly not the optimal answer. Full fascial stretch of the ankle–foot The points below provide a step-bystep guide to this stretch: 1. have client stand up and lean against the wall in a lunge position. 2. Sit behind them on the floor and cross your legs around their ankle of the leg that is back. Use you adductors to squeeze/stabilise their leg (Fig. 9). 3. Grasp the front of their ankle by inner lacing your fingers just above the ankle joint (Fig. 10). 4. Lean back with your entire body as they press their hips forward into the wall. 5. Think of pulling their tibia behind their femur. 6. have client slowly shift right then left to stretch the inner and outer fascia; while leaning back, move your body from side to side opposite to the client. 7. Repeat until no further gains in ROM. This fascial stretch is one of our many ‘game changer’ techniques that will go far beyond the squat to help

Figure 9: Lower Superficial Back Line stretch. (Photo credit: C. Frederick, 2014)

Figure 10: Anterior view of the hand position used in Figure 9. (Photo credit: C. Coons, 2013)

The Spiral Line runs through the: n Splenius capitis and cervicis n Rhomboideus major and minor n Serratus anterior n External oblique n Abdominal aponeurosis/linea alba n Internal oblique n Tensor fasciae latae/Iliotibial tract n Tibialis anterior n Peroneus longus n biceps femoris n Sacrotuberous ligament/sacral fascia n Sacrolumbar fascia/erector spinae. Figure 11: Spiral Line. Left, posterolateral view; right, anterolateral view. [Primal Pictures, adapted from Myers (2)]

many other functional activities like gait, running, jumping and much more.

2. FST stretch for pronation dysfunction Put in simple, basic terms pronation dysfunction is a condition where the medial arch is lowered and the foot is abducted. because most often the knee follows the direction of the foot, the knee(s) will also go into internal rotation, along with the hip joint. Although there is no one ‘cure’ for this condition (and many athletes function fine with it), loading a squat with weight over feet that pronate and internally rotate the entire lower extremity is generally not a good idea. Whereas an orthotic strategy would seem to be the best solution, it is the author’s opinion that the more you are able to correct dysfunction of your client, the less they will be reliant on external devices like orthotics. In many cases, corrective work will eliminate the need for anything else, thereby being the bestcase scenario for health and function. First, review the anatomical structures involved in an additional myofascial chain: the Spiral Line (SL) (Fig.11) FST of the Back, Lateral and Spiral Lines The author has found the following FST protocol in combination with 18

Full Lateral and Spiral Line stretch 1. After locking the ankle–foot position noted in Figure 12, ‘steer’ the foot starting with small circles, progressing to larger ones (Fig. 13). 2. Aim for opposite shoulder, progressing out and across arm. 3. Perform PNF at three different angles (or as needed) starting at the opposite shoulder and ending high above the opposite elbow. helpful tips include: n Contraindicated with sciatica, herniated discs. n A general precaution is to start gently, with slow, small movements as nerves can quickly get irritated. n Stop and do not repeat if client feels numbness, pins and needles or temperature change anywhere.

specific neural activation, strengthening and awareness training beneficial in improving alignment and reducing pronation to improve motor patterning for the squat (Fig. 12): 1. The client lies supine on a table or the floor. 2. The trainer hooks one hand around the calcaneus, the other hand wraps around the foot as shown in Figure 6. Position the foot in as much inversion-dorsiflexion without much adduction (ie. avoid twisting the ankle). 3. Lock into this position and progress to the full LL and SL stretch below.

Standing pronation correction Pronation and supination are triplanar motions, not only of the ankles and feet but also of the entire body. Therefore we must be comfortable with assessing, correcting and training the entire fascial body. When attempting to correct pronation dysfunction as a causative factor with aberrant movement patterns in the squat, ultimately all fascial lines must be engaged in corrective training. you have been previously given a standing and supine FST correction. Now by emphasising a previous FST strategy you just learned, you can start re-training new motor patterns

Figure 12: Invert and dorsiflex the ankle–foot. (Photo credit: C. Coons, 2013)

Figure 13: Full lateral and spiral line stretch. (Photo credit: C. Coons, 2013)

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while simultaneously giving a corrective fascial stretch: 1. The client first lunges until they feel slight stretch, then shifts the hips laterally (Fig. 14). 2. The practitioner shifts opposite, while maintaining a posterior pull in line with the clients shifted hip. 3. Return to centre/start position and repeat until no gain in ROM or client no longer feels much. do not have the client shift medially as the lateral shift is what moves and stretches structures that help supinate the foot. Naturally, after corrective training, the client must be re-assessed to see if they have more dorsiflexion and/or have reduced pronation dysfunction. Other helpful tips include: n balance FST training with arch lifting and supination neuromuscular activation; wearing vibram FiveFingers® or similar product has helped many but not all. n Client will find it much easier to

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implement your coaching correction of proper form for squats after FST corrective work is done first. n Make a verbal deal with the client and suggest a trial to get them to wean off orthotics with the above programme. The suggestion is to wean off 1 hour per day but if the client ever gets pain then have them go back into orthotics and try weaning twice as slow (ie. ½ hour per day) if they are still willing. Good candidates are those with no pain and have moderate to minimal pronation dysfunction. This plan is contraindicated in those with severe foot problems, pain and/or has been prescribed orthotics for specific medical conditions making them dependent on them and under medical supervision.

SuMMaRY This is the conclusion of an attempt to introduce you to how to use the Stretch to Win – Fascial Stretch Therapy® (STW-FST) flexibility

Figure 14: Standing pronation correction. (Photo credit: C. Coons, 2013)

system to correct faulty movement patterns in the squat. Athletic training can progress safely and not get interrupted or slowed down by pain, weakness or imbalances caused by movement restrictions by adding in FST techniques to your client sessions. A consequence of this is better, faster, more complete results with greater confidence gained from both practitioner and client.

References 1. Frederick C. Improve squat patterning with Fascial Stretch Therapy: part 1. sportEX dynamics 2014;41:27–32 2. Myers T. Anatomy trains. churchill Livingstone 2013. ISbN 9780702046544 (£29.46). buy from Amazon http://spxj.nl/1tUvkNT 3. Schleip R, Findley TW, Chaitow L, huijin, PA. Fascia: The tensional network of the human body. churchill Livingstone 2012. ISbN 978-0702034251 (£27.48). buy from Amazon http://spxj.nl/vqv3qu 4. Frederick A, Frederick C. Stretch to Win. Human Kinetics 2006. ISbN 978-0736055291. (Kindle £9.42 Print £9.92). buy from Amazon http://spxj.nl/1nCepMc 5. Frederick A, Frederick C. Fascial Stretch Therapy™. Handspring 2014. ISbN 978-

1909141087 (£29.66). buy from Amazon http://spxj.nl/1tbq5yz

FuRTHER RESouRCES 1. Fascial Stretch Therapy by C. Frederick and A. Frederick. Handspring Publishing 2014. ISbN 978-1909141087. (http://budurl.com/FSTbook) 2. Stretch to Win by A. Frederick and C. Frederick. Human Kinetics 2006. ISbN 978-0736055291. (http://budurl.com/StretchToWinbook) 3. Fascial Stretching Therapy workshops by Stretch to Win. Watch Chris and Ann Frederick’s video about how FST can improve your practice on their website. (www.StretchToWin.com)

THE AUTHOR CHRIS FREDERICK PT KMI Chris has been a physical therapist (PT) since 1989, focusing on orthopaedic and sports manual therapy – particularly with integration of Fascial Stretch Therapy and Kinesis Myofascial Integration (KMI) – along with personalised movement prescription to restore function. He has an extensive background in dance, both as a professional dancer of classical ballet, as well as being a practitioner in the specialty of dance physical therapy/physiotherapy. Chris is also well versed in the ancient movement and healing arts of tai chi and qigong. He is a co-author with Thomas Myers of the chapter on stretching in the seminal book Fascia: The tensional network of the human body edited by Robert Schleip et al. (3). Chris is certified by Thomas Myers in Kinesis Myofascial Integration and is co-author with his wife, Ann, of the books Stretch to Win and Fascial Stretch Therapy (4,5). With Ann, Chris directed his own highly successful clinic for Fascial Stretch Therapy, physical therapy/physiotherapy, Structural Integration, chiropractic, acupuncture, sports massage and Pilates for nearly 20 years. He is now co-director of the Stretch to Win Institute at www.stretchtowin. com, where he is lead instructor in certification training workshops in Fascial Stretch Therapy. n do you agree with the author and the article’s premise that his clinical experience shows better results when full global or entire fascial lines are engaged in treatment and training, rather than in an isolated strategy? n do you agree with the article’s premise that the most effective means to fully stretch a muscle is by means of positioning and technique that targets additional muscles above and below, as well as to the sides of the targeted one? n do you agree with the author’s statement that not only is full extension ROM necessary for optimal function but an additional 1–3° of hyperextension is a goal in order to match the uninvolved knee as well? n Many professionals have traditionally promoted that foot pronation dysfunction is a structural condition that cannot be changed through manual therapy or exercise. The author concludes otherwise, stating clinical evidence that FST can correct pronation dysfunction and offers solutions. What are your thoughts on this controversy? DISCUSSIONS

4. Science of Flexibility by M.J. Alter, 3rd edn. Human Kinetics 2004. ISbN 9780736048989. (£42.50). buy from Amazon http://spxj.nl/1ATOiZ6

KEY PoInTS n Fascial Stretch Therapy (FST) may be used to correct common knee problems in the squat. n Some knee pain conditions that may occur in the squat may be relieved with FST techniques. n FST may be used to correct common ankle–foot problems in the squat. n Some ankle–foot pain conditions that may occur in the squat may be relieved with FST techniques. n FST techniques can be used to improve neuromotor patterning. n The squat problem of anterior knee pain can be solved by stretching the Superficial Front Line of fascia. n The squat problem of posterior knee restrictions can be solved by stretching the Superficial Back Line and the lower Deep Front Line of fascia. n The squat problem of restricted ankle dorsiflexion can be solved by stretching the Superficial Back Line and lower Deep Front Line of fascia. n Pronation dysfunction in the squat may be corrected by stretching the Lateral and Spiral Lines of fascia.

