Click here for this edition’s Table of Contents

Upper Extremity

Shoulder

1) Too many people advance too quickly with pull up progressions.  Too few spend enough time mastering the hang.  Dan Pope writes a nice concise post with 3 basic hang exercises for the shoulders.  And he backs it up with some solid biomechanical logic.

2) Eric Cressey gives a nice 3 minute breakdown of proper cueing for the scaption exercise.  I think a tactile cue for posterior tilting the scapula is one of the best rehab interventions out there.  

3) Heart disease and rotator cuff symptoms are linked in a new study. Maybe it has to do with circulation? Or maybe the rotator cuff symptoms are just the output of a lifestyle dysfunction?

4) Erson shares a nice example of a motor control shoulder dysfunction.  Before you jump to conclusions, assess their movement impairment with different patterns (i.e. posture changes, sequencing, distal positioning, centration, etc.). Continue reading “2017 Hits : Vol. 1 : Clinical Upper Extremity”

Table of Contents

Miscellaneous

• “The patient’s nervous system can sense both a lack of practitioner confidence, as well as a lack of control.” -Dr. Andrei Spina (via Shante)

1. “Evidence has shown that performance and variability have an inverse curve relation (too little variability, performance suffers and with too much variability, performance also suffers). Current evidence shows that an optimum balance of variability seems to be the key to maximize performance of an individual and achieving this balance is key in recovery.” –Adriaan Louw

2. Assessing gait is a skill we should always continue to develop.  Even on the blink level it provides useful information.  “Walk speed = “vital sign”. Connects to fall risk, dependency, & hospital. Community design & PA programs matter”

3. This might explain why marathon runners often stumble into our clinic a month before their race.  “Overtrained athletes have abnormal inflammatory and anabolic responses to exercise, indicating that their body is not responding to exercise the way that it should.” Continue reading “2017 Hits : Vol. 1 : Clinical”

Click here for this edition’s Table of Contents

1) Everyone is different (joint, osseous structures, myofascial structures, developmental history, etc.).  So it’s easy to understand why “there are no systematic advantages of one foot strike pattern over another when it comes to running economy”.  #DynamicSystem

2) “Proximal joints act as motors and distal joints as adjustable dampers & springs” -Derek Griffin

3) Are we overlooking the blood flow component of tendinopathies?  “Tendon blood flow tends to decrease with age and compression, which often results from increased mechanical load. This decreased vascularization, at least theoretically, can contribute to the probability of tissue damage as tissue compliance and flexibility will be compromised (LER). Oxygen consumption of ligaments and tendons is 7.5% lower than skeletal muscle, which may contribute to longer healing times (2,3).”

4) The Gait Guy’s breakdown of a case study is always worth the time.  In this one they find the driver in the spine.  In this one they breakdown the biomechanics of 4 different runners.

5) What do we use to regulate ourselves?  Thought or awareness?  Seth teaches us how using thought can lead to chronic pain.  “But we can’t think our way out of a physical “problem”. The autobiographical self (story we tell ourselves) and the embodied self (our experience in the present moment) are separate neural networks.“ Continue reading “Fall Hits 2016: Clinical”

The Hits

This is just a collection of some of my favorite articles from the past month.  I bolded the numbers of the articles that I found most remarkable.  Of course, this is just my bias.  I think all the articles here have value.  I just realize that some readers may be looking for something more brief.

Also, I want to encourage any reader to share their favorite articles, books, or podcasts of the month in the comments below.  There’s only so much information that I can go through in a month.  I know there’s a ton of great stuff out there that isn’t on my radar.  It will not only help introduce me to new perspectives, but it will provide other readers this opportunity as well.

Epistemological Arrogance

1) “Epistemic Arrogance: measure the difference between what someone actually knows and how much he thinks he knows.  An excess will imply arrogance, a deficit in humility.  An epistemocrat is someone of epistemic humility, who holds his own knowledge in greatest suspicion.” -Nassim Nicholas Taleb

2) Complex does not mean complicated – “Complicated systems are usually built from design, and include cars, computers and buildings. Complex systems were not built but evolved, and include living things, ecologies and economic systems.”  Great piece by Todd Hargrove

3) Sometimes in the buffet style of information digestion that is the internet, there will be “gurus” out there who will claim “all health problems can be fixed with these “3 things you’re not doing”.  Or worse, they’ll take a “if your not doing ___ you’re missing the boat” approach.  

