When we as health care or fitness professionals meet someone for the first time, we are assessing them as soon as we meet them, as we talk to them and during the formal portion. Why do we do this?
It is vital because it provides information that correlates with a person’s pain, past history of injuries and, most importantly, it can identify imbalances that have the potential to be corrected with education, stretching, proper strengthening and time.
However, how do you truly assess movement? Start with an in place static assessment from all views as described previously. Then perform a dynamic movement squat, lunge, walking, reaching and what does the client do? Analyze the motion focusing on