Fascial Stretch Therapy by Chris and Ann Frederick

Written by the pioneers of Fascial Stretch Therapy™, this highly illustrated manual provides an in-depth and very practical description of FST™ a system of manual therapy and movement training that can be used by a variety of bodywork and movement therapy specialists to reorganise and realign body structure.

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sportEX dynamics 2014;42(October):13-20

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BY Dr Chris Norris PhD, MCsP

houlder pain is a common occurrence both in sport and in the general public, with up 30% of individuals reporting pain in their lifetime. Over half (50%) complaining that symptoms last beyond 3 years (1), so treatment must be aimed not just a short-term relief, but at longterm management. Up to 65% of all shoulder pain can be attributed at least in part to impingement (2), the subject of this article. The results of surgical treatment for impingement are actually comparable to those of conservative (non-surgical) treatment, but in the long-term up to 1/3 of patients are left with persistent pain and disability (3). To understand this condition we need to look at the make-up of the shoulder region (anatomy), what goes wrong (pathology), and how best to treat the condition (management options).

Shoulder impingement Impingement accounts for up to 65% of all shoulder pain, and yet studies have been unable to determine the precise structure which is at fault. This article uses an evidence-based approach to guide clinical practice by looking at anatomy, pathology and function of the shoulder region. By understanding how to optimise shoulder function, treatment of several body regions can be combined to address impingement problems. A number of hands-on manual therapy techniques are described for the initial management of shoulder impingement problems.

ANAtoMY The arm is attached to the trunk through the shoulder girdle with the scapula (shoulder blade) resting on the back of the ribcage, and the shoulder held away from the trunk through the clavicle (collar bone), which acts as a strut. As the arm is moved away from the body, movement actually occurs between the clavicle and breastbone (sternoclavicular joint), clavicle and scapula (acromioclavicular joint), scapula and ribcage (scapulothoracic joint) and the shoulder joint itself (glenohumeral joint). The shoulder offers the greatest range-of-motion of any joint in the body, and is said to sacrifice stability for mobility. Compared to the hip joint for example, which is also a ball and socket, the shoulder joint has a larger ball (head of the humerus) and a relatively small socket (glenoid fossa), the glenoid fossa being 1/3 the size of the humeral head itself. The joint is surrounded by a loose capsule with a volume twice that of the humeral head. As the arm moves away from the body movement occurs in a specific sequence throughout the shoulder girdle and upper trunk. This sequence is very precise, and when it breaks down as a result of poor muscle timing, impingement is often the result. The roof of the joint www.sportEX.net

(coracoacromial arch) is formed by the coracoacromial ligament together with the coracoid process and acromion process. The area below

online

the coracoacromial arch is called the subacromial space officially defined as having the humeral head as its base, and the under surface of the anterior

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Figure 1: Anatomy of the shoulder (video in online version). [developed by sportEX]

tABle 1: CAuses of suBACroMiAl CoMPressioN (C. Norris, 2014) intrinsic n Tendon trauma (partial or full thickness tears) n Tendon degeneration n Bursal swelling

extrinsic n Referral from cervical spine n Postural changes to thoracic spine n Altered scapular movement n Altered humeral movement n Tightness of posterior shoulder structures (rotator cuff/capsule) n Altered bony orientation (osteophytes).

acromion, coracoacromial ligament and the acromioclavicular joint as its roof. Within the subacromial space there are three structures: the supraspinatus tendon, subacromial bursa and long head of the biceps tendon (2). Subacromial impingement syndrome (SAIS) occurs when the tissues within the subacromial space generate pain or are compressed. Once general medical considerations have been eliminated, mechanical compression may be considered either intrinsic due to changes in the structures within the subacromial space or extrinsic due to external compression of the space (Fig. 1) (Table 1). The height of the subacromial space (acromiohumeral distance or AHD) is approximately between 7 and 14mm in healthy subjects (3). A reduction in AHD may occur at rest, but only measurement taken during active arm elevation is able to demonstrate functional narrowing. Magnetic resonance imaging (MRI) studies of AHD have demonstrated smaller distances in the region of 3mm during arm elevation in those with rotator cuff tendinopathy due to SAIS (4).

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Figure 2: Scapula movement as the arm moves into abduction (video in online version).

MoveMeNt Movement of the arm away from the side of the body is termed the abduction cycle and may be conveniently described in three stages, although the cycle itself is a continuous process (Fig. 2)(5). In stage one it is what we donâ&#x20AC;&#x2122;t see as clinicians which is important. The scapula should remain fixed to the ribcage through action of the scapula stabilising muscles especially the serratus anterior, supported by the trapezius. As the arm moves from the side of the body, the muscle action of the scapular stabilisers fixes the scapula to the ribcage and so the scapula appears to sink into the surrounding muscle mass. There is a very slight upward displacement of the humeral head and this movement should be limited by a synergistic action of the rotator cuff drawing the head of the humerus downwards while the deltoid abducts the arm and draws the head of the humerus upwards. From the force vectors of the muscles, the infraspinatus and subscapularis are best placed to provide downward

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displacement of the humeral head in opposition to the upward translation brought about by deltoid action, while the supraspinatus is a more effective compressor, drawing the humeral head further into the centre of the glenoid. Decreased electromyographic (EMG) activity in the infraspinatus and subscapularis together with the middle deltoid has been seen in subjects with SAIS from 30 to 60Â° abduction (6). The long head of the biceps has been shown to assist in stabilising the head of the humerus in an anterior and superior direction and to decrease pressure within the subacromial space (7). Fluctuations of translation of the humeral head are relatively small in the healthy subject, with movement in the region of 1mm being recorded. The humeral head should remain centred within the glenoid. Where the rotator cuff muscles have reduced activity, or contract too late in the movement upward displacement of the humerus occurs due to the unopposed pull of the deltoid. Antero-posterior movement of the humeral head varies with values between 0.7 and 2.7mm of anterior translation and 1.5 and 4.5mm of posterior translation being recorded for different ranges of abduction (8). Increased superior and/or anterior humeral head movement is associated with SAIS, with increased superior translation of 1.5mm and increased anterior translation of 3mm being quoted (2). Tightness in the posterior capsule induced surgically in cadavers results in an increase the superior and anterior humeral head translation (9). This finding has been used to justify manual therapy aimed at the posterior capsule, and exercises such as the cross-body and sleeper stretch (Figs 3 and 4). Although these techniques are often effective therapeutically in SAIS, they will probably affect both the posterior rotator cuff and capsule as it unlikely that the capsule can be selectively isolated non-operatively (2). As abduction progresses the greater tuberosity moves closer to the subacromial arch and to prevent the two structures touching lateral rotation of the humerus occurs, and the capsular ligaments relax to allow maximal movement. In addition, to sportEX dynamics 2014;42(October):21-28

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move the subacromial arch away from the approaching humerus the scapula must upwardly rotate during stage 2 of the movement, an action brought about by a force couple between the serratus anterior working in parallel with the upper and lower fibres of the trapezius. The opposite movement (downward rotation of the scapula) occurs through action of the levator scapulae, rhomboid, and pectoralis minor muscles and is a requirement in activities where the body is lifted on the fixed arm such as a dipping action in the gym. If these latter muscles become dominant or are stiffer through tightness, upward rotation of the scapula will occur more slowly, or be more limited in range. Decreased performance in the serratus anterior and lower trapezius has been identified in subjects suffering from rotator cuff tendinopathy due to SAIS, with reduced total EMG activity and onset of activation (3). The scapula is a relatively flat bone moving on the curved shaped drum of the ribcage. As we move the arm above the horizontal position to draw it overhead upward rotation of the scapula is complete and the scapular is drawn around the ribcage. This lateral movement is only possible if the kyphotic curve of the thoracic spine is reduced to produce a flatter ribcage surface. This action forms stage 3 of the abduction cycle, and will be limited where the thoracic kyphosis is increased (round shouldered posture) or stiffer. In both cases the increased curvature of the thoracic region limits lateral movement of the scapular meaning it is difficult for the subject to lift into pure abduction to draw the arm level with the ear. Instead the arm moves forwards (flexion abduction) towards the side of the face, as a compensatory action.

PAthologY It is generally considered that compression of the soft tissues between the head of the humerus and the acromion during abduction and elevation causes pain, with the classic impingement test combining abduction and internal rotation (Empty can sign) to press the greater trochanter onto the under surface of the acromion, sandwiching any impinging structure www.sportEX.net

Figure 3: Cross-body stretch. (Photo credit: C. Norris, 2014)

