Teaching Movement, Expanding PT, Embracing Failure: Movement Debrief Episodes 2 & 3

Here are this week’s Movement Debriefs. I’m hoping to get on a regular schedule once I get settled into my new gig as a PT Mercenary, but hope you enjoy.

Anchoring Old Movements to New, Prioritizing PT’s Professional Needs

In Episode 2,  we discuss the following concepts:

  1.  Visit 2 & 3 of our patient with the lumbar fusion
  2. Using familiar concepts from old exercises in new exercises
  3. Strategies to enhance learning.
  4. Prioritizing Problems in the Profession.

Embracing Failure and The Dunning-Kruger Effect

In Episode 3,  we discuss the following concepts:

  1. My Failure
  2. The Dunning Kruger Effect – and how to hack it
  3. Embracing Failure
  4. Learning from Failure

Change The Context: 3 Tools to Treat Neck Pain

Basket Case Study

The other day I woke up with some right-sided neck pain. I had some discomfort and slight limitations rotating or sidebending right.

Now I’ve already completed many systemic-oriented treatments, and don’t really have a go-to non-manual for the occasional crick in the neck. I was unable to get any manual therapy, nor were self-mobilizations effective.

What’s a guy to do? Continue reading “Change The Context: 3 Tools to Treat Neck Pain”

Chapter 15: In Conclusion

This is a chapter 15 summary of the book “Movement” by Gray Cook.

The Goal

The goal of movement retraining is to create authentic unconscious movement at acceptable levels. We can develop many methods to achieve our goals, but working under sound principles is paramount. Some of the principles Gray advocates include:

  • Focusing on how we move.
  • Look to movement to validate or refute your intervention.
  • Movement is always honest.
Of course I did my corrective exercise, I swear.
Of course I did my corrective exercise, I swear.

When designing a movement program, we must operate under the following guidelines:

  • Separate pain from dysfunctional movement patterns.
  • Starting point for movement learning is a reproducible movement baseline.
  • Biomechanical and physiological evaluation do not provide a complete risk screening or diagnostic tool for comprehensive movement pattern understanding.
  • Our biomechanical and physiological knowledge surpass what we know about fundamental movement patterns.
  • Movement learning and relearning follows a hierarchy fundamental to the development of perception and behavior.
  • Corrective exercise should not be rehearsed outputs. Instead, it should be challenging opportunities to manage mistakes on a functional level near the edge of ability.
  • Perception drives movement behavior and movement behavior modulates perception.
  • We should not put fitness on movement dysfunction.
  • We must develop performance and skill considering each tier in the natural progression of movement development and specialization.
  • Corrective exercise dosage works close to baseline at the edge of ability with a clear goal.
  • The routine practice of self-limiting exercises can maintain the quality of our movement perceptions and behaviors and preserve our unique adaptability that modern conveniences erode.
  • Some things cannot be fixed, but change what you can.
  • The brain that learns function can learn dysfunction.
  • Be safe, be satisfied, and play.
I can always tell when movement is sassified.
And I can always tell when movement is sassified.

Chapter 14: Advanced Corrective Strategies

This is a chapter 14 summary of the book “Movement” by Gray Cook.

Inputs

Corrective exercise is focused on providing input to the nervous system.  We are allowing the patients and clients to experience the actual predicament that lies beneath the surface of their movement pattern problem. It is okay for mistakes to be made, for these errors help accelerate motor learning. Minimal cueing should be utilized, as we want to patient to let them feel the enriching sensory experience.

Mistakes are good...I wouldn't be here without them.
Mistakes are good…I wouldn’t be here without them.

Motor Program Retraining

There are several different methods in which we can achieve a desired motor output.

1)      Reverse patterning – Performing a movement from the opposite direction.

2)      Reactive neuromuscular training – Exaggerating mistakes so the patient/client overcorrects. Use oscillations first, followed by steady resistance.

3)      Conscious Loading – Using load to hit the reset button for sequence and timing.

4)      Resisted exercise – Makes patterns more stable and durable.