Those of us in clinical practice know it’s not this simple.  The problem is that ranting about a simple, secret solution to a complex problem gives people either false hope or it makes them feel bad as a clinician that they don’t know about the “secret answer”.  And I don’t think anyone in healthcare should be making clinicians feel bad or teaching through narcissistic ways.

My intention with this article is simply to put something out as a clinician that says it’s not simple.  There are no easy answers when it comes to treating the human species.  Each patient will be complex.  It’s a very intricate system with many parts.  It doesn’t work out all the time.  Some people don’t get better.  Sometimes they need a different approach or control parameter. Continue reading “April Hits 2016 : Epistemological Arrogance, State of Healthcare, Cognitive Bias, Arm Ergometer, Insulin/Glycemic Index, Nutrient Timing, Reform the World”

The Hits

This is just a collection of some of my favorite articles from the past month.  The bolded the numbers of the articles that I found most remarkable.  Of course, this is just my bias.  I think all the articles here have value.  However, I realize that some readers may be looking for something more brief.

Also, I want to encourage any reader to share their favorite articles, books, or podcasts of the month in the comments below.  There’s only so much information that I can go through in a month.  I know there’s a ton of great stuff out there that isn’t on my radar.  It will not only help introduce me to new perspectives, but it will provide other readers this opportunity as well.

Clinical

• “The job of a skilled therapist is to detect where the system is open to change, to provide the appropriate new input to destabilize the old pattern, and to facilitate the person’s seeking of new solutions” -Esther Thelen (via Seth Oberst)

1) One of the better ACL articles I’ve read in a while.  Read this post – especially the part on terminal knee flexion.  Great explanations and quick video demonstrations.  Very useful for the clinic tomorrow.  Here’s one gem from the article series – “The ability of the hamstring to pull the heel to butt is a necessary pre-requisite for dorsiflexion.”

2) The Longus Capitus attaches to the foramen magnum?  How did I overlook that?

3) Sick of patients asking for you to put their pelvis/SIJ back in place?  Try these 3 steps to change their thought virus.

Challenge a Concept

Provide an Alternative Concept

Provide Evidence for a New Concept Continue reading “February Hits (2016)”

News

Unfortunately, my time in NYC is coming to an end. I’ve spent over 8 years here and I’ve enjoyed the buzz, the people, the music, and the late night slices . However, I’m ready for a lower cost of living, a little less concrete, a little more nature, and a slower pace. So I’m moving to Asheville, North Carolina in January.

I wrote this article on 5 things I’ve learned from my mentorship at Dynamic Sports Physical Therapy.  I feel that one thing missing from the movement social media world is a discussion on the things that happen “behind the scenes” that make the difference between a good clinician and a great one.  While evidence, trendy semantics, cool neuro language, the latest performance enhancement, and arguments over what someone else is doing can be fun to read, they don’t always translate to improving clinical performance.  

If there’s anything I’ve learned from my 5 years as a PT in NYC, it’s that there’s a lot more to treating patients than what you can read in a journal, book, or blog.  Hopefully the article above will help explain this concept (yes, I know it’s a blog and I’ve just contradicted myself, but if you read it you’ll get the point). Continue reading “December Hits (2015)”

Clinical

• “Each time we introduce an assumption, we also introduce a new bias into the final solution” -Serge Gracovetsky

1) “Our neurological wiring has evolved into networks of patterned behavior designed to efficiently complete tasks mandated by the environment. Anatomy provides the frame to carry out these behaviors; the changes to structure are the tangible result of our habits. But once we open up some behavioral options for new habit formation, anatomical abnormalities don’t seem quite so concrete and problematic.”-Seth Oberst

2) Here’s the last category of the Coaching & Cueing series – Proprioceptive Cues

3) Want another tool for decreasing muscle tone? Try shortening the muscle and use some reciprocal inhibition.