Figure 3: Sleeper stretch. (Photo credit: C. Norris, 2014)

between the two. The classical development of impingement syndrome is of mechanical compression through three progressive phases (10). The condition has been said to begin (stage I) in the younger patient (under 25) with oedema and haemorrhage through persistent overhead activities, leading to deterioration of the tendon and bursa (stage II in the 25â&#x20AC;&#x201C;40-year-old) to final full thickness rupture and bone spur formation in later life (stage III, over 40 years of age). This progressive pathology has now been challenged (11). If compression of the supraspinatus tendon occurs beneath the subacromial arch, the direct mechanical strain should lead to abrasion to the tendonâ&#x20AC;&#x2122;s upper surface. However, damage to the inferior (joint) side of the tendon has been found in over 90% of cases (7) in athletes and over 80% of cadavers (12), representing internal impingement (13). The prevalence of partial thickness tears in cadavers has been shown to be roughly 30% with damage to the articular aspect of the tendon or intra-tendon substance (14). The fibres on the lower (non-acromial) side of the tendon have a smaller cross sectional area than those on the upper surface. The lower fibres are therefore more vulnerable to tensile loading, especially during elevation where tendon strain is increased. Movement of the upper tendon fibres upon the lower may result in intratendinous shearing, giving reaction through physiological failure

of the lower tendon fibres rather than injury through external compression (11). Where external compression is a cause of SAIS, the shape of the acromion becomes relevant. Three types of acromion have been described, flat (type I), curved (type II), and hooked (type III) (15). The suggestion is that rotator cuff tears as a result of SAIS are more common in those with a hooked acromion, justifying the need for surgical removal of the anterior/inferior aspect of the acromion (acromioplasty). However, many asymptomatic individuals have been found to have a curved or hooked acromion, and it has been suggested that the success of acromioplasty may be due to enforced rest following surgery rather than to the surgical procedure itself (11). The shape of the acromion itself may be a secondary rather than a primary effect. Bony spur formation of the acromion seems to be at the insertion of the coracoacromial ligament. A repetitive upward translation force (due to impaired action of the rotator cuff) may create tension at the acromial insertion of the ligament which is smaller than the coracoid side. The ligament may be a source of pain as free nerve ending have been identified within it (11). The subacromial bursa is innervated by the lateral pectoral nerve and subscapular nerve, and is capable of both nociception and proprioception. Removal of the bursa (bursectomy) alone gives the same degree of pain relief as bursectomy combined with 23

acromioplasty with no significant differences at 2.5 years’ follow-up (16). Changes to the supraspinatus tendon seen in SAIS indicate that the condition is likely a tendinopathy rather than a tendinitis. No infiltration of cells associated with inflammation are seen within tendon in specimens taken during surgery, but increased volume of the tendon seen experimentally may be the result of a reactive phase similar to Achilles or patellar tendinopathy (11). An increased vascular response (neovascularisation) in degenerative areas of the supraspinatus has been noted with Doppler ultrasound (17), suggesting a healing response to microtrauma as is seen in tendonitis in other body areas. The presence of tendinopathy and increased metabolic response during a reactive phase would suggest that relative rest and graduated loading should form part of the management of this condition.

pain, but may be less useful at identifying the pathological tissue responsible for the pain. Traditional passive tests aim to compress the structures within the subacromial space by combining some degree of abduction with internal rotation (Table 2). With many conditions there can be a poor clinical correlation between pathology and pain, and the shoulder is no exception to this. Some subjects may have pain with few apparent indicators on imaging, whereas others are asymptomatic in the presence marked bone or soft-tissue changes. Systematic review with meta-analysis of the Neer and Hawkins–Kennedy tests for impingement (and the Speed test for labral pathology) concluded that diagnostic accuracy is limited (18). The use of clinical tests as symptom provoking procedures to monitor treatment effect has been proposed for SAIS (1) using the shoulder symptom modification procedure which provides a logical synopsis of common tests and methods from several areas of physiotherapy, such as mobilisation with movement (MWM), exercise therapy, manual therapy, and taping. Techniques in four areas are used (Table 3). The patient-described outcome is normally that of pain measured on a numerical rating scale (NRS) or visual analogue scale (VAS), with a minimal clinical important difference (MCID) being set at a 30% improvement from baseline to represent a meaningful change (19). Movement range may also be used to assess the effectiveness of a technique.

PAtieNt AssessMeNt

humeral head positioning

Tests used to assess SAIS are effective at provoking the subject’s

Pressure techniques are used on the humeral head which are similar to

tABle 2: CoMMoN CliNiCAl tests for sAis (C. Norris, 2014) test name

Action

1. Neer’s sign test (Fig. 5)

1. Also called the forward flexion impingement test. Stabilise the scapula and grip the arm below the elbow with the other hand. Passively elevate arm into full flexion. Positive if pain is produced at end of passive elevation.

2. Hawkins–Kennedy (Fig. 6)

2. Elbow flexed to 90°, shoulder passively forward flexed to 90°. Take shoulder into internal rotation.

3. Full/empty can test 3. Also called Jobe’s test and the Scaption test. Passively elevate arm to 90° in scapular plane. Turn hand down so thumb point towards floor for (Fig. 7) internal rotation (Empty can) and apply resistance to abduction. Repeat with palm up for external rotation (Full can).

65% OF ALL SHOULDER PAIN CAN BE ATTRIBUTED TO IMPINGEMENT Figure 5: Neer’s test (Photo credit: C. Norris, 2014)

Figure 6: Hawkins– Kennedy test. (Photo credit: C. Norris, 2014)

Figure 7: Empty can test. (Photo credit: C. Norris, 2014)

tABle 3: shoulDer sYMPtoM MoDifiCAtioN ProCeDure [Adapted from Lewis (1)] Anatomy involved

Mechanical technique

n Humeral head n Scapular position

n Application of mobilisation with movement n Passive stabilisation or modification with or without taping n Neuromodulation procedure to address pain and movement quality n Reduction of increased kyphosis.

n Cervical spine n Thoracic spine

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traditional MWM procedures but used with manual pressure, belts or elastic tubing. Either anterior or posterior directed pressure is maintained during the subject’s movement in an attempt to reduce symptoms. Movements which caused pain during testing may be repeated using minimal resistance to modify symptoms. External rotation and humeral head depression are performed to restrict or modify internal rotation and elevation stresses which traditionally exacerbate SAIS. A posterior glide MWM applied manually has been shown to immediately reduce pain by 20.2% and increase movement range by 15.3% in a group of subjects with anterolateral shoulder pain which restricted shoulder elevation (19). In this study the increase in motion range was not related to change in pain, leading the authors to suggest that joint or muscle mechanisms may be responsible for the movement change rather than pain.

scapular positioning Manual techniques and taping may be used to slightly modify scapular position, as altered scapular kinematics is often associated with impingement symptoms (20). The same scapular modifications may then be used for re-education. Scapular position of elevation/depression, protraction/ retraction, tipping (also called tilt, representing rotation about a mediolateral axis), and rotation (rotation about an antero-posterior axis) are all compared to the unaffected side and modified if required. Scapular winging may be modified by manual stabilisation or taping, to assess the effect on the subjects symptoms.

radiculopathy If shoulder pain arises from the cervical spine, manual therapy to this region can affect pain and movement in the shoulder region. Both soft tissue- and joint-based techniques may be used. A study that used lateral mobilisations applied to the C5/C6/C7 spinous processes in sitting demonstrated both a reduction in pain (mean 1.3cm measured in a VAS scale) and an increased abduction motion range (mean 12.5° measured using video analysis) in patients with shoulder www.sportEX.net

pain of at least 6 weeks duration (21). Cervical mobilisation has been shown to increase lateral rotation motion range at the shoulder in subjects with restricted movement in the absence of shoulder treatment (22). Oscillatory mobilisation was given to the C4/5 and C5/6 segments, with lateral rotation range at the shoulder increasing from 0–1/4 range to 1/2–3/4 range. It was suggested that pain referred from the cervical spine to the shoulder resulted in increased muscle tone to the shoulder musculature restricting motion range at that joint. The restricted and/ or painful shoulder movement should be performed and cervical tissue treatment applied to assess change in the shoulder symptoms.

thoracic kyphosis Changes to the thoracic kyphosis have been shown to alter scapular tipping and rotation, and to decrease the amount of elevation at the glenohumeral joint (2). Altering thoracic and scapular posture has been shown to significantly increase shoulder flexion and abduction range in the scapular plane, and to delay the point of onset of pain within the motion range in subjects with SAIS (23). Manual techniques using overpressure and/or taping may be used to reduce the subject’s kyphosis and movement quality is reassessed. Where thoracic stiffness is present localised manual therapy may be applied, as this has been shown to change impingement signs (Neer, Empty can, Hawkins– Kennedy, and Active abduction) in subjects with impingement syndrome (24).

therAPY Initial management involves hands-on therapy, and as pain eases and function improves rehabilitation becomes more important as hands-off techniques come to the fore. Rehabilitation is covered separately in another article (25), whereas in this article we focus on manual techniques. Therapy aims to reduce the subject’s symptoms during aggravating movements, and to improve movement quality as a lead in to rehabilitation, which may begin either in parallel with manual therapy or subsequent to it. Tightness of the posterior

THE ABDUCTION CyCLE IS CENTRAL TO THE UNDERSTANDING OF THIS CONDITION shoulder tissues is often associated with anterior and superior translation of the humeral head, so soft-tissue techniques aimed at the posterior tissues may be used in parallel with joint-based techniques. Lateral rotation is an important movement during rehabilitation, but this movement direction may be limited in subjects suffering from impingement. Therapy aims to: (i) reduce symptoms, (ii) mobilise the joint in an antero-posterior and inferior direction, (iii) release tight posterior structures, and (iv) address the cervical and thoracic spine.

sitting lateral cervical mobilisation (fig. 8) Cervical mobilisation is traditionally carried out with the client lying, with their head supported. However, where shoulder symptoms are referred from the cervical region they are usually experienced in the standing or sitting position. Choosing the sitting position for cervical mobilisation has the advantage that the shoulder may be tested and re-tested for pain and movement after the cervical mobilisation. Begin with your client sitting in a hard back chair, or support their back with your shin if they are sitting on a treatment couch. Cradle your clients head with your left arm Figure 8: Sitting lateral cervical mobilisation. (Photo credit: C. Norris, 2014)

THE ABDUCTION CyCLE IS CENTRAL TO THE UNDERSTANDING OF THIS CONDITION

(use a towel or paper sheet to protect their face), and use your thumb or flexed finger to apply the mobilisation to the side of the spinous process. Target the levels from C4â&#x20AC;&#x201C;C7 as these refer to the shoulder region, and begin the mobilisation pressing towards the non-painful arm (contralateral side). If symptoms remain unchanged, repeat the mobilisation towards the side of pain (ipsilateral side). Small amounts of movement (small amplitude) as used at end range, traditionally called a grade IV mobilisation.

lying thoracic postero-anterior mobilisation (fig. 9)

Figure 9: Lying thoracic postero-anterior mobilisation. (Photo credit: C. Norris, 2014)

Figure 10: Thoracic taping. (Photo credit: C. Norris, 2014)

Figure 11: Glenohumeral antero-posterior mobilisation using cupped hand. (Photo credit: C. Norris, 2014)

