PT on the Net Research

What's Behind the Injury?


There is nothing more frustrating for a strength coach or personal trainer than a client or athlete who has a nagging problem or injury. It is not the role of the trainer or strength coach to treat these injuries. However, the exercise professional often finds him/herself in this position due to the lack of education provided by the medical profession. It should be pointed out that this does not justify practicing without a license.

In most situations, with a little digging and creative networking, good trainers and strength coaches can find medical professionals who are willing to participate in a “functional” philosophy for injury treatment and prevention. Personal trainers and strength coaches are in an excellent position to help guide this process without trying to treat the injury.

As a physical therapist and board-certified orthopedic specialist, I am amazed each day with the length of time patients, athletes and clients have had to deal with unnecessary nagging problems and unresolved injuries. They arrive and spend our first 20 minutes together telling me all the things that have not helped them. In these situations, I often find myself in the role of problem solver, and it seems that in many of the cases the solutions are not complicated at all.

Chronic problems such as tendonitis, bursitis, strains or sprains are not always the result of an injury. Many times, knee, ankle, shoulder and back problems arise with no specific trauma, and in certain instances, exercise and competition seem to exacerbate the problem. It is important that when faced with these types of problems, you are able to help clients be educated and well informed when seeking treatment for a musculoskeletal injury. There are two fundamental rules that should always be practiced in physical medicine.

First, physical therapists are trained to use bilateral comparison when evaluating a musculoskeletal injury; this means assessing not simply the injured or involved side but completely mapping out discrepancies between the involved and uninvolved side. I am always amused by my patients and athletes when I grab the uninvolved knee or shoulder and they say, “Wait a minute. It’s the other side that hurts.” I laughingly say, “Whose shoulder or knee would you like me to compare this to, yours or that of someone else?” This type of comparison will allow the clinician to completely map out the available range of motion, muscle tone and appropriate stress tests on the uninvolved joint in question, prior to testing the uninvolved side. This helps me decide what dysfunctions may have been pre-existing to the injury and which ones have arisen since the problem has been present.

The second rule of orthopedics is to always clear the joints above and below. This means that if someone presents with a knee problem, it is the clinician’s responsibility to assess the function of the involved side hip and ankle and not to simply compare it to the opposite knee. It seems that at least twice a month in my practice, a young athlete who has already had knee surgery will present in my clinic and not understand why the knee surgery did not cure the problem. They actually present with the same symptoms they had prior to surgery, and now they just have three extra holes in their knee to go with their unresolved problem.

During my assessment in these situations, it is not uncommon to identify significant flexibility or strength problems in the hip and ankle of the involved knee. It is quite common for the athlete to have reduced ankle dorsi-flexion, which renders the gastroc/soleus muscle ineffective on deceleration moves. Plyometrics and quick deceleration rely on at least a quick stretch to initiate a muscle contraction in the plantar flexors. If flexibility is reduced, then how can their quick stretch occur? In many of these types of situations, the knee problem will spontaneously resolve by addressing the muscle imbalances and flexibility problems in the hip and ankle.

It is now my responsibility to explain to the young athlete how the knee was a re-injury that occurred everyday when getting back to activity with a dysfunctional ankle and hip. These same discrepancies are noted in clients and athletes with chronic shoulder problems. They may have had extensive evaluation by a physician including a MRI scan of the shoulder, and yet has anyone looked at the thoracic spine mobility for rotation, extension and flexion? The scapular stabilizers cannot function normally because their length-tension ratio is compromised whenever the thoracic spine cannot appropriately position itself for each activity.

I do not propose that personal trainers and strength coaches perform physical examinations of this nature. However, I do feel that movement screening is completely within the professional scope and responsibility of personal trainers and strength coaches. The Functional Movement Screening (FMS) is only done to map functional movement patterns, their limitations and asymmetries. A more involved functional test is called the Selective Functional Movement Assessment (SFMS), which is performed by a physical therapist, chiropractor or physician to arrive at a functional diagnosis. When fundamental functional movements are found lacking in individuals wishing to train and exercise, problems can arise.

You could have the best teaching techniques and the best workout program in the world, but if athletes bring poor movement patterns to your program, they will inevitably compensate. These compensatory movements that develop will actually assist in reinforcing their problems. The result will be poor mechanics, which can lead to micro trauma, reduced muscular efficiency, increased fatigue and poor proprioception. Simply screening the fundamental movements will help you guide physical therapists and physicians when it is necessary to make a medical referral.

It is interesting to note that both athletes who possess a full and unlimited deep squat and those who have extremely restricted mechanics in the deep squat can both possess the same amount of patellar femoral pain or tendonitis at the knee. This is important information because it identifies the difference between a stability and mobility program. By simply conducting a movement screen, you not only get to map out which movements are within functional limits and which ones are extremely lacking, but you also get an opportunity to observe which movements provoke symptoms. Many times, your clients are unaware of a problem because they automatically avoid problem movements.

I feel that the future of fitness professionals is dependent on their ability to responsively screen fundamental movement patterns and look for any discrepancies. Research tells us that imbalances between left and right function correlate with injury. Knowing this, if we increase the activity level with someone who has functional asymmetries between the left and right side of their body, greater amounts of compensation and substitution will be required to execute even the most simple exercise moves. It is this information and research that drove me to look at the human body in a different way, to develop functional movement assessment and functional movement screening tools.

Exercise professionals need to create professional relationships that work both ways between the medical, fitness and conditioning professions. The end result will be more consistent holistic care for athletes and clients. Research is showing that static structural alignment measures are not objective with prediction of functional movement problems. Screening and assessment that involves fundamental functional movement not only lends itself toward corrective exercise but also is emerging as a more consistent and reliable way to screen individuals wishing to participate in exercise and competition. Successful management of injuries in the exercise profession is best done with prevention. However, in the event that injuries and problems do arise, an objective and consistent approach to mapping out the functional problems that exist may serve to clarify the causes and cures for those little nagging issues that always seem to pop up in training.