The Gait Guys want you to decrease hypertonic muscles by stretching the antagonist?  Interesting article on reciprocal inhibition and muscle spindles.

Erson wants you to try shortening the muscle for 30-60 seconds before you go aggressive. Continue reading “October Hits (2015)”

Clinical

1) Read this one – the most detailed and thorough blog post on movement variability.  Great stuff from Dave Tilley.

“With movement practice, it is believed by some that coordinative variability decreases (better able to synergies motor patterns for general movement planning) while elemental variability increases (more strategies to generate real time adjustments or handle different conditions while still successfully completing the given task or skill).” Continue reading “August Hits (2015)”

Clinical

1) Sure, it’s a dynamic system and the nervous system has a huge influence.  But you can’t dissociate the physicality of our world from the human body.  Simple biomechanics can have a profound effect on your patient’s movement.  Here’s an example of how the first class lever works to Increase Glute Med Activity.

2) Don’t forget about the frontal plane aspect of the bunion deformity – “the degree of first metatarsal pronation is linearly related to the amount of medial deviation of the first metatarsal”

3) Kathy Dooley goes over the Obturator Externus – “When this muscle is locked long, it will contribute to hip compression. Since the muscle travels from the anterior outer pelvis posteriorly to the greater trochanter’s inner fossa, it works as a sling with obturator internus to keep that femur jammed into the acetabulum. “ Continue reading “June Hits (2015)”

Clinical

1) Lately, I’ve been interested in the connection between vision and the cervical spine.  Here’s two interesting articles I found this month.

“The direction of eye movements was horizontal when the sternocleidomastoidmuscle on one side of the neck and the splenius on the other side were activated, and downward when both splenii muscles were vibrated.”

“During neck rotation SCM and MF EMG was less when the eyes were maintained with a constant intra-orbit position that was opposite to the direction of rotation compared to trials in which the eyes were maintained in the same direction as the head movement.”

I put people in challenging developmental positions and have them use their vision to either increase motion or to dissociate their vision from their cervical spine (changing muscle activation patterns).

2) Still don’t think vision and the cervical spine are related?  Check out this research article on Continue reading “April Hits (2015)”

Clinical

1) I first learned about the relationship between the pelvis and hip ROM from Chris Johnson – you can instantly increase hip IR on the table by having the patient posterior pelvic tilt.  Then upon studying the concepts of SFMA, DNS, and PRI, I began to understand how the pelvis (as well as diaphragm/thorax/spine) influences the hips.  Now I understand that most hip impingement patients are really pelvis patients, not femur patients.  Mike Reinold wrote a concise and simple post on this concept here.

2) The Gait Guys go over the Continue reading “February Hits (2015)”

One of the best things about the information age is the amount of great content out there.  There are so many smart, generous individuals sharing information that can improve your skills and increase your quality of care.  These blogs are accessible, straight forward, and clinically applicable.  Here is my year end summary of some of my favorite stuff from this past year.

I came out of the stone-age and started using Google Analytics, which allowed me to see which of my articles were most popular, and which ones were only read by my girlfriend.  It wasn’t what I expected.

Keep in mind that these lists are in no particular order.  And also, this is just a small amount of the great articles out there.  It’s just the ones I enjoyed the most from a years worth of Hits.  If your favorites weren’t listed here, please feel free to leave a comment with your Top Reads. Continue reading “The Best of 2014”

– November Hits –

1) Stress is stress.  And there are many outputs that can occur in response to stress.  Too often we get stuck obsessing over just one of the outputs – PAIN.  As movement professionals we should focus on the output that we’re the most proficient at – MOVEMENT.  If you disagree, Zac Cupples will convince you in this phenomenal article.  “Assessing movement may be the simplest way to assess an individual’s stress status.”

2) Decreased hamstring strength increases ACL loading during sidestep cutting.

