Integrating Rehab and Performance, Part 1: The exam

This week we are going to give examples of Integrated Rehab And Performance Centers patient exam. More specifically, we are looking at an example of how we integrate lower body joints with the pelvis and spine. You will see why phases of care progress from working on specific mobility at precise joints, into motor control for joint complexes and regions, and then integrating that new mobility and motor control into big picture and broad movement patterns that the patient/ client needs for their sport, hobby, and goals. Today, we are looking at the lower body exam portion for a CrossFitter looking to improve their snatch position and snatch performance while avoiding knee pain.

The Patient Exam

Here is the general outline of what we did in terms of a comprehensive, one hour exam.

·      SFMA top tier screen

This helps us identify which global or broad multi-joint movement patterns are showing signs of asymmetry or missing range of motion/ control.

·      More precise but still broad movement patterns.

In this case, we looked at a goblet squat and overhead squat since these were more pertinent to the patient’s goals.

·      Specific joint by joint testing.

This involves a lot of table-testing to gain an understanding of every muscle, joint, and ligament playing a role in the pain and/ or dysfunction.

·      Chiropractic exam.

This exam looks at which areas of the spine are missing “joint play” or are restricted. With this exam, we can get a look at which spinal segments or regions of the spine are limited in mobility and can be improved with chiropractic adjustments. We also look at the “joint play” and feel of the extremity joints. We also do any pertinent orthopedic testing to assist with diagnosis of musculoskeletal pain and dysfunction.

Findings

In this example, we had limitations that presented themselves in the global movement screen that we focused in on all the way down to the individual joints.

·      SFMA top tier screen

The major findings from this screen showed that there are dysfunctions limiting tests all the way from the feet together deep squat, multi-segmental flexion (toe touch), and multi-segmental rotation.

·      Patient specific broad movement testing

This this level of testing, we really noticed a lot about the foot and ankle. In this case, he had what appeared to be flat feet on both sides. This looks like the arch of the foot has disappeared and the inside edge of the foot is in full contact with the ground. We had the patient do a goblet squat and a walking gait analysis. Both showed this flat foot presentation. When the patient would snatch, we noticed his right heel struggled to stay flat on the floor and he always re-positioned his feet during every rep, rotating his foot more and more outward and lifting the heel.

·      Precise mobility testing

Here we found hip internal rotation worse on the right than the left (10 degrees vs. 15 degrees), ankle dorsiflexion was limited on both sides, and hip flexion limited to 90 degrees on the right and 100 degrees on the left (aiming for 120 degrees), and a positive Ober’s test on both sides (tells us the pelvis is likely in an anterior orientation on both sides). We also found missing tibial internal rotation on both sides and a difficulty to actively control pronation and supination movements of the foot. 

·      Chiropractic exam

Here, we found restriction in the pelvis to move into extension on both sides, T/L junction stiffness (where the mid back meets the low back), diffuse thoracic spine restriction from extension, and C/T junction restriction (where the cervical spine meets the thoracic spine).

Here is a quick video of a small handful of the movements tested. Watch or listen to the podcast episode that goes with this article (Youtube and Spotify).

Deciphering the data

Regarding the SFMA top tier testing, we know there is restriction to global flexion from the squat and multi-segmental flexion findings. We also know there is rotation restriction manifesting in gross lack of rotation through the spine, pelvis, and lower extremity.

The gait analysis tells me the flat foot position is likely not a genetic flat foot (also supported by the fact that a calf raise could re-create the arch for him). Instead, the foot is everted, which is an orientation of the foot in a position where the bottom of the foot wants to push itself outwards. This creates what looks like a flat foot, but in reality, he is searching for contact with the ground since the joints above the foot (the ankle and hip) have lost the ability to put the foot in a position to pronate normally due to mobility loss.

These findings were confirmed with missing hip internal rotation on both sides, especially that right side resulting in an asymmetry. Further, there was missing tibial internal rotation on both sides and a lack of motor awareness or control over supination and pronation movements of the foot.

Further, we have spinal mobility issues and restrictions at key areas such as the pelvis, T/L junction, and Thoracic spine. These areas are essential to allowing the lower extremities to move through their ranges of motion (like the pelvis affecting the hips ability to create space for internal rotation) and for the upper body to create room for movement at the shoulder (like the thoracic spine effecting the glenohumeral and scapula’s ability to do shoulder flexion).

Overall, we have missing availability of movement of the pelvis, hip, and ankle, with more drastic changes on the right side relative to the left. This is correlated to the right ankle problems showing as compensation to the missing movement options when they are needed most, like the bottom of a heavy snatch! We can also see the compensation of an apparent flat foot, which is actually an orientation of the feet in eversion due to these same findings.

Summary of the integrated rehab and performance exam

The exam demonstrated above reflects the patients’ goals, limitations, and athletic ability. Not all exams will look that same. For example, this was a performance-based exam, where the patient was not experiencing any explicit pain. Most of the patients at IRPC do present with pain, on top of their movement, fitness, or sport related goals. Also, patients will often have histories of injuries and surgeries that have created restrictions or barriers in their health and performance. This means other exams will include varying degrees of the above exam procedures, plus more pain oriented and orthopedic testing based off the patient’s complaints and history.

Otherwise, we still focus a large portion of our exam and treatment on the mobility and motor control capacity of the patient. We address pain directly, but most of our treatment focuses on the indirect cause of pain (the root cause) that is often located elsewhere in the body. Regardless of whether or not a patient is in pain or not, functional movement assessment and detailed anatomical and biomechanic based assessment is always at the forefront.

Learn more about how we treat with these same principles in part 2!

-Dr. Nick DC, TPI, CSCS

If you would like to learn more about your body, pain, and performance, send Dr. Nick an email at contact@integratedrpc.com or call at (585)478-4379, or schedule a FREE discovery visit at Contact.