Sports Medicine Services Select Medical Outpatient Division Family of Brands Finding the Weak Link-...

Sports Medicine ServicesSelect Medical Outpatient Division Family of Brands

Finding the Weak Link- Movement Screening

David A. Hoyle, DPT, MA, OCS, MTC, CEASNational Director of WorkStrategies

2 |SPT SMS-2015 Finding the Weak Link (Movement Screening)-Hoyle

Learning Objectives

Finding the Weak Link- Movement Screening Learners will understand the appropriate use of full body

versus regional screening. Learners will be familiar with the common altered

movement patterns associated with hip dysfunction.

3 | SPT SMS-2015 Finding the Weak Link (Movement Screening)-Hoyle

Hip- Shoulder Analogies

Shoulder Rotator Cuff Deficiency leads to arthritis Tendinopathy precedes

bursal changes Tendinopathy is usually

degenerative Labral tears usually

degenerative Significant changes in

asymptomatic populations increase with age

Hip Rotator Cuff Deficiency leads to arthritis Tendinopathy precedes

bursal changes Tendinopathy is usually

degenerative Labral tears usually

degenerative Significant changes in

asymptomatic populations increase with age


The role of the rotator cuff of the Hip


Introduction to Movement Dysfunction


Who has influenced study of movement dysfunction

• Fredrick Matthias Alexander– Australian Born (1869) Actor– “Man’s Supreme Inheritance”- 1945

• Joseph Pilates– German born physical education instructor

1883-1967– Your Health: A Corrective System of

Exercising That Revolutionizes the Entire Field of Physical Education in 1934, and Return to Life Through Contrology in 1945.

• John V. Basmajian– 1921-2008– Muscles Alive- Their Functions Revealed by

Electromyography- 1962

• Vladimir Janda– Czechoslovakian Neurologist 1923-2002– First Book published on muscle function

and testing in 1949– 16 books and 100’s of articles

• Florence Kendall– American Physical Therapist 1911-

2006– Muscles: Testing and Function With

Posture and Pain

• Shirley Sharman– American Physical Therapist – Diagnosis and Treatment of

Movement Impairment Syndromes

• Gary Gray– American Physical Therapist– “Lower Extremity Functional Profile”-

1995

• Gray Cook– American Physical Therapist– Movement- Functional Movement

Systems Functional Movement Screen-


Development and Motor Control• We are all born with movement synergies

(reflexive movement patterns)– ASTNR– STNR– Grasp Reflex– Stepping Refex– Startle– Parachute

• We overcome synergies by programming new movement patterns. Motor learning/motor control.

• Movement screening assesses the motor control that inhibits reflexive movement.

• In times of stress and maximal effort we tend towards reflexive patterns.

• As a result of injury or illness motor control can become inhibited resulting in a return to reflexive patterning.


Information Technology

• Hardware– Strength– Flexibility

• Software– Motor Control

• Motor Learning• Motor Unit recruitment


Screening

Performance Based

Function

Strength

Movement Pattern

Flexibility

Treatment Based

Function

MovementPattern

Strength Flexibility


Janda Muscle Imbalances

Tonic (Prone to Tightness)• Gastroc-Soleus• Hip Adductors• Hamstrings• Rectus Femoris• Iliopsoas• Tensor Fascia Lata• Piriformis• Erector-Spinae (thoraco-lumbar)• Suboccipital muscles• Quadratus Lumborum• Pectoralis Major & Minor• Latissumus Dorsi• Upper Trapezius• Levator Scapulae• Scalenes• Sternocleidomastoid

Phasic (Prone to Weakness)• Peroneals• Tibialis Anterior• Vastus Medialis• Vastus Lateralis• Gluteus Maximus• Gluteus Medius• Transversus Abdominus• Multifidus• Rectus Abominus• Abdominal Obliques• Serratus Anterior• Rhomboids Lower & Middle• Trapezius• Deep neck flexors

http://www.muscleimbalancesyndromes.com/what-is-muscle-imbalance/



Janda’s Lower Crossed Syndrome• Lower-Crossed Syndrome (LCS) is also referred to as distal or

pelvic crossed syndrome. • Tightness of the thoracolumbar extensors on the dorsal side

crosses with tightness of the iliopsoas and rectus femoris. • Weakness of the deep abdominal muscles ventrally crosses

with weakness of the gluteus maximus and medius. • This pattern of imbalance creates joint dysfunction,

particularly at the L4-L5 and L5-S1 segments, SI joint, and hip joint.