Where the thoracic kyphosis is accentuated and/or the thoracic spine is stiff to extension, mobilising the thoracic vertebrae in a postero-anterior (PA) direction can be useful. Begin with your client lying on their front. Use a folded towel or pillow for extra padding beneath the chest is preferred. Use your pisiform bone to apply a localised force to the spine, reinforcing your right hand with your left. Target the spinous process or transverse process for localised central or unilateral PA mobilisations, or use one hand on each side of the spine for a more generalised extension force. Each spinal level has a number of joints all of which will be affected to some degree by this mobilisation. Centrally to the spine each level has a spinal disc, and then at each side of the thoracic vertebra is a facet joint, costotransverse joint, and costovertebral joint.

thoracic taping (fig. 10) Mobilisation and exercise are able to produce fairly high forces which are applied over a relatively short period. Where postural correction is required taping is appropriate as it applies low level force but over an extended period. The time period is important as it gives the opportunity for the client to adapt to the new posture and reinforces correct posture. Begin with your client either lying flat on their front (prone lying) with the couch end tilted upwards by 10 to 20Â° or a folded towel beneath their chest, in both cases to place the thoracic spine into extension. If your client is able to perform and hold the sternal lift action (active thoracic

extension) the taping may be applied in sitting or standing. The taping is placed on the skin with some tension to provide skin stimulation. Where kinesio tape (K-tape) is used it can be placed directly onto the skin, but where zinc oxide tape is used an undermesh should be used to protect the skin. If using K-tape, the first part of the tape (2cm) is placed on the skin under no tension to secure it firmly. The tape is then stretched to 25% (some tension) or 50% (greater tension) of its length and placed onto the skin. The end 2cm of tape is again stuck to the skin under no tension to ensure a firm attachment. Where zinc oxide tape is used the undermesh is placed onto the skin under no tension, and the zinc oxide, which is non-elastic, is attached to the mesh and pulled downwards to give tactile feedback for thoracic extension. Greater or lesser force may be used depending on the clientâ&#x20AC;&#x2122;s needs.

glenohumeral antero-posterior mobilisation (fig. 11) We have seen that one of the most common scenarios with shoulder impingement is that the humeral head moves forwards (anterior) and upwards (superior) increasing the likelihood of compression to the subacromial structures. Mobilisation is the opposite direction (posterior and inferior glides) can relieve symptoms. Antero-posterior gliding can be performed with your client lying or sitting. The lying position supports the trunk and enables greater force to be applied, whereas the sitting position enables active shoulder movements to be performed more easily as a precursor to MWM techniques. Use the heel of your hand as a contact area and cup the humeral head to make the technique more comfortable. your other hand may be placed over the clavicle to provide counter pressure and limit movement of the scapula and trunk.

Posterior joint soft-tissue massage in a cross-body position (fig. 12) Tightness of the posterior joint is associated with shoulder impingement, as restriction posteriorly can press the humeral head anteriorly to reduce the sub acromial space. Begin with your sportEX dynamics 2014;42(October):21-28

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client lying on their unaffected side. Fold their affected arm across their chest to place the posterior structures on stretch. Target the structures in tissue layers from the superficial to the most deep, altering your massage depth accordingly. Work into the tissues gradually beginning with the posterior deltoid, and then move more deeply to the teres major and minor. Deeper still are the supraspinatus and infraspinatus, and finally after working through the muscle tissue you will reach the posterior joint capsule. Use two or three fingers gripped together as your massage contact area to apply the required pressure, or chose a massage tool such as a knobbler. Assess the effectiveness of your massage procedure by pain (assessed on a VAS scale from 1–10), joint stiffness (assessed by resistance to motion and joint end feel), and tissue tension (assessed by tissue resistance to palpation pressure). your client may use the cross-body position as a stretch for home use. Ask them to take their affected arm across their body and apply overpressure with the non-affected arm. Hold the stretch for 20–30seconds and perform 3 repetitions morning and evening.

inferior glide at 90° abduction (fig. 13) Have your client lie on their back on a treatment couch (supine lying) with their affected (left) shoulder close to the couch side. Stand to the left side of your client with your right hand cupped over the top of the shoulder (middle deltoid) and the left hand close to the top of their inner arm. Both hands are positioned close to the joint line, and the client’s arm is abducted to 90° or the greatest range possible for them up to 90°. The action is to move the arm straight downwards (inferiorly) by pressing with your right hand and guiding with your left. The action can combine both superior and inferior movement drawing the arm superiorly slightly (10–20%) providing there is no pain, and emphasising the inferior direction (80–90%). A rhythmic action is used within the free ROM just moving to the point of restriction but not into it, traditionally called a grade III mobilisation. www.sportEX.net

Mobilisation with movement to abduction (fig. 14) MWM combines passive movement of the joint (therapist action) with active movement (client action) to improve movement quality with the aim of reducing symptoms. In the case of shoulder impingement, the aim is to create a greater range of pain free motion to flexion/abduction. Begin with your client sitting or standing and stand behind them. Use your cupped hand over the top and front of their shoulder joint approaching from the medial side. Ask them to raise their arm forwards and outwards at an angle of 30° to their body (scaption) with their thumb upwards (lateral rotation at the glenohumeral joint). As they do so draw their shoulder joint towards you to impart a posterior glide. you may use your other hand to monitor their scapula and if necessary gently press it against their ribcage to encourage stability or draw it downwards to discourage upward shifting. As an alternative to hand pressure, you may use a webbing belt (yoga belt) looped over your clients shoulder.

Figure 12: Posterior joint soft-tissue massage. (Photo credit: C. Norris, 2014)

suMMArY This article has demonstrated how the anatomy of the shoulder can contribute to the pathology of shoulder impingement and has described tests that are useful for assessing a patient’s condition as well as monitoring treatment. The reader will also now be familiar with a number of hands-on manual therapy techniques for treating these conditions.

Figure 13: Inferior glide at 90° abduction. (Photo credit: C. Norris, 2014)

References 1. Lewis JS. Rotator cuff tendinopathy/ subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports medicine 2009;43:259–264 2. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. clinical Biomechanics 2003;18:369–379 3. Seitz AL, McClure PW, et al. Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? clinical Biomechanics 2011;26:1–12 4. Graichen H, Bonel H, et al. Three dimensional analysis of the width of the subacromial space in healthy subjects and patients with impingement syndrome. american Journal of roentgenology 1999;172(4):1081–1086

Figure 14: Mobilisation with movement to abduction. (Photo credit: C. Norris, 2014)

5. Norris CM. Managing sports injuries: a guide for students and clinicians (4th edn). churchill hurchill Livingstone Elsevier 2011. ISBN 0702034738 (Kindle £23.17 Print £46.46). Buy from Amazon http://spxj.nl/1wD4mzW 6. Reddy AS, Mohr KJ, et al. Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement. Journal of Shoulder and Elbow Surgery 2000;9:519–523 7. Payne LZ, Deng XH, et al. The combined dynamic and static contributions to subacromial impingement. A biomechanical anaysis. american Journal of Sports medicine 1997;25 801–808 8. Ludewig PM, Cook TM. Translations of the humerus in persons with shoulder impingement symptoms. Journal of orthopaedic & Sports physical therapy 2002;32:248–259 9. Harryman DT, Sidles JA, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. Journal of Bone and Joint Surgery (am) 1990;72:1334–1343 10. Neer CS. Impingement lesion. clinical orthopedics 1983;70–77 11. Lewis JS. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? physical therapy reviews 2011;16(5):388–398 12. Fukuda H, Hamada K, yamanaka K. pathology and pathogenesis of bursal side rotator cuff tears: viewed from en bloc histologic sections. clinical orthopedics and related research 1990;75–80 13. Edelson C, Teitz C. Internal impingement in the shoulder. Journal of Shoulder and Elbow Surgery 2000;9, 308–315 14. Loehr JF, Uhthoff HK. The pathogenesis of degenerative rotator cuff tears. orthopedic translation 1987;11:237 15. Ticker JB, Bigliani LU. Impingement pathology of the rotator cuff. In: Andrews JR, Wilk KE (eds) The athlete’s shoulder. churchill Livingstone 1994. ISBN 0443088470 16. Henkus HE, de Witte PB, et al. Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. Journal of Bone and Joint Surgery (Br) 2009;91:504–510 17. Levy O, Relwani J, et al. Measurement of blood flow in the rotator cuff using laser Doppler flowmetry. Journal of Bone and Joint Surgery (Br) 2008;90:893–898 18. Hegedus EJ, Goode A, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. British Journal of Sports medicine 2008;42:80–92 19. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s mobilisation with movement technique on range of movement and pressure pain threshold in pain-limited

shoulders. manual therapy 2006;13:37–42 20. Ludewig PM, Cook TM. Alteration in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. physical therapy 2000;80(3):276–291 21. McClatchie L, Laprade J, et al. Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Manual Therapy 2009;14(4):369–374 22. Schneider G. Restricted shoulder movement: Capsular contracture or cervical referral – a clinical study. australian Journal of physiotherapy 1989;35(2):97– 100 23. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of orthopaedic & Sports physical therapy 2005;35(2):72–87 24. Boyles RE, Ritland BM, et al. The short term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. manual therapy 2009;14:375–380 25. Norris CM. Shoulder impingement. sportEX medicine 2014;60:27–35.

further resourCes 1. Managing Sports Injuries: a guide for students and clinicians (4th edn) by C. Norris. churchill Livingstone Elsevier 2011.. ISBN 0702034738 (Kindle £23.17 Print £46.46). Buy from Amazon http://spxj.nl/1wD4mzW

n Describe the abduction cycle. n Name and describe the rotator cuff muscles. n On a partner, identify the sternoclavicular and acromioclavicular joints. DISCUSSIONS

KeY PoiNts n impingement accounts for up to 65% of all shoulder pain. n in order to treat shoulder impingement, a thorough understanding of the shoulder anatomy and pathology of the condition is needed. n the shoulder offers the greatest range-of-motion of any joint in the body, and is said to sacrifice stability for mobility. n Compared to the hip joint, the shoulder joint has a larger ball (head of the humerus) and a relatively small socket (glenoid fossa). n As the arm moves away from the body, movement occurs in a specific sequence; the breakdown of which can often result in impingement. n the classical development of impingement syndrome is of mechanical compression through three progressive phases. n the use of clinical tests as symptom-provoking procedures to monitor treatment effect has been proposed for sAis. n Manual therapy to the shoulder region aims to reduce pain and enhance tissue healing. Joints are mobilised and muscle stiffness eased. n Within traditional therapy approaches there is often a focus on isolation actions at the shoulder. alone it may fail to restore full function.