When you can deadlift that much, most anything is stable and durable.

Movement Chapter 13: Movement Pattern Corrections

This is a chapter 13 summary of the book “Movement” by Gray Cook.

Back to the Basics

Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:

  • Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
  • Sensory integrity: Uncompromised reception/integration of sensory input.
  • Motor integrity: Uncompromised activation/reinforcement of motor output.
  • Freedom of movement:  Perform in functional range and achieve end-range.
FREEDOM!!!! Of movement. And if the Road Warrior says we need to move free I listen.

Getting Mobility

There are 3 ways to gain mobility:

1)      Passively: Self-static stretching with good breathing; manual passive mobilization.

2)      Actively: Dynamic stretching, PNF.

3)      Assistive: Helping with quality or quantity, aquatics, resistance.

Getting Stability

In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:

1)      Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.

2)      Static stability – done when rolling is okay but stability is compromised in more advanced postures.

3)      Dynamic stability – Advanced movement.

We progress in these stability frames from easy to further difficult challenges.

Assisted → active → reactive-facilitation/perturbations

I would black my face out to if someone was having me do this exercise.
I would black my face out too if someone was having me do this exercise.

Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:

1)      Fundamental – Supine, prone, rolling (requires unrestricted mobility).

2)      Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.

3)      Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.

The only legit way to practice single leg stance.

Movement Chapter 12: Building the Corrective Framework

This is a chapter 12 summary of the book “Movement” by Gray Cook.

A Whole Lotta P

When we build our corrective framework, we must take into account the 6 P’s:

1)      Pain – Is there pain with movement? Staying away from pain improves motor control.

2)      Purpose – What movement pattern are we targeting with corrective exercise and what problem are we addressing (i.e. mobility, stability, dynamic motor control)?

3)      Posture – Which moderately challenging posture is the best starting point for corrective exercise that allows for reflexive activity?

4)      Position – Which ones demonstration mobility/stability problems and compensatory behaviors?

5)      Pattern – How is the dysfunctional movement pattern affected by corrective exercise?

6)      Plan – How can you design a plan based on findings?

The goal when designing the correction is to stay in the middle ground of the autonomic nervous system while providing a rich sensory experience.  Movement pattern dysfunction is a behavior that needs to be addressed and changed.

Movement Chapter 11: Developing Corrective Strategies

This is a chapter 11 summary of the book “Movement” by Gray Cook.

Autonomics

All exercise affects tone and tension. This influence is the basis for movement. The autonomic nervous system determines movement as threatening or not, which determines requisite tone. It is important to nudge movement towards further nonthreatening yet advanced stimuli.

 

FMS Corrections

Proceeding to correct under FMS protocol is determined by screen results and changed via exercise.  We first correct mobility, next reinforce stability, then retrain movement patterns. Stability training in particular follows a sequence:

1)      Challenge posture and position.

2)      Build mid-range strength.

3)      Develop end-range stability.

Movement patterns are corrected in the following hierarchy:

ASLR & Shoulder mobility → rotary stability → pushup → Inline lunge → hurdle step → Deep squat

 

SFMA Corrections

The SFMA corrective pathway is nonlinear unlike the FMS. The breakouts will tell you which direction to go to restore optimal movement.

The options are also increased. Often to gain mobility, you would utilize various manual therapies or other modalities. To alter stability, taping, orthotics, braces, or anything else to increase motor control may be utilized.

Movement patterns are corrected in the following hierarchy:

Cervical spine → Shoulder multi-segmental flexion & extension→ Multisegmental rotation single leg stance → Squat

Depending on how movements present, certain therapies are utilized:

DN – manual therapy and corrective exercise.

DP – Manual therapy and modalities.

FP – Modalities and manual therapy.

FN – General exercise.

Modalities? No FN way...See what I did there??? Ah hell with it.
Modalities? No FN way…See what I did there??? Ah hell with it.