• Specific postural changes seen in LCS include anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension. – If the lordosis is deep and short, then imbalance is predominantly

in the pelvic muscles; – If the lordosis is shallow and extends into the thoracic area, then

imbalance predominates in the trunk muscles (Janda 1987).

http://www.muscleimbalancesyndromes.com/janda-syndromes/lower-crossed-syndrome/

http://www.muscleimbalancesyndromes.com/janda-syndromes/lower-crossed-syndrome/


Janda Muscle Imbalance

• With postural/muscle imbalance joints are not in an optimal position.

• Muscles also are not in an optimal position.

• Example– GH instability– PFPS



Janda’s Recommended Eval

• History• Postural Assessment• Balance Assessment• Gait Assessment• Movement Pattern Assessment• Manual Muscle Testing• Muscle Length Assessment• Soft Tissue Assessment


Posture, Balance, and Gait


Postural Imbalance

• Opposing muscle groups affect joint position in an adverse way.– Tightness (hypertonicity) of one muscle(s) and

abnormal lengthening (hypotonicity) of it’s reciprical muscle(s).

– May cause stress about a joint.• (Iliac tightness and glut med/max inhibition causing SI jt

stress)

– May cause problems up or down the kinetic chain.• Glut med/min inhibition and TFL hypertonicity causing

patellofemoral dysfunction.


Buttock Region

• Look at:– Size and Symmetry – Shape

• Rounded• Not Hanging or Flattened

– sign of inhibition.

• Related to – SI jt dysfunction on the

ipsilateral side– Ipsilateral hypertonicity

of:• Iliacus• Piriformis• Recuts abdominis

– Contralateral glut med inhibition/weakness


Thigh

• Hamstrings– Hypertrophy with glut

max inhibition and ipsilateral thoracolumbar paraspinal hypertonicity.

• Adductors– Prox 1/3

• Normal shallow S-Curve• Deep S-Curve or Adductor

notch indicates hypertonicity of the one joint adductors (Pectineus)

• Associate with – LLD, lateral shift and hip

jt dysfunction.– Hip Abductor Weakness


Spinal Extensors

• Hypertrophy/Hypertonicity– Weak or inhibited glteals– Poor deep stabilizers– Hyper lordosis

• Horizontal Groove– Segmental

hypermobility.


Pelvic Tilt/Abdominal Wall

• ASIS height– Pelvic Tilt– Anterior• Short Leg

– Tight/hypertonic Adductors

• ITB tightness• Glut Med weakness

• Abdominal Wall– Upper and Lower

Quadrants– Left vs. Right

• Lateral Rectus Groove– Hypertonic Obliques– Weak Rectus

• Lateral Bulge of abdominals– TA hypotonicity

• Elevated Rib Cage– Faulty Breathing Pattern.


Quad and ITB

• Tightness– Associated with Ant tilt

of ilium.– Identified through lateral

groove of the thigh.– Associated with weak

Glut Med and hip external rotators.

– Contribute to a superior lateral shift of the patella.


High Activation/Hypertonic Muscle

• Higher resting muscle tone• Lower irritability threshold• Inhibits the muscles reciprical muscle.• Relaxation of a tight/hypertonic muscle can

lead to immediate strength gains of it’s reciprical muscle.

• Continuous hypertonicity of one muscle can lead to muscular/postural imbalance.


Evaluation of Movement Patterns


Traditional Testing

Strength has traditional been tested:

• Isometrically• Maximum “Make” or “Break

Testing”• Attempt to “isolate” muscle

function.• Primary emphasis on force

production – Grade (0-5 or zero-normal)

Functional Movements are:

• Occasionally Isometric but generally dynamic.

• Rarely require maximal force.• Never occur in isolation.• Quality and control are often

more important than maximal output.