THE AUTHOR Dr CHRIS NORRIS PhD, MCSP Chris is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. He is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website www.norrisassociates.co.uk.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

thiS quiz iS accESSiBLE

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with a SuBScription that incLudES onLinE accESS to thiS JournaL.

sportEX dynamics 2014;42(October):21-28

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Biotensegrity

An introduction to A series of Articles on Biotensegrity And the new science of Body Architecture BY Joanne avison KMi, e-RYT500

hen I first came across ‘tensegrity’ in the late 1990s, it sounded like yet another long word in the list of terms I would have to learn if ever biomechanics were to make any sense to me. In those days I was a practising yoga teacher, learning anatomical muscular origins, insertions and actions as zealously as I could. I lived in a kind of ‘constant hope’ that perhaps if I knew all the bones, the 600-odd muscles and every related behaviour, I might make sense of the yoga postures, or (one day) biomechanical function. Tensegrity was introduced to me by Thomas Myers. I studied with him to become a Structural Integration manual practitioner and eventually teacher; but that wasn’t my purpose. I longed to make sense of how people move (and why they might have restrictions) – regardless of which sport they are in or their preferred movement practice. Why were posture and motion such important issues and how come all that I had learned in anatomy didn’t really explain the experience of working with people? We all move uniquely. Classical biomechanics and anatomical study do not necessarily explain how; they seem to include various, often linear theories with as many counter-theories. I lived in the chasm between what I was learning and what actually happened in the classroom. They rarely made complete sense of each other. I cut my Structural Integration teeth on the proofs for the first edition of Anatomy Trains, published in 2001

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The “science of body architecture” includes the latest research into the fascia; the tensional network of the human form. Biotensegrity is an emerging field that raises new questions and insights into how this fascial connective tissue matrix is tensioned and how crucial that is to human structure. It evolves many of the classical concepts of biomechanics and offers new and intriguing perspectives on how we naturally move ourselves in space. In this first article the basic concept of biotensegrity is introduced (in plain English) in a very accessible way to enable the reader to understand how important this concept is to physical and manual therapists alike. (1), so I was hooked by the notion of anatomical continuity. Myers spoke of Buckminster Fuller, the architect he had worked with at one time, the man’s genius and the whole idea of geodesic geometry as a metaphor for human structure. Although it was clearly fascinating, it still seemed like ‘yet another’ mysterious theory. Tensegrity was a challenging notion at the time and my yoga teachers dismissed it roundly as a ‘fad’. That was bait enough to go and explore the whole field. It has proved the most rewarding resource to movement and manual practice, despite the fact that it is complex and fraught with misconceptions. Somehow it begins to makes sense of many biomechanical explanations that otherwise reduce movement to very limited and local areas of the body. If you watch a dance, movement, exercise, athletics or sports performance one thing will strike you - in experience, bodies move as a whole. They balance from crown to ground and back again and something bigger than levers and upright inverted

pendulums was needed to satisfy my insatiable curiosity and devotion to wholeness. Please note, my fascination with human form did not arise from a love of sport. On the contrary; I was the one at school who took 5min or more to run a lap of the track and eventually succeeded in being so absent from P.E. classes, that my name fell off the list and I wasn’t even registered as missing. It was from my love of learning ballet and fine art, figure drawing and studies of Leonardo da Vinci that led me to the field known as sacred geometry. Before you dismiss that as confirmation that this article is about a fad, by some ‘woo woo’ yoga nut, remember that our ancient forefathers did not separate mind, body and being in categories assigned to different authorities. They sought founding principles of the natural world; the physical and the metaphysical that explained life, ie. the living variety that moves around and speaks for itself. Not just the post-mortem basis of assessment that assumes we are 29

put together on a mechanical premise by which we can be taken apart, as if the cogs make sense of the whole machine. Such reductionist theory arose a century after da Vinci. The importance of fascia (Box

Box 1: connecTive Tissue: conTinuous and undeR Tension (J. avison, 2014) In the late 1980s, Jaap van der Wal (now Professor Emeritus) did a ‘tissue sparing’ dissection of the human elbow. In traditional anatomical procedure, the surrounding fascial soft tissue is scraped out of the way to get to the important parts that require ‘clean’ dissection as their main asset. Fascia was named for its discrete components. Jaap van der Wal performed a dissection that removed everything else; that is all BUT the connective tissue. His work revealed that this architecture was continuous throughout the joint and beyond. This allowed the joint to be held under tension at all angles. It was also discovered that mechanoreceptors (movement sensors) were between the layers of soft tissues. He proposed that this was in order to detect subtle changes in tension and ‘inter-layer motion’, or tissue glide. This PhD thesis was not published, since medicine wasn’t ready for the implications. It came to be presented for the first time at the 2nd International Fascia Research Congress in Amsterdam, in 2009. Dr Robert Schleip, Thomas Findley and Dr Peter Huijing invited Professor van der Wal to present his work on the continuity of the fascia as this “transanatomical architecture and its proprioceptive substrate”, (2,3). It is a fascinating presentation and challenges many aspects of our traditional understanding of fascia and the general principles of locomotion of the human body.

Box 2: The aRchiTecTuRe of conTinuiTY Jaap van der Wal was Associate Anatomy Professor at the University of Maastricht. This new method of dissection was developed by one of his colleagues H. van Mameren in the 1970’s. van der Wal came to work in the laboratory of Professor Drukker (then Chairman) where Van Mameren did his studies and under his supervision van der Wal started to follow the same procedure and researched the importance of this Connective Tissue or Fascia ARCHITECTURE in the process of proprioception. It came about that this “continuity thinking” in architectural terms, fitted the way our proprioception and body sensing is organised. It made sense of our movement sense, so to speak. “It was not the anatomy of bones and muscles that was instrumental for proprioception, but the architecture of continuity” Jaap van der Wal. Excerpt from YOGA: Fascia, Anatomy & Movement by J. Avison 2014 (4). (Reproduced by permission of Handspring Publishing)

1) and the idea of it as continuous architecture necessary for proprioception (Box 2) developed relatively recently after Professor Jaap van der Wal created new dissection techniques that allowed the study of soft tissue structures that were traditionally removed.

PRoPRiocePTion and geoMeTRY Proprioception comes from the Latin ‘proprius’, meaning ‘one’s own’ and ‘ception’ from perception. Thus it refers to our own self-perception. This includes our internal and external sense of our selves in space – and time. The idea that a joint is under continuous tension and is structurally formed by a self-sensing (proprioceptive) architecture raises many questions and classical assumptions about movement. Think of a tent or a marquee. In order to stand up, it is a structure held under continuous and appropriate tensional balance. It is not a tensegrity structure as such, because it requires an external frame (ie. to be pegged to the ground). However, it provides a metaphor that readily explains how a structure held ‘under tension’ can appear. The fabric and guy wires are tensioned by the poles and pegs in different ways to maintain the spatial properties (inner space and outer shape) of the relatively soft architecture. If one part is moved, it moves the whole. A spider’s web is a tension– compression structure. The suggestion is that we too are tension–compression structures; but we do not require an outside frame as the web does. This qualifies us as a bio-tensegrity architecture. Another example of tensegrity is a bicycle wheel. The hub and the rim are the compression elements and the spokes (a minimum of 12) form the tensional elements. They require no outside frame for their tensional integrity. Behind it all, if we are to understand in more detail how it makes sense, is something to do with the most ancient forms of mathematics, originating in India. Beyond the yoga postures that filtered into our modern culture, are the ancient mystery schools and Vedic sages that originated the numeric system we use today; arising from a profound

understanding of geometry and the need to describe nature’s forms and relationships in its terms. Alongside the proprioceptive attributes of the tissue, is the way they are constructed to optimise and manage such details of our sensory awareness. Geometry plays a vast and valuable role in the emerging science of Body Architecture, especially as it becomes clear that we cannot be measured in linear, non-biologic terms. Early biomechanics lessons require that we ‘imagine a straight axis through the centre of the body’ in order to manage the sagittal, coronal and transverse planes. However, we don’t have a straight axis through the centre of the body; it is curved. We are non-linear biologic systems that arrive whole and complete on the pitch, field, track or court and we move our selves. This new paradigm includes that essential feature of our ability to stand up and move around, the way we do. It seeks to account for our individuality, variability and innate ability to respond to our internal and external environments. We change accordingly and restore our shape naturally in response to outside Geometry is a foundation of understanding biological form that begins to explain our innate design and our wholeness on many levels; including the three dimensions we occupy in physical space – four dimensions if you include time. It brings us to understanding such aspects of our structure as proportion, form, relationship and even the physical literacy that comes under headings such as ‘neuromuscular co-ordination’ and ‘kinaesthetic awareness’. They are part of our sensory architecture: structure and function become as inseparable as the parts of us. How biotensegrity architecture behaves in terms of human (or animal) movement is bridging the worlds of physiology and psychology in the art and science of motion. It makes sense of the tensional nature of the collagen matrix we live and walk around in. The knowledge of geometry as the hidden world behind our world, within our body’s internal world, has gradually become more popular in recent years. We will explore several different subjects related to this that sportEX dynamics 2014;42(October):29-33

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collagenous tissue architecture n Biotensegrity geometry: micro to macro – is this a scale free paradigm?

