Integrating Rehab and Performance, Part 2: The Treatment
This week we will show some example progression through the three stages of care for a performance patient. His main goal was improving his snatch catching position. He notes from videos that his right heel elevates off the ground when catching the snatch and doing other overhead movements. Let’s see how we progressed this patient based off our day 1 findings and primary goal.
Summary of the day 1 evaluation
The day 1 comprehensive evaluation showed that not only was his heel elevating on the deepest portion of the snatch, but also externally rotating outward with the inside edge of the foot collapsing as a whole towards the ground (everting). Further, we found right and left hip internal rotation deficits with asymmetrical and worse findings on the right (10 degrees on the right, 15 degrees on the left). We also found tibial internal rotation restrictions symmetrically on both sides and both feet oriented into eversion, mimicking a flat foot position. He also tended to weight shift away from his right side. From more precise testing, we saw anterior orientation of the pelvis with anterior and posterior chest expansion limitations, showing as reduced internal rotation of both shoulders (30 degrees on the left, 25 degrees on the right). Check out part 1 for the lower extremity highlight of the initial exam.
Phase 1: Addressing orientation
One thing we need to address in this phase for performance patients is the presence of orientations. If this was a rehab patient, we would also be focusing heavily on pain in this phase. For our patient, we were most concerned with the anterior pelvic tilt and the impact it was having on the lower extremity range of motion, especially internal rotation of the hips and the eversion seen in both feet. Other upper extremity and rib cage findings were addressed in this stage but will not be detailed in this article.
To make change at the pelvis and bring back space for internal rotation at the hips, we used chiropractic adjustments throughout the spine and pelvis, hips, ankle, and foot. We also used soft tissue techniques at the low back, hip capsule, and ankle. For corrective exercises to begin addressing biomechanics, we used the 90/90 hip lift exercise, foam roller rectus femoris drill, breathing cuing and diaphragm control, and more to help progress along in this phase. The results were an increase in bilateral internal rotation and better breathing mechanics. Here is an example of a few of these exercises being performed…
Phase 2: addressing mobility asymmetries directly
We had direct evidence that the patient was pulled out of an anterior orientation at the pelvis. The Ober’s test was passed on the left and nearly passed on the right and we got improvement on internal rotation on both sides. Any anterior tilting of the pelvis was now having minimal effect on his biomechanics and mobility. In phase two, his hip internal rotation measurements showed 30 degrees on the left and 15 degrees on the right. We now must directly address the asymmetry in mobility. Hands on work still included chiropractic adjustments, soft tissue release of the right hip capsule specifically, and bilateral ankles. We now used our time with correctives to attack that left side internal rotation AND his ability to externally rotate out of the left side/ shift into his right side.
It is important to note here that testing at this phase revealed an accompanied loss of motor control ability to shift into his less “accessible” leg. In this case, the right hip was lacking internal rotation which is needed in order to shift to that side. We often see hip shifts in squats and other movements away from the side of missing internal rotation. See the article “Are You Hip Shifting While Squatting”
So, we knew we needed to get back both right hip internal rotation and learn to shift/ put weight into that hip again. Here are some drills we did to do just that!
We also wanted to start learning to come out of the bilateral foot eversion and begin supinating and pronating again. This meant we had to use exercises and drills that biased a full foot arch position (supinated) and positions that forced us to feel and create foot pronation. We incorporated these drills and exercises directly into our lower body training for the hip and pelvis!
Phase 3: Putting it all together
Now, we must learn to keep our foot flat and the weight evenly distributed while catching and standing up a snatch. This means we need access to hip range of motion in flexion, external, and internal rotation, knee flexion, and foot and ankle dorsiflexion, pronation, and supination. All these things need to be able to occur to prevent compensations (like the heel lift and turn that brought this patient to the clinic in the first place). We have been working on the individual components so far and began integrating a few with the efforts to create foot pronation and supination as well as hip shifting with the abduct and shift drill. Now we must truly challenge these ranges of motion.
We started with a more advanced version of the abduct and shift. A few other exercises we did included weighted lateral hip hinges, staggered stance squats, and some retesting with lighter overhead squats. Below is an example of the weighted lateral hip hinges and side shifted kettlebell swings…
As we progressed, we incorporated more snatch balances, heavier versions of the previous exercises, and more work that incorporated the upper extremity and overhead mobility we did not mention in these articles.
Conclusion
This creates the total package of care for the patient. We meet them where they are at and rebuilt from the ground up, leaving no stone unturned and addressing every level of compensation. As a rehab and performance chiropractor, I use every tool I have to help my patients achieve their goals. Chiropractic adjustments, soft tissue mobilizations, corrective exercises and performance training are integrated together to follow the progression of the patient through their treatment plan.
And look at him now!
-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.