Exercise Categories

There are several exercise types that can be utilized depending on one’s goal:

  • Functional: Purposeful exercise that displays carryover to other activities. Can be general (for movement patterns) or specific (for certain skills). These generally enhance physical capacity.
  • Corrective: To create a functional base, normalize tone, and allow movement freedom.
  • Conditioning: Create positive neurophysiological adaptations in structural integrity/performance over periods longer than a single exercise series.
  • Movement prep: Work on patterns needed for activity.
  • Skill training: For specific skills.

Movement Chapter 10: Understanding Corrective Strategies

This is a chapter 10 summary of the book “Movement” by Gray Cook.

Mistakes, I’ve Made a Few

When we are talking corrective exercise design, people often make 4 mistakes:

1)      Protocol approach: Exercise based on category.

Problem – 1 size fits all.

2)      Basic kinesiology: Target prime movers and some stabilizers.

Problem – fails on timing, motor control, stability, and movement.

3)      Appearance of functional approach – Use bands and resistance during functional training.

Problem – If the pattern is poor, adding challenges to it can increase compensation. There is also no pre-post testing.

4)      Prehabilitation approach – Prepackaged rehab exercises into conditioning programs as preventative measures to reduce injury risk.

Problem – Design is based on injuries common to particular activities as opposed to movement risk factors.

Several, so it seems.

There are also certain mistakes that are often made when utilizing the FMS and SFMA:

1)      Converting movement dysfunction into singular anatomical problems.

2)      Obsessing over perfection in each test instead of identifying the most significant limitation/asymmetry.

3)      Linking corrective solutions to movement problems prematurely.

The overarching rule is to address these movement deficiencies first, as we do not want to put strength or fitness on top of dysfunctional movement.

 

The Performance Pyramid

When designing an exercise program, we look for three areas to improve performance: Movement, performance, and skill.

performance pyr

It is important that program design is based on the individual’s needs and has these qualities in a hierarchal fashion. For example, if one performs excellent on functional performance capabilities but has poor foundational movement, injury risk may increase.

 

Program Design

When implementing corrective exercise, it is important to provide the correct stimulus amount. We want the individual challenged, but not struggling for dear life.

  • Too easy – >30 reps with good quality.
  • Challenging, but possible – 8-15 reps with good quality and no stress breathing. There is a decline in quality secondary to fatigue towards the end of rep ranges.
  • Too difficult – Sloppy from the beginning and only worsens.

Rarely does increasing difficulty equate to increasing resistance. Oftentimes you may advance the exercise position, decrease the base of support, or add more movement complexity.

You may have to remove some activities that feed into dysfunction from one’s current programming, lest you wish to not change the movement pattern. Often how quickly one changes his or her ability to move depends on how diligent one is with corrective exercise.

Realize that corrective exercise should only be supplemental and temporary to what one is doing. It is supposed to be corrective in nature, not preventative.  Moreover, movement scores can decrease with hard training, so continual reassessment is important.

I do active leg lowering and wall ankle dorsiflexion while I'm taking NO Xplode bro.
I do active leg lowering and wall ankle dorsiflexion while I’m taking NO Xplode bro.

The corrective exercise pathway should proceed as follows:

1)      Exercise selection is driven by screen and assessment.

2)      A thought out framework gives you the best possible choices.

3)      Retest, note positive or negative changes, and then use results to modify next session.

4)      Reassess once an obvious change is noted to see what the next priority is.

Ain’t no need to question the Authority

Movement Chapter 9: Analyzing the Movements in Screens and Assessments

This is a chapter 9 summary of the book “Movement” by Gray Cook.

While I have broken up these sections into patterns, much of what Gray talks about does not involve the patterns themselves, but are still good points to know. Ergo, much like the book itself, this post may seem a little disjointed 🙂

The Deep Squat

One’s inability to squat is not considered a single problem. Instead, a disconnect is present between the body and the brain in the squatting pattern. Our brain sees things in patterns, and the squatting pattern essentially gets smudged. Before performing the squat as an exercise, we must first groove an optimal movement pattern.