Figure 1: Needle Tower, Washington DC, USA. The picture was taken from underneath Kenneth Snelson’s famous tower, which demonstrates the structural style known as tensegrity. (Photo credit: S. Levin, www.biotensegrity.com)

In each of these articles, we will include one of the leading researchers and their particular take on the relevance of biotensegrity principles. The purpose of this will be to provide some historical background and also explain how all-encompassing tensegrity is and why it is worth understanding on more than one level. Regardless of your favoured area of expertise, if you can see how the organisation of form is designed under tension, you will begin to understand why the new field of fascia research cannot be fully applied without recognising these principles of living, moving form.

The TeRM

Figure 2: The spine as a column. A column, in architectural terms (a) is a compression structure and the spine (b) is called the ‘spinal column’. Any tilt or shift to the ground immediately threatens structural integrity. Yet we can constantly adapt to different angles and shapes and relationships to the ground. (Image credits: J. Avison)

are all relevant to sport, fitness and physical performance. We will explore these ideas with related exercises to see how they work in practical terms. In doing so, we will highlight some of the most recent research into the principles of biotensegrity and see how we can apply the new questions to all fields of movement. For example, key to its application are the following topics: n stretching: why we should and when we shouldn’t; the big debate n embryology: how we all began as human architects – has that changed? n Levers and pendulums: why the cuckoo rather than the clock has the key n fascia: our tensional matrix of www.sportEX.net

Tensegrity was the term coined by Buckminster Fuller from the words ‘tensile’ and ‘integrity’. He did not, however, originate the architectural forms from which the term derived. It was one of his students, the renowned artist Kenneth Snelson, who first built what he called ‘floating compression structures’ (Fig. 1). Traditionally we consider the spine as a column. A column is a compression structure; such as shown in Figure 2. This is an architectural form in a non-biological linear construction. Figure 3 is a model of a tensegrity mast, demonstrating the geometry of tensegrity, which can hold itself in apparent defiance of gravity, much like a bird (Fig. 4), animal, fish or tree for example. The bird’s spine, if it was

Figure 3: A tensegrity mast. This model demonstrates the geometry of a tensegrity architecture that can hold itself in defiance of gravity; much like a bird, an animal a fish or a tree for example. (Model author’s own; designed by Bruce Hamilton www.tensegrity.com)

formed on a compression basis, could not have structural integrity even at a tilt, let alone be responsive and selfsustained in the horizontal plane. The human spine is also a biotensegrity structure that can be held horizontally (Fig. 5). In a structure such as this (ie. any animal spine) there are two main components: tensional members and compression members. They have different features in that the tensional members are continuous and the compression members are discontinuous. However, (and here is where the difficulties begin) neither can ‘be’ under tension or compression, without the other. Essentially the tension and compression features, combined in certain very specific ways, give rise to a third state; which is tension– compression (Fig. 6). The tension–compression elements can be likened to the yin and yang principles in chinese medicine, or Ida and Pingala (the symbol of the feminine and masculine forces) in Yogic philosophy. Each one is distinct. However, their combination (when balanced in the ‘right’ relationship) yields a third state. That third state in yogic terms is called ‘Shushumna’ and might be regarded as the neutral state. Symbolically, Shushumna is the third form, or force, arising from the combination of the other two. In a tensegrity or biotensegrity structure that is the unifying of (discontinuous) compression and (continuous) tensional members in a ‘polarity partnership’. Under certain geometric laws, these can be organised in such a way that they occupy space using the least amount of materials in a highly adaptable and flexible form that can maintain its shape when moved or self-motivated. (See the mast in Fig. 3 for a static model). The two aspects unite and become interdependent, giving rise to possibilities unpredictable from the sum of the parts. These are natural laws of biologic forms which will be explored in the subsequent articles. In such a structure, despite the ability to remain flexible and strong – the aspects or forces (compression and tension) don’t relinquish their mutual state of balance without cost to natural motion and structural integrity. 31

Figure 4: A biological floating compression structure. Notice how this bird is flying parallel to the earth; the bones in its spine and neck remain profoundly connected; they don’t fall off just because they are in a horizontal position. They are not formed in a compression structure. (Image reproduced by kind permission of Shane McDermott, Wild Earth Illuminations, www.wildearthilluminations.com)

Figure 5: The spine is not a compression column. Katie, somewhat like the bird, can hold her spine relatively easily in the horizontal plane. This is not a model of a column. Furthermore the strength and size of the muscles and bones in her standing foot, do not account for the ability to hold her body at this angle without threat to her structural integrity. (Image reproduced with kind permission from Katie Courts)

Indeed, in order to fully appreciate how the fascial matrix works, we have to accommodate paradox. Nowhere is this more essential than in appreciating biotensegrity as (at least) a metaphor for our three-dimensional movement apparatus. Fascia connects everything to everything else in the body. It also disconnects everything from everything else; at the same time. Without it there is no distinction between two muscles, or two vessels, or the extra cellular matrix and the organs within it. Everything in the body is wrapped or invested in this fascinating material. When applied to our human physiology, we have first to accept the presence of the fascia, the connective, organising tissue of the organism. It is around every muscle, muscle fibre, fibril and bundle; around every bone 32

and vessel and gland; around every organ and capillary. It contains the ground substances (or ‘internal sea’) of our whole living body. It forms the collagenous matrix of our human architecture, which is, importantly, a tensional matrix. Biotensegrity lives in one particular question about the fascial matrix. What tensions it? The answer to this is both complex and simple at the same time – be warned that the ability to ‘hold two paradoxical ideas simultaneously’ will be your counter-intuitive, but nonetheless essential key to understanding biotensegrity. From embryo to elder, it gives rise to the elastic body we can enjoy when fitness and vitality is optimal. It also provides new questions about how we might prevent injury and optimise motion when fitness and vitality are compromised. In each article we will explore this question and include reference to some of the key researchers in this emerging field that provides compelling explanations of the art and science of movement. We will endeavour to weave their work into the material presented and make sense of how various aspects of biotensegrity actually apply in real life on the field (or on the mat, pitch, court, course, pool, gym, classroom or home). I invite you to embark on this journey with all that you have learned about muscles, bones and biomechanical bits and sections of the body to find a context for all that content. It is not without good reason that the research into the fascial matrix (and biotensegrity as its architectural principle) is being referred to as a paradigm shift. It is a new context that changes the relationships and shifts the perspective through which to view all the content it describes. Stephen Levin (orthopaedic surgeon, international speaker and author of many articles on Biotensegrity at www.biotensegrity.com) is considered to be the Father of Biotensegrity (Fig. 7). He coined the term ‘bio-tensegrity’ to distinguish this work as applied to living beings in the physiological context of biological forms. We will include his work in each of the articles as he has spent many years researching from his experience in surgery and working with human structure.

Figure 6: The spine as a biotensegrity structure. This model shows the tensegrity geometry of the human spine; albeit without the continuous relationship of the tension-compression elements of the rest of the structure. (Image reproduced with kind permission from Tom Flemons, www. intensiondesigns.com)

Figure 7: Dr Levin standing under Snelson’s Needle Tower. (Photo credit: S. Levin, www.biotensegrity.com) sportEX dynamics 2014;42(October):29-33

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In subsequent articles we will include the work of the following specialists: n Tom Flemons, geometry n Donald Ingber, microbiology n Danielle-Claude Martin, movement research n Graham Scarr, osteopathy n Leonid Blyum, biomechanics. References 1. Myers T. Anatomy trains: myofascial meridians for manual and movement therapists, 3rd edn. Churchill livingstone 2013. ISBN 978-0702046544 (Kindle £27.97 Print £37.63). Buy from Amazon http://spxj.nl/1t2W4eq 2. van der Wal J. The architecture of the collagenous connective tissue in the musculoskeletal system – an often overlooked functional parameter as to proprioception in the locomotor system. Presented at the 2nd International Fascia Research Congress 2009, Amsterdam, The Netherlands. spxj.nl/1rmwfrA 3. van der Wal J. The architecture of connective tissue as a functional substrate for proprioception in the locomotor system. international Journal of therapeutic massage & Bodywork 2009;2(4):9–23. [This article was published as a supplement to the presentation (Ref. 2) and includes a revised version of part of the author’s doctoral thesis, submitted to the University of Maastricht in 1988, entitled “The Organization of the Substrate of Proprioception in the Elbow Region of the Rat”.] 4. Avison J. The science of body architecture. In Yoga: fascia, anatomy & movement (chapter 3). handspring publishing 2014. ISBN 978-1909141018. (£28.75) Buy from Amazon spxj.nl/1pI7I0P

fuRTheR ResouRces 1. Handspring Publishing (www.handspringpublishing.com) 2. Bodywork professional development (www.bodyworkcpd.co.uk) 3. www.joanneavison.com

KeY PoinTs n in natural motion, the human form moves as a whole structure. n fascia research is transforming our understanding of human structure and form by creating a new context for the content of the so-called musculoskeletal system. n Biotensegrity is an essential part of the paradigm shift in movement, manual and medical treatment of human structure. n in injury prevention and performance enhancement the knowledge of biotensegrity is fundamental to optimal vitality and elasticity. n new dissection techniques revealed the continuity and importance of fascia. n Tensegrity structures are self-supporting tension– compression structures. n The human spine is not a compression column, but a biotensegrity structure.

