Return to Play after a 5th Metatarsal Fracture – Case Report

I was recently featured on my buddy Scott Gray’s podcast,  a great clinician in the Florida area who I have a lot of respect for. Before we dive into the podcast, let me tell you a bit about why I like this guy so much. It’s not just because he is a part of the IFAST family. I’ve been going back to the basics as of late, reviewing concepts such as tissue pathology, anatomy, surgical procedures, and the like. If there is anyone who has the fundamentals down savagely well, it is Scott Gray. He put out an Ebook called “The Physical Examination Blueprint”, which you can download by subscribing to his newsletter. Here he details all the essentials on screening your patients. To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care. Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook. In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination. Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out. Rehabbing a 5th Metatarsal Fracture to High Level Basketball In

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How to Treat Pain with Sitting – A Case Study

Case studies are much more valuable than many give credit for. It is this type of study that can often lead to sweeping changes in how further research is conducted, often create paradigm shifts in their own right. After all, there was only one Patient H.M. One thing that I wish I saw more in case studies was the clinician’s thought process. Why did they elect to do this treatment over that, what were they thinking when they saw this? How do they tick? I was fortunate enough to have an online client of mine suggest to that I make her a case study, and it was a very rewarding experience on both fronts. My hope is that you can see how a clinician thinks first-hand, and see the challenges a clinician faces… When you can’t work with your hands.

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Master Sagittal Plane, Coaching Progressions, Detaching, & TFL Inhibition – Movement Debrief Episode 5

Did you miss Movement Debrief live yesterday? Though much more fun live, I have a video of what we discussed below. This debrief was quite fun, as we had an impromptu viewer q&a. Thank you Alan Luzietti for the awesome questions! If you follow along live on Facebook or Youtube, I will do my best to answer any questions you ask. Yesterday we discussed the following topics: Why you should emphasize sagittal plane activities longer than you think How to coach exercises to maximize client learning and compliance Why detaching from your client encounters makes you a better clinician Viewer Q&A – “centering from the chaos” & TFL Inhibition Lastly, if you want the acute:chronic workload calculator I spoke about, click here. Without further ado: Master Sagittal Plane Coaching Progressions Detaching Refocusing TFL Inhibition

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Course Notes: Postural Respiration

Another Course in the Books As an official Ron Hruska groupie, the tour continued to the Big Apple to learn a little Postural Respiration. And in NYC, everything is bigger. The biggest city I had prior been exposed to was Chicago. The cities feel similar, only NYC has twice as many people on the same size streets. I felt like this course was one of my less understood areas in the system, as Respiration was my first live PRI course. Taking this class the second time around really cleaned up a lot of things for me, and Ron was on point as always. So let’s dive into the cranium…I mean pelvis….I mean thorax. Oh sorry, wrong course. Laying the Foundation  The three foundational courses aim to inhibit tone, twist, torque, and tension in the human system by various methods. In Myokinematic Restoration, mastering the frontal plane with both legs inhibits the system. In Pelvis Restoration, active leg adduction inhibits the system. In Postural Respiration, trunk rotation inhibits the system. When these powers combine, the goal is to simultaneously maximize phases of gait and respiration. This development allows for total-body freedom to move, breathe, live, and create amidst our incessant desire to run on our built-in right stance autopilot. There is nothing wrong with right stance, but it becomes wrong when it is all you know. “There is nothing wrong with half the gait cycle until it becomes the full gait cycle.” ~Ron Hruska. Make a Memory – The Zone of

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The Post Wonderful Time of the Year: Top Posts of 2013

The Best…Around Time is fun when you are having flies. It seems like just yesterday that I started up this blog, and I am excited and humbled by the response I have gotten. Hearing praise from my audience keeps me hungry to learn and educate more. I am always curious to see which pages you enjoyed, and which were not so enjoyable; as it helps me tailor my writing a little bit more. And I’d have to say, I have a bunch of readers who like the nervous system 🙂 I am not sure what the next year will bring in terms of content, as I think the first year anyone starts a blog it is more about the writing process and finding your voice. Regardless of what is written, I hope to spread information that I think will benefit those of you who read my stuff. The more I can help you, the better off all our patients and clients will be. So without further ado, let’s review which posts were the top dogs for this year (and some of my favorite pics of course). 10.  Lessons from a Student: The Interaction This was probably one of my favorite posts to write this year, as I think this area is sooooooo under-discussed. Expect to be hearing more on patient interaction from me in the future. 9) Clinical Neurodynamics Chapter 1: General Neurodynamics Shacklock was an excellent technical read. In this post we lay out some nervous system basics, and

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Treatment of Shredded Cheese of the Hip: A Case Report and Rant

A Long Day I officially eclipsed my longest work day ever. Started seeing patients at 7:30 am and finished training my last client at 10 pm. So exhausting, but the bright side is my new schedule prevents me from waking up that early ever again! Hooray for sleeping in…sort of. I figured while I had some time in the airport before my next course, I would write a little something about a patient I evaluated right before my lunch break on this long day. Needless to say, I didn’t get much of a break. Her Story This lovely lady is a nurse with a history of chronic left hip pain. She has predominately been treated surgically via labral repairs and muscle reattachment. Her most recent symptom exacerbation involved putting on her socks about a month prior. She heard a pop as she bent over and could not walk. She initially saw two ortho docs. One specializes in total hips, the other in scopes.  Since she was not appropriate for a total hip, this doc referred this lady to his associate. After some imaging was done, she found out that she could not have surgery because she had several muscle tears. Or in the language that the doctor used: “I have nothing to work with. Your hip is shredded up like cheese.” This lady knew no other treatment but surgery, and hearing this news was devastating for her. Thoughts of a brutish life and an end to her fulfilling job flooded

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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. 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.

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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. 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 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)     

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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.

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

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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. 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.   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

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