Preferably while listening to someone groovy like Marvin Gaye

One interesting point regarding the squat is that as an exercise it is often a top-down based movement. However, when we learn to squat in development, the movement occurs bottom-up. So one way to train the squat is by starting from the bottom of the squat and working to standing. This method ensures full mobility to perform a full deep squat.

To relate the SFMA to the squat pattern, Gray is very clear about not training the squat if one cannot touch his or her toes.

Hurdle Step and Single Leg Stance

These two movements simultaneously test mobility and stability of both legs. Oftentimes in these patterns you will see a high-threshold strategy (HTS), in which a hyper-protective core response occurs. Research demonstrates that this stabilization strategy can cause poor motor control to occur. These tests also are basic precursors for stepping, running, and climbing.

In this section Gray also mentions that he does not recommend assessing static postures; namely because posture is dynamic and changing.

Inline Lunge

The inline lunge is more a test of control and efficiency as opposed to strength.  Because we talk about control, we must discuss stability. It is important to note that stabilizers do not necessarily need to be strengthened, as these muscles will never be able to overpower prime movers. Instead, these muscles should be trained for endurance, timing, or quicker action.

 

Shoulder Mobility Reaching Test

These tests assess reciprocal arm patterns and thoracic spine mobility. The movement is challenging because opposing movements end up borrowing mobility and stability from other segments, thus potentially impairing these qualities.

Thoracic extension is necessary to perform this pattern. However, oftentimes people will compensate with thoracic flexion. This compensatory pattern can rob the scapulae of ground to help stabilize the movement.

 

Active Straight Leg Raise

There are several necessary components to perform this movement optimally:

  • Adequate down leg extension (otherwise substitution with anterior pelvic tilt and lordosis occurs).
  • Adequate mobility and flexibility of the elevated leg.
  • Pelvic stability prior to and during the movement.

Another interesting tidbit from this section was that research has demonstrated that one’s ability to perform a sit and reach correlated with arterial flexibility.

 

Core Stuff

The pushup, rotary stability, and rolling patterns all assess core functioning. In particular, the pushup looks at reflexive core action, rotary unilateral and diagonal patterns, and rolling the ability to separate upper and lower quadrants.

It’s all in the reflexes.

Movement Chapter 8: SFMA Assessment Breakout Descriptions and Flowcharts

This is a chapter 8 summary of the book “Movement” by Gray Cook.

What to Look For

The SFMA breakouts are utilized to determine if one’s movement deficiencies have a mobility or stability origin. There are further possibilities in each of these categories.

It Could Be a Mobility Problem

There are two subsets of mobility problems that include tissue extensibility dysfunction (TED) and joint mobility dysfunction (JMD). From here, we can break it down even further in each subset.

Here are some potential TEDs

  • Active/passive muscle insufficiency
  • Limited neurodynamics (they said neural tension; come on Gray!)
  • Fascial tension
  • Muscle shortening
  • Hypertrophy
  • Trigger points
  • Scarring/fibrosis

And here are some potential JMDs

  • Osteoarthritis/arthrosis
  • Single-joint muscle spasm/guarding
  • Fusion
  • Subluxation
  • Adhesive capsulitis
  • Dislocation
This is the only TED that I deal with.

It could be a Stability Problem

These issues are also known as stability or motor control dysfunction (SMCD). Most conventional therapies would treat these complaints by strengthening the stabilizers, but this is problematic. When something works reflexively, how can we train something volitionally and expect changes? To train these muscles we must focus on proprioceptive and timing-based training.

There are several examples of SMCD problems.

  • Motor control dysfunction.
  • High threshold strategy.
  • Local muscle dysfunction/asymmetry.
  • Mechanical breathing dysfunction.
  • Prime mover or global muscle compensation behavior or asymmetry.
  • Poor static stability, alignment, postural control, asymmetry, and structural integrity.
  • Poor dynamic stability, alignment, postural control, asymmetry, and structural integrity.