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THE AUTHOR JOAnnE AvisOn KMi, E-RYT500P J Joanne is cofounder and director of the Art of Contemporary Yoga Teacher Training school, (AOCY) accredited (UsA), Yoga Federation of india, worldwide by Yoga Alliance (U European Yoga Alliance and iPTi (independent Professional Therapists international). she holds E-RYT500 status, (“E” denotes experience) with many thousands of registered teaching hours over the last two decades, accumulated all over the world since she graduated in 1995. Joanne is also a fully accredited Professional structural integrator (Kinesis Myofascial integration school) and a member of iAsi (international Association of structural integrators). she taught at the KMi school of structural integration (Maine, UsA) and went on to teach Anatomy Trains™ in the UK, pioneering its application to Movement Practitioners in Yoga, Pilates, and then in professional sports, including English Premier League soccer Clubs and to golf professionals. Jo also consults for a number of professional teams and sports figures. in furtherance of her study of anatomy, she studied Craniosacral Therapy and Human Dissection. As a CMED Graduate (2004), Joanne has studied extensively in human development as well as specialising in soft tissue and the links between archetypal behaviour and physiological patterns. Her intensive studies include Human Dissection and movement research in Fascial Fitness with Dr Robert schleip. she is a certified Craniosacral Practitioner and her early background in art and design always informs her lively approach to teaching and learning. Her lectures, workshops and webinars are extremely informative, downtoearth and practical. Like her latest book, YOGA: Fascia, Anatomy & Movement (Published by Handspring Publishing Ltd, 2014) they are all animated by her lively illustrations and focus on Plain English. Jo seeks to make sure the participants in her courses understand the context of the work and receive it in many different learning styles so they ‘get to take away and play’, interpreting the knowledge to fit their own practice. Joanne designed the yoga teacher-training programme to include the study of fascia and biotensegrity as an expanded context for applied anatomy and biomechanics. Her considerable experience in both movement and manual therapy inspired the school’s unique approach to yoga and integrated Applied structural Anatomy. she devotes a lot of her time to the Diploma Course in The Art of Contemporary Yoga & science of Body Architecture. The 1–2 year certification is renowned in the UK and Europe for the highest qualification of intermediate and Advanced Yoga Teachers. The course includes Applied Anatomy, Archetypal integration of the Psychosomatic Body, Restorative and Dynamic Yoga as well as Meditation and applied Philosophy. Joanne currently teaches regular workshops and webinars around the world on structural Anatomy, Biotensegrity and Fascial Fitness. (www.fasciasymposium.co.uk and www.bodyworkcpd.co.uk for recent presentations)

DISCUSSIONS

n How is your body held together? n When you move one part of your body, what happens to the rest of it? n Is movement or stillness local or global to your architecture?

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sportEX dynamics 2014;42(October):34

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AnA An Atomy A tomy & Soft tiSS SSue ue injury review By Dr Simon Kaye, Sports Physician and General Practitioner

online & Mobile £24.95 print copy available at tiMe oF purchaSe aS a £6.99 upGrade with online purchaSe

ANATOMY & SOFT TISSUE INJURY REVIEW by Dr Simon Kay

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11/07/2013 10:58

contentS n Overview of diagnosis and treatment of sports injuries n Shoulder Joint and girdle n Elbow and Wrist n Ankle n Knee n Spine n Hip joint and pelvic girdle

This resource is packed with animations and is highly visual coviering all the major joints and surrounding soft tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals. It is also a perfect tool for showng patients and clients exactly which anatomical structures they have injured. The resources is regularly updated and expanded with new images and animations. n Back to basics revision of anatomy of each joint n Includes 53 anatomy animations and video clips to bring the facts to life n Covers diagnosis and treatment options with background theory and evidence based medicine

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n Provides tips for examination, learning exercises and highlights key points n Gives links to further reading n Useful for practitioners and those in training

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Rota spinatus (SS),(see Video girdle ying Follow g the sho issue, at the h anatom ralis majo s and to eac )) oralis osis and high ments of to move shoulder accompan and diagn of supra laris (SSc – pecto r, bicep fashion, related d bot (PM) mino with ic ssed and movelook at the ng up the coverin ks in this ntric centr iques subscapu movers pectoraliss ic/ec ately maki be asse /ecce like an groupe ary r, detailed entric tures nt techn ture can und it st Kay loo We have are so intim 2. Prim teres majo in a conccentr struc assessmeeach struc and surro head again ly tissue id, w. delto simple they how the joint humerus act most dial joint, elbo o to as les some showing lder ro-ra s . er the close is one shou musc hume osed ge, rus. joint, to hold during red by the foota les like togeth the radiuination) rotating lly diagn the humeRC musc job is g stability eral (GH) e joints are cove 2. the rotation of action/ differentia -hum ining e. Their The tainin rview ation/sup ing are are h contr gleno girdle. Thes sleev main les the (pron ove allow twitc GP the y plete thus y ally the musc lder n Kay, incom facilitates in a slow rus into specificall the shou id fossa rotator cuff of longitudinthe ulna Simo which anatom les act the hume the head lder or make up d joint the gleno ts. The By Dr musc of aroun -ulna that men The shou ion two jointsto move radio The RC the head n is pulledted t. move joints rs. les the uct men g these tendo 3. move on pullin hand of five s: move is effec PM musc en as the prime introD g how vitallopment, i.e. ion, it is joint fashi rotating Rotation for ing the short joint as follow-humeral iderin t: t pulat nt: d (AC) isometricfossa, allow muscles the scapula. Cons n deve rate nsible oin for Poi huma RC respo and mani are injure 1. gleno ioclavicular id of nsible Key gh three sepa K 1). gleno are to rdination joint being at the rus. The acromium le respo that they 2. acromoclavicular pinatus the arm note lthouugh are all musc on (see Video altho the hume under the eye co-o in a way infras tus c joint , ed, is with with s they capsule fashi capularis 3. corac ising , serra are. elbow joint e ulothoraci joint medially surpr asne or cuff shoulder internally rotat lder is they the subs / eccentric (trapezius n of the shou fine 4. scap oclavicular of the or the sam injection onli rotate, the rotat ion and ula little the inatio ion in entric h both by as lise, s rnally r rotat stabi a conc of the scap (in whic 5. stern neutral posit er exte The combwrist allow plus powe enclosed facilitate 2). ulae) les external rotation, in neith e s, is The position h can musc or scap al figur rm and our hand chest, mical whic function ssory intern (see forea of the the anato rotation). and levat g of n a single a wide range side The acce posterior therapy isn’t rnal : flexio positionin ction of use in mind occurs that this in full exte ior and directions anter grip. Perfehand’s role, that in llent ements elbow jointon entS six ‘basic’ n (coronal with positioned exce w mov the true not the is, and promote tensi lbow movem occurs inction/adductio axis of the roelbo of as ions n/ex t er be lder nd men - flexio via the hume of funct and wrist ion can ment ), abdu ion (arou Move ShoulDt of the shou mobile plane re 3) direction rotat the elbow g. Manipulat iple’ move ‘basic’ le, as men (in in one plane) (Figu (sagittal external isn’t Move a need as gross is a ‘multn of all six nsion and ding positionin which ment (sagittal and threa shot. inatio and exte internal dial joint the true d nth moveis a comb fine as ing our hair putting a ), and ulna joint. humero-ra d part of as turne plane The seve which the other nding on The as comb t terms) to be rus). tion, joint, considerethe hand depe hume ation men ically the GH shoulder s move circumduc – supin rview techn allow rily at called the joint, to back (palm y ove ments. occurs prima joints in : elbow from front al. move ple pronation The ment vertic d anatomelBowof three jointsjoint) Rotation involve multi from the aroun up) and re 4a+b). the move the consists faces hinge of rity of (Figu of from: (a ments angulation (palm majo joint ction move ee of lar facet the the floor) The elbow ro-ulna g abdu degrees, the articu faces of GH with the degr ple durin hume 0 of the ratio lates 1. the 25-3 is 2:1 consists For examneutral to h articu ment play which rus whic on the ulna s into n from the GH joint, ees the move ment the hume surface move le come is at 0 degr oracic ruent the clavic 30-9 cong ula-th n from t to scap of abduction men move 90 degrees n after