• Sequencing of movement and muscle activation determine quality. (0nset and timing)


Key Observations of Evaluation of Movement Patterns

1. Firing order of muscles2. Compensatory patterns of movement3. Initiation of movement as an indication of

“motor control”.4. Comparison of left and right.5. Muscle trembling is an indication of a lack of

control or weakness or fatigue.


Guidelines for Testing

• Be able to visualize parts of the body being tested.

• Use minimal verbal cues as not to influence movement patterns but rather to reveal “preferred patterns” of movement.

• Avoid tactile cueing.• Perform multiple trials in a slow enough

manner to reveal control and consistency (3-6 trials).


Recommended Movement Patterns and Strength Assessments

Janda’s Six Movements Patterns

• Hip Extension• Hip Abduction• Curl-up• Cervical Flexion• Push-up• Shoulder Abduction


Janda’s Six Movement Patterns


Test 1Hip Extension Movement Pattern Test Purpose- Observe the preferred

movement recruitment pattern of the hamstrings, gluteus maximus, spinal extensors, and shoulder musculature.

Test- Patient lies prone with arms at side, head neutral, and feet over end of the table in neutral hip rotation. Patient is asked to slowly lift their leg towards the ceiling.

Preferred Pattern- hamstrings, gluteus meximus followed by contralateral erector spinae and last ipsilateral eractor spinae.


Hip Extension Movement Pattern Test

Typical Abnormal Compensations Over activation of the hamstrings and

erector spinae and delayed or absent contraction of the gluteus maximus

Worse substitution is when the thoracolumbar extensors or even the shoulder muscles initiate the movement with delayed or absent gluteus maximus contribution.

Inability to maintain knee extension is a sign of hamstring dominance.

Hyperlordosis and anterior pelvic tilting. Other Considerations

Hypertrophy of the hamstrings and thoracolumbar extensors.

Atrophy of the gluteus maximus.


Test 2Hip Abduction Movement Pattern Test

Purpose-provides direct information about the quality of the lateral muscular pelvic brace and indirect information about the stabilization of the pelvis in the frontal plane.

Test- Pt is sidelying with bottom leg flexed and top leg in a neutral position in line with the trunk. Pt lifts leg toward the ceiling.

Preferred Pattern- Hip abduction of 20 degrees without any hip flexion or internal or external rotationwith a stable trunk and pelvis.


Hip Abduction Movement Pattern Test Typical Abnormal Compensations

Tensor mechanism substitution- hip abduction is combine with flexion due to the combined action of the Tensor as a hip flexor and abductor.

Quadratus Lumborum substitution- Hip abduction is initialted by contraction of the QL before 20 degrees of hip abduction resulting in a lateral pelvic tilt or hip hike. Role of QL changes from pelvic stabilizer to primary mover

Other Considerations Tightness of ITB Atrophy of Gluteals Poor results of SLB test.


Test 3Trunk Curl-up Movement Pattern Test Purpose- Tests the interplay

between the iliopsoas and the abdominals.

Test- Patient is in supine hook-lying. The patient rounds the upper trunk until the inferior angle of the scapula are off the supporting surface.

Preferred Pattern- The abdominal muscles contract and shorten falexing the spine and posteriorly tilting the pelvis.


Trunk Curl-up Movement Pattern Test

Typical Abnormal Compensations Performed preferentially with hip flexion with maintenance of the lordosis and anterior

pelvic tilting. Minimal flexion of the upper trunk is noted. Other Considerations

Kendall advocated using two tests one for the lower and one the upper abdominals. • Upper abdominals- Upper rectus and internal obliques with curl-up.• Lower abdominals- external obliques and lower rectus abdominals with double leg

lowering.


Single Leg Stance Test

Purpose- Test for overall compensatory movements. Test- Patient is standing on one foot with the other

foot by the side but not touching the stance leg. Preferred Pattern- The abdominal muscles contract

and shorten flexing the spine and posteriorly tilting the pelvis, the shoulders and hips remain over the knees.

34


Single Leg Stance Test

Typical Abnormal Compensations Stance hip adducts, trunk moves outside the pelvis or opposite hip drops.

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