Relatedness

Mobility and stability can influence one another. If I were to lose mobility at one segment, motor control can be distorted at nearby segments. Conversely, if I lack motor control, abnormal mobility may occur to compensate. However, the progression remains the same—restore mobility, then improve stability.

Honorable Mentions

Though the following testing protocols did not make the SFMA, they should still be tested per Gray:

  • Neurological exam.
  • Muscle strength.
  • Joint stability/mobility
  • Tissue tension testing (so…painful…to…write)
  • Identify neuromuscular trigger points
  • Impairment measurements

SFMA Rules

Here are some basic rules to implement when utilizing the SFMA that I picked up from there course.

1)      No warm up.

2)      If it looks like a dog and smells like a dog – it’s a dog.

3)      Be picky. Not bad = not good.

4)      No shoes.

5)      Monkey see, monkey do…perform the movement.

Sometimes it can go too far though...story of my life.
Sometimes it can go too far though…story of my life.

The SFMA generally also follows these basic ideas of testing, which can help assist you through the breakouts

  • Bilateral vs. unilateral
  • Loaded vs. unloaded
  • Active vs. passive

You will notice that the breakouts are a little different than what is presented in the book. These are the official breakouts from the current (6/2013) SFMA course.

Active Cervical Flexion

1. Start with supine cervical flexion (looking for chin to chest)

  •  FN: SMCD
  • DN, DP, FP: Move on

2. Passive supine cervical flexion (chin to chest)

  • FN: SMCD
  • DN, DP, FP: Move on

3. Active supine OA flexion test (20 degrees)

  • FN Bilaterally: If passive cervical flexion was DP/DN – TED/JMD; if FP – potential SMCD.
  • DN: OA flexion JMD/TED &/or possible cervical flexion JMD/TED
  • DP/FP: Stop; treat with modalities over exercise.

Active Cervical Extension

1. Supine cervical extension

  • FN: SMCD
  • DN: JMD/TED
  • FP/DP: Stop; treat with modalities over exercise.

Cevical Rotation-Lateral Bend

1. Active supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

2. Passive supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

3. C1-C2 cervical rotation test

  • FN: If test 2 was DP/DN, treat as lower cervical JMD/TED; if FP, could be an SMCD.
  • DN: C1-C2 JMD/TED &/or possible lower cervical spine JMD/TED.
  • DP/FP: Stop.

Upper Extremity Pattern 1 (MRE)

1. Active prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown below.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

2. Passive prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown above.
  • DN/DP/FP: Move on.

3. Active prone shoulder 90/90 IR test (60 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder extension (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder IR (60 degrees &/or total arc of 150 deg)

  • FN: Shoulder IR SMCD; note this and move on.
  • DN: Shoulder IR JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder extension test (50 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder extension (50 degrees)

  • FN: Shoulder extension SMCD; note this and move on.
  • DN: Shoulder extension JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern one JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Upper Extremity Pattern 2 (LRF)

1. Active prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

2. Passive prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

3. Active prone shoulder 90/90 ER test (90 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder flexion/abduction (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder ER (90 degrees &/or total arc of 150 deg)

  • FN: Shoulder ER SMCD; note this and move on.
  • DN: Shoulder ER JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder flexion/abduction test (170 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder flexion/abduction test (170 degrees)

  • FN: Flexion/abduction SMCD; note this and move on.
  • DN: Flexion/abduction JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern two JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Multi-Segmental Flexion (MSF)

1. Single leg forward bend (touch toes)

  • FN/DN/DP/FP: Move on.

2. Long sitting (touch toes; 80 degree sacral angle).

  • FN: Move to rolling breakout.
  • DN/DP/FP: Move on.

3. Active SLR (70 degrees)

  • FN: Move on.
  • DN/FP/DP: Move on to passive SLR (#5)

4. Prone rocking (full rock back position)

  • FN: Move on to rolling breakouts.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Spinal flexion JMD/TED. Treat this first then reassess. Breakout can be stopped for now.

5. Passive SLR (80 degrees)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

7. Supine Knee to chest (knees touch chest)

  • FN: Posterior chain TED &/or active hip flexion SMCD.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Hip JMD &/or posterior chain TED.

Multi-Segmental Extension (MSE)

SPINE BREAKOUT

1. Backward Bend (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: Stop the breakout; go to upper body extension flowchart.
  • DN/FP/DP: move on.

2. Single leg backward bend  (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: SMCD or anterior core TED; go to upper body extension flowchart.
  • DN/FP/DP: Move on.

3. Press up

  • FN: May have SMCD; but check other breakouts. Stop the spinal breakout.
  • DN/FP/DP: Move on.

4. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Move on to Prone on elbow unilateral extension (#6)
  • DN/FP/DP: Move on.

5. Lumbar locked (IR) passive rotation/extension (50 degrees)

  • FN: Thorax extension SMCD; check upper/lower extension breakouts.
  • DN: JMD/TED; check upper/lower extension flowcharts.
  • DP/FP: Stop and treat pain.

6. Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

7.  Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: TED/JMD.
  • DP/FP: Stop and treat pain.

LOWER BODY BREAKOUT

1. FABER Test (2 fist distance)

  • FN: Move on.
  • DN/DP/FP: Hip/SI JMD/TED or SMCD (only if stabilized FABER changed mobility). Note this and move on.

2. Modified Thomas Test (flat to mat)

  • FN: Move on.
  • FN w/ knee straight: Lower anterior chain TED. Treat.
  • FN w/ hip abducted: Lower lateral chain TED. Treat.
  • FN w/ hip abducted & knee straight: Lower anterolateral chain TED. Treat.
  • DN: Hip extension JMD/TED &/or core SMCD. Treat.
  • DP/FP: Stop and treat pain.

3. Prone active hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

4. Prone passive hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN: Hip extension JMD/TED.
  • DP/FP: Stop and treat pain.

UPPER BODY BREAKOUT

1. Unilateral shoulder backward bend

  • FN: Double check press up on spine extension breakout as well as cervical spine.
  • DN/FP/DP: Move on.

2. Supine lat stretch hips flexed (arms to table)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

3. Supine lat stretch hips extended (arms to table)

  • FN: Lat/posterior chain TED &/or possible hip extension dysfunction; check lower body flowchart.
  • Flexion improves but not full: Same as above. Note these changes and move on.
  • DN/DP/FP: Move on.

4. Lumbar locked (ER) Unilateral extension (50 degrees)

  • FN: Scapular/humero-glenoid SMCD.
  • DN/DP/FP: Move on.

5. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Shoulder girdle JMD/TED.
  • DN/DP/FP: Move on.

6. Lumbar locked (IR) passive rotation/extension

  • FN: Thoracic SMCD.
  • DN: Thoracic JMD/TED.
  • FP/DP: Treat the pain.

Multi-Segmental Rotation (MSR)

SPINE BREAKOUT

1. Seated rotation (50 degrees)

  • FN: Go to hip rotation breakout
  • DN/DP/FP: Move on.

2. Lumbar locked (ER) unilateral extension (50 degrees)

  • FN: Move on to prone on elbows unilateral rotation (#5)
  • DN/DP/FP: Move on.
  • DN/DP/FP switches sides: Move on to to rolling breakouts.

3. Lumbar locked (IR) active rotation (50 degrees)

  • FN: Shoulder girdle TED/JMD.
  • DN/DP/FP: Move on.

4. Lumbar locked (IR) passive rotation (50 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Thoracic JMD/TED.
  • FP/DP: Stop and treat pain.

5. Prone on elbows unilateral rotation (30 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

6. Passive prone on elbows unilateral rotation (30 degrees)

  • FN: Lumbar SMCD.
  • DN: Lumbar TED/JMD.
  • DP/FP: Stop and treat pain.

HIP ROTATION BREAKOUT

1. Seated active hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on to prone active hip ER/IR (#3)
  • DN/FP/DP: Move on.