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join anx the ity. s arti ana ). The injured plus l phal ro-iliac . With Dista s the as previou rmation erely tive instabil pulsion, toe) acutely to the sac cle review (5th at nly sev rela re info anx ng and y, pro le phal e form for mo commo due to its of the bod in squatti and injuries s. This arti Midd toe) most the samthe article stly (5th port und as walking t as change follows e is the ulder mo w sup the gro y, as in imal end of and the foo Prox The kne the sho e is to allo o near joint n of at the the bod phalanxGP mediate like tors box toe) Inter ving acceleratio limb, n of the kne of the Kay, iform in (see n(5th be mo cune id joint ing Simo um Sacr functio g position can either wing rap By Dr injured ment ral erview : allo Fifth joints lloliga y ov monly tarsal n of femo is Pate allowin Propulsion the foot ral joint meta of two ral proportio abulum, st com talo-fibular ly simple n ial anatomconsists the tibio-femo the tibia ilium ving high ing. femo mo Med acet r thick the of tive sitt mo knee s the iform joint or by the labrum of The joint ral ruent due to cune anterio is a rela of inversio e of le is er main Late of the facettwo cong abulum covered by a running 1. the ists iform to furth acet and head lised (behind The anker limb, the d ankle) severity the mortic as cons cune with the ing. stabi femur acting ioned 1-2). lla) , which GP further tissue, pate tures in kick m (figs. hip is id r, cush articulate the low sic spraine but as the joint and ch can be le, ective n Kay, of the Cubo the femu cular struc which acetabulu of the conn Simo entS ved in neck n r ces on two avas -talar r en the ral position r projected the injury vem ed whi By Dr the ank (the clas surfa Navicula femu deep by lity is femu e mo ps are invol ntous es, the sub be disrupt consider from Talus - a joint on The neut of the uctionto its stabi ly. stabilisedsici s laterally l joint ligame muSclmuscle grou . s les ie. facet the neck ly and knee introDmostly due at least acute ent increas joint can ry. We will aneumora the men musc with s Calc of the patella-fe V-shaped h articulate lla Differ tring posterior injury nosu ow ment The hip, injured joint, of femoro- injuries ankle article. 2. the e inju whic pate slightly m. tibio n move flexion - hams i-membra y from of een shallthe patella ral h. The help g sem a rarel recognitio ent and the true as any kne foot in this betw r is acetabulu femo of undin some 1. Knee dinosus, the ral troug for the two main gem which surro menisci with um the femu With the back the femo a fulcrum r impin joint and ists of ischi joint severe ar joint and semi-ten s femoris le, popliteus, front entS head of cons by three with ges. as n. ice acetabula -iliac lling in chan only acts tibia, LiGamstanding, the acetabulum allow mort ists and bicepssory musc to flexio muscles The ankle ntially the sacro situation hip is to sub-tal to a cle, trave into the t s prior the to lar Femur acce esse cons mus s , Whils ting ricep s into : )knee (simi the les, the ion of the vastu efficient. in ricep and inser work joints joint tightly musc the limbs ver ks the nsion - quad lateralis, (fig.3): quad held ankle unloc s in wood the talus ent ally more no part ents knee The funct trunk on otion. Howetibia GP exte 1. the joint vastu of the pays of the it mechanic key ligam oral ligam the two medialis. also aid N Kay, 2. Knee s femoris, tenon including facet ort of is to fibula g locom -fem ent withh ts inter ing and s SIMo . s ular the supp foot durin les men and mak by artic ulate 1. Ischio moral ligam ent. that and ing and ie. rectu and vastu musc the ularly e of move By Dr the knee femur . Man strike Note of the which artic on the tibia mius partic n of the Tibia ing, jump ter fibula heel the ankle is fixed 2. Ilio-fe femoral ligam tighten with n) medialis gastrocne ulatio e rang d to ces – the stand ion of of force at (teno ing, runn hip, to grea level the foot his legs surfa the mortice) a whol The the artic tibia is linke ligaments ) and r rigid 3. Pubo e ligaments ing us to r. e joint ruent the ing, walk on the or The funct pation n when upright on and femu powe ide a the sing The cong h form sub-talar (ACL Thes e phas flexio stand all involve le nding dissi ht s of ty, allow muscle , s all tibia g cros (whic to prov propulsiv knee depe Talus ligament ent (PCL). allow ted g facet straig (see of musc ndly fibula t of gravi t use of the extension s of the kickin r degrees the hip bear ple and two stroncruciate mass inferior complica effec running s on of this can stand the facet joint in full of grea and seco a stable iater ligam they have three Fibula 2. the e ut a t facet cruccula or lesse of time that ht. For exammit ing and is a large e purpose use the anterior eriorNavi As part the ents Pleas witho een the congruen lity. beca s. lise there be ity. g walk mation). to allow weig are unt ract joint prim trans ligam stabi stabi betw ugh durin amo will cont id bone talar le activ s are not oiliac the post nly for of body hips infor ht, ss and Altho the hip, the otion, not ly. They covered and the exce lock to of gait musc Sacr xes to avoid -weig the mmo supp more joints injurie the sub- ground. talus and cubo and ising refle multiples l ing se refer body Unco vascular 1 for tring or on around is for locom of the SI ent joint neum the to minim stand mus cle s Box e (plea sportEX the foot, uneven ments of lingreas the joint s twist lity calca le thet spinaately main whils that hamsthis articl may on ligam in te half ising, and ioning a good thehurd within ACL stop musc hiphas Calcaneu move note opria gThis shed by relies the posit the stabi rol oxim the nt anterior rough joint appr ENTS entric ssed appr t. runn throu es publi pain from the if aghpatie injury s for containedvium. The s and The PCL to cont durin of the Similarly symphysis joint addre allow ht rs vermen bone ht. r. and concare used occu sition g than ous articl lly the MovEM aNKLE Femero- ar move ankle weig howe weigafter ent femu by syno the two ntric and durin icant theitis the pubic and oppo abul to previ topic). Usua weights, ligam Ecce ing,arthr signif acet of body on the een posterior muscles of the foot oF ThE t of the truetion, plantar o 1). why gth tion and leg ACL ss jump tibia betw of huge with stren ient % men for this injury is moren. . Exce ionticula joint the shin ments the knee defic-500themiss of the along femur (see disar Move in one direc plane) (vide alar ation s. r ntothe joint bea 400 le the glide S twist flexio the trans facet t withi toultim ttal leg, ately rs musc the move and supin strain on rciSe of powe rior, Theuse the subt and on the stops the knee ents occu beca end of fermen on knee a ion (sagi a and s of trunk tibia also move is ante the joint ently G eXe at th ility of sion effect nG l at the pronation can put traum of ligam r and the thesstrans lesr from of the nin ’t inher ie. tibial dorsi-flex dimension for inver exce rni to Look and and The stabthe array mino s pane glide would ear s model musc al Lea ation hip wasn joint pronation of the foot gh to ntrically, can to and femu g the omic esthetic): omical see e extra s). The three ver allow leads the ntricrs slow if the throu of ecce Onlin tors and pronbox and ng ecce ation. This n (kina that ritis. the anat same with howe is a due g the tibia surroundin onse to an anat ton, to s inver for video ptionlder, nsoarth o 2) cal joint oste s on pron disrushou .prime move mea contracti ectin muscles tions (vide itions article neutral and are the ght line. r. the in the in resp facet then an skele under verti conn sion Defin when the rate of to occu n of g the e,As often ated knee hum The of ever strai (see s riptio . stabl stron a ts lock the the more the in of of desc ation men very are activ ligaments control r far er point only nded ions supin 3-5 for a move the faces sure. N.B. the rim occu which the posit e trigg h not and it’s how s pres joint with jointS ular joint fully exte Knee caus within ents whic but also figure ward eversion sion ion is ately anD ro-acetab up the hip the leg down ther, ments). ment of rCISE tensions the ligam eS of thers in two al posit approxim r of inver nd , firing toge femo S t move EXE s ining is omic Bon i.e. the It ched occu tilted ent NG Try exam bone anat th thee femu that make of: The move movemenrough grou stret s pelvis ) ss The hip six joints consists ting can the two they are cal and allow movemt of the knee LEarNI of the of terac hold to take esthetic): which ttal plane. which joints ng exce men the verti riorly. when coun : foot is one (sagi hip girdle ular (FA) Move n (kina ulated foot tly, to fully the tions ut putti 30 to tilted ante twist s the tighten ch receptors . The direc of etab allow extension ion or girdle unt witho main an artic d apart sligh aspects ro-ac (SIJ) slightly off stret of rotat knee to on and into acco 2 x femo -iliac joints the n Flexi ll amount be prise e the 3-D r. sma to allow 2 x sacro symphysis ion nA appreciat joint. can occu ion is stable junct rotat re flexion 1 x pubic ar-sacral This subtalar ugh very befo altho 1 x lumb FA joint, ‘unlock’ The

this sly in Previou (issue cles. t st er arti , hip join and wri e w refresh ue 44) injury the elbo of the spin t (iss ies of ulder join 46) and title ue the ser sho cle the last in ered the le joint (issn this arti girdles. cov is the ank e give muscle re This we have 45), hav mo ue e we ociated to series e joint (issAlthough becom . and ass kne I have but difficult ds47), that han ue 49) the spine al, atic nd (iss e fou pragm a practic apy, joints re about her ch I hav ies in a it is it is mo rap this, physiot l theory, approa y, the for n rap ow ious apology the ofascia ne. People, ing my ing var no sports cture, my dici ient Review politan, mix ch. I make involves x me pun stic pat ch. It ns, acu orthodo y holi cosmo ce’ approa approa mobilisatio good old that a trul t ‘eviden ary care ssage, iatry and differen on, primlation, ma pod are so ues, h sports, essential. manipu ns techniq of whic : their each eve, roles ons, Mulliga es and different five secti is, I beli spin d into to perform their approach divide d specialise based

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is ical GP n Cerv acic n Kay, n Thor bar n Lum al two-fold: tion Duc the spine is with n Sacr ygeal. to l cord ion of n Cocc spina e roots The functction of the ned to l nerv g spina is desig positionin ical and limbs 1) Prote n of the cerv ents ical spine and allow r limbs distributio ive segm of good rmost , uppe r limbs, The cerv the skull relat oses is joint the trunk . lowe ort uppe their of phys arms and supp for purp The two sym Support pelvis use of the skull ed ing. 2) Pubic evolv on the of the ribed and of have and hear and skull locomotion lems desc the body me vision vertebrae ion. ing prob ently, funct the r allow of has becoring cervical ally differ latte Most (Atlas) bral to the anatomic vertebra relate first vertend vertebra below an the first from the seco From the rate y to lex. lop sepa fused are comp e, they deveeen anatom brae and has ectiv betw fuse are The verte gical persp which vertebrae embryolo centres The three of age. from 15 years 8 and Simo By Dr

intro

SubScription includeS acceSS on ipad, android and Kindle Fire tabletS. For more information visit the Manuals + Guides section at www.sportEX.net

studEnt rEsourcEs sportEX publish journals and e-learning resources for people studying manual therapy and injury rehabilitation. If you run a training course and would be interested in providing access to these resources see the bottom of the page for more details. All resources are available online and via our mobile app. BEST of MANUAL THErAPy oNLINE BEST OF

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Includes the “best of the best” of published sportEX articles on the topic of manual therapy. n 29 articles, many with multimedia animations, technique video clips and related quizzes to reinforce learning and retention of key points n Authors include world class practitioners such as Whitney Lowe (USA), Tom Myers (USA), Paula Clayton (UK), Bob McAtee (USA), Brad Hiskins (Aus) and Chris Norris (UK), amongst others

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ANAToMy & SofT TISSUE INjUry rEvIEW oNLINE anatomy & soft tissue injury review by Dr Simon Kay

Written by sports physician, dr Simon Kaye, this is a perfect resource for anyone studying anatomy and sports injuries. n Includes 53 animations and video clips to bring the anatomy to life n A randomised quiz lets you check your learning as you study n Continuously updated with new animations added as they are developed

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THE MASSAgE THErAPIST’S SUrvIvAL gUIdE oNLINE n Written by Australian soft tissue therapist robert granter, this guide offers a wealthy of information on surviving life as a massage practitioner n It covers 8 areas: How to seek appropriate mentors; getting inspired about your profession; optimising your technique; optimising your treatment positions; Looking after yourself and avoiding injury; Using treatment therapy tools to relieve pressure on your body; Staying inspired and Protecting your business with adequate insurance

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