3) “If your tongue is on the roof of your mouth, you are connecting palate, pharynx, hyoid, jaw, and skull.  You are stabilizing your airway, so you can breathe, while anchoring your TMJ so it doesn’t deviate. Now, your body is more balanced and can better ambulate.” –Kathy Dooley Continue reading “November Hits (2014)”

– September Hits –

1) “Maintaining the short foot position can generate an arch and produce a monstrous feed-forward loop that maintains tension and stability throughout the system reinforcing to the brain that force can be safely produced. When the arch collapses the nervous system quickly downregulates in an attempt to avoid excess force thru the entire lower quarter while in an unstable position, yielding decreased output.” -Seth Oberst on foot positioning

2) Tendinopathy research goes pretty deep.  There has been a lot of progress over the years, but there is still a ton we don’t know.  Here are 2 posts to update your knowledge: 1) Peter Malliaras’s tendinopathy research post 2) 10 Clinical Pearls from ISTS 2014

3) Adriaan Louw and the ISPI just published a great study on pain education and how it can save the healthcare system a ton of money.  Here is a quick flow sheet to understand the process.  He also has a nice post on the important question, is it a tissue problem or a pain problem?  Adriaan’s Medbridge course is worth the subscription alone. Continue reading “September Hits (2014)”

– July Hits –

1) Have you heard about using isometrics to decrease pain associated with tendinopathies?  I was unfamiliar with this concept so I thought I’d send out a tweet to one of the leading experts, Jill Cook.  She gave some great advice that you can immediately use in your practice.  Jill’s guidelines: Continue reading “July Hits (2014)”

– May Hits –

1) Do you know about the anti-icing movement?  Many are advocating against cryotherapy post injury.  Some blindly jump on the bandwagon, some feel threatened and become defensive, and most of us just want to know why.  I’ve recently come across a couple great articles on the theory and evidence that explains why we should not ice injuries.  Even if you continue to ice, you should at least know what it really does (e.g. numbing effect, descending modulation, body temp regulation, placebo). Continue reading “May Hits (2014)”

– March –

1) Communication is just as important as the intervention.  Seth Oberst writes a great post on the difference between external and internal cues.  “It’s now being shown that athletes focusing on the results of the movement are producing more force, jumping higher, generating better performance in stressful situations, and increasing fluidity and multi-tasking.”

2) Evolution has shown us the importance of diet and the jaw on our growth as a species.  Here’s an interesting site on the jaw and it’s relation to the co-morbidities.

3) Want to learn how to pistol squat?  Click here. Continue reading “March Hits (2014)”

– January 2014 –

1) Pain and Central Sensitization is a growing topic in our field.  And for a good reason, pain is the #1 reason people come to see us.  Plus, chronic pain is becoming more and more common.  It’s great having so much information available to learn about these topics, however, there isn’t a lot of information on the specific clinical application.  I sought out pain expert, Adriaan Louw, to answer some clinical questions on pain science in this months post.

2) Charlie Weingroff goes over some theory on why ankle mobility is important for glute activation.  He also has a great article on how different body types tend to move and perform. Continue reading “January Hits (2014)”

-OverheadShoulder-Jerk-ALL-Hammy-Memory-FrontSquat-Speed-Mistakes-GMI-LowerTraps-Pain

1)  Down and back isn’t always right for our shoulder patients.  In fact, some people need the opposite.  This months article goes over how to assess and treat someone for overhead shoulder exercises.

2) This is awesome – slow-mo clean & jerk video with analysis from olympic lifting coach Jim Schmitz.

3) A new knee ligament?  Researchers have found an Anterolateral Ligament (ALL) in the knee.  Is this a profound advancement in anatomy?  Or is this just a carved out fascial thickening?

4) Great perspective on hamstring tightness.  Mike Reinold discusses how a tight hip flexor can pull the pelvis into an anterior pelvic tilt, thus decreasing the contralateral straight leg raise.  You could use the 90-90 active posterior chain test in hooklying to further Continue reading “November Hits”

Kettlebells – Runners – Habits – Longevity – Med Ball – Tightness – Goblet – Yoga – Elbow Grease

1) Kettlebells are becoming more and more common in fitness and rehab.  If you don’t use them, you should.  Here’s this months article on my expirience at the premier kettlebell workshop.