2. Seated passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on.
  • DP/FP: Stop and treat pain.
  • DN: Hip JMD/TED. Make note of this and move on.

3. Prone active hip ER/IR  (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN/FP/DP: Move on.

4. Prone passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN: Hip JMD/TED. Go to tibial roation and lower body extension breakouts
  • DP/FP: Stop and treat pain.

TIBIAL ROTATION BREAKOUT

1. Seated active Tibial ER/IR

  • FN: Double check lower body extension flowchart.
  • DN/DP/FP: Move on.

2. Seated Passive Tibial ER/IR

  • FN: Tibial rotation SMCD.
  • DN: Tibial rotation JMD/TED.
  • DP/FP: Stop and treat pain.

Single Leg Stance

VESTIBULAR AND CORE BREAKOUT

1. CTSIB (Static)

  • FN: Move on.
  • DN/DP/FP: Potential static vestibular dysfunction. Refer out/treat. Can move on to Half-kneeling narrow base (#3)

2. CTSIB (Dynamic)

  • FN: Move on.
  • DN/DP/FP: Potential Dynamic vestibular dysfunction. Refer out/treat. Move on in breakout.

3. Half-Kneeling narrow base

  • FN: Go to ankle breakout.
  • DN/DP/FP: Move on.

4. Rolling breakouts

  • FN: Move on.
  • DN: SMCD. Go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.

5. Quadruped Diagonals

  • FN: SMCD; go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.
  • DN: SMCD or shoulder flexion/hip extension are DN; go to ankle flowchart.

ANKLE BREAKOUTS

1. Heel walks

  • FN: Move on to toe walks (#3)
  • DN/DP/FP: Move on.

2. Prone passive dorsiflexion (20-30 degrees)

  • FN: Dorsiflexion SMCD; note and move on.
  • DN: Dorsiflexion TED/JMD; note and move on.
  • DP/FP: Treat pain and move on.

3. Toe walks

  • FN: Move on to seated ankle inversion/eversion (#5)
  • DN/DP/FP: Move on.

4. Prone passive plantarflexion (30-40 degrees)

  • FN: Plantarflexion SMCD; note and move on.
  • DN: Plantarflexion JMD/TED; note and move on.
  • DP/FP: Treat pain and  move on.

5. Seated active ankle inversion/eversion

  • FN: If no above impairments, then there is a proprioceptive deficits. Otherwise treat above impairments.
  • DN/DP/FP: Move on.

6. Seated passive ankle inversion/eversion

  • FN: SMCD.
  • DN: JMD/TED.

Overhead Deep Squat

1. Interlocked fingers behind neck deep squat

  • FN: Recheck extension breakouts
  • DN/DP/FP: Move on.

2. Assisted squat

  • FN: Core SMCD. Make sure MSE is clear.
  • DN/DP/FP: Move on.

3. Half-kneeling dorsiflexion (20-30 degrees)

  • FN/FP/DP: Move on.
  • DN: TED/JMD; check MSE/SLS breakouts, note and move on.

4. Supine knees to chest holding shins

  • FN: If dorsiflexion normal, then SMCD; If dorsiflexion was DN, then knees/hips/core are normal; if dorsiflexion was DP/FP, then treat dorsiflexion. Chec MSE.
  • DN/DP/FP: Move on.

5. Supine knees to chest holding thighs

  • FN: Knee JMD/TED. Check MSE.
  • FP/DP: Stop and treat pain.
  • DN: Hip JMD/TED. Check MSF for hips an MSE.

Segmental Rolling

1. Prone to supine upper body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

2. Prone to supine lower body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

3. Supine to prone rolling with upper body

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

4. Supine to prone rolling with lower body

  • FN: Likely a weight-bearing or higher level SMCD if all patterns were FN; return to the chart that tested rolling.
  • DN: Likely a fundamental SMCD in any of the above patterns.
  • DP/FP: Go back to chart that tested rolling.

Conclusions

Phew, that 2000+ words later and we have a lot of stuff. Digest this information, and give these breakouts a try.