2) Erson goes over 5 things to look for in runners.  “Running is one sport that arguable needs more symmetry than most. I tell my runners it’s because you’re doing the same thing over and over for 1000s of steps until you stop!” Continue reading “September Hits”

– Fatigue – High Heels – Motor Learning – Mobility – Threshold – Strengthening – Parachute – Protocols – Armbar – Neuro –

1) I think exercise programs like crossfit and P-90X are great.  They get more people moving and interested in their health.  And in today’s society, decreasing the amount of sedentary people is very important.  However, when exercises are performed past failure a ton of things go wrong.  A new study showed there is a deterioration of lower extremity biomechanics when fatigue hits.  This causes a dangerous cascade of events: compensations, inefficient movement, substitution movement patterns, and an increased risk for injury.  While many of us already know this, many of our patients don’t.  Educate them. Continue reading “July Hits”

Language – Hip Hinge – Ankle/Hip – Weingroff – Boyle – Core Exercise – Knee Valgus

1) “An alteration of the language output may be as clinically potent in desensitising pain neurosignatures and it certainly has not been considered as deeply in rehabilitation.”  David Butler discusses how correcting patients language & thoughts relating to their pain is just as important as it is to correct their movement output.  This month’s JOSPT has a related article on the how movement system diagnostic labels can prevent the disconnect between diagnostics and treatment processes that pathoanatomic labels create.

2) The hip hinge is one of the most important movement patterns for anyone that moves.  This months article goes over what it is, how to assess it, and how to correct it. Continue reading “May Hits”

5 Ways to Expand – Lateral Stability – Video Analysis – RTC Myths – Breathing – SIJ – Carbs

1) PT School lays down the necessary foundation to develop your career.  There are many important things that we don’t learn in school.  Erson goes over 5 of these things.  I completely agree.

2) This might be a nice progression for patients that have already mastered the sagittal plane and have topped out with isolated hip strengthening (bridges, clamshells, side-step, etc.).  Eric Cressey goes over advanced lateral stability training.

3) Chris Johnson goes over the details of how to videotape your runners for analysis.

4) Mike Reinold describes his 4 RTC myths in this article.  Mike makes a great point on Continue reading “March Hits”

Coordination – TRX Y’s – Nocebo – Hallux Mobility – Neuro Approach

1) Maybe we should slow down a little bit.  Todd Hargrove goes over why slow movement is important for coordination and movement efficiency.  This can be very useful when attempting to teach the “motor morons” how to move right.  I specifically liked the Weber-Fechner Law, which describes that the relationship between the physical magnitiudes of a stimuli and the perceived intensity of the stimuli.

2) Overhead movements are usually butchered by patients.  When trying to activate the lower trap many patients compensate with a rib cage flare, hyperlordosis, forward head, and unusual grunts.  Cressey quickly goes over how to teach the TRX Y’s in this 2 minute video. Continue reading “January Hits”

November Hits

Eccentrics – TPI – Foot Intrinsics – Rib Cage – Upward Rotation – Cubiod

1) My co-worker, Michelle Briancisco, has been talking about using eccentrics to increase ROM for years.  She has found it really works well when patients aren’t responding to traditional muscle lengthening techniques.  She hypothesizes that it neurologically alters the afferent motor output and also provides the patient with a sense of control during the lengthening.

2) Saw this on Erson’s site.  I remember doing this at the TPI course.  There’s a plethora of good shoulder warm up exercises to choose from for your patients. Continue reading “The Hits”

September Hits

Popliteus – Hamstring Syndrome – Gray Cook – Calf Strain – Pavel Tsatsouline

1) The popliteus is an important structure of the knee that is often overlooked by many clinicians.  While it may not be the main contributor to knee dysfunction, it can still have a major impact.  Some patients need greater activation of this muscle, while others
benefit from a release.  This is a good post on the popliteus and it’s functional role in the knee joint.

2) I recently had a patient with hamstring syndrome.  She had been previously mis-diagnosed with piriformis syndrome, ischogluteal bursitis, lumbar radiculopathy, and hamstring tendonosis.  Understanding how to differentially diagnose these patients may lead to a more specific treatment and a better outcome. Continue reading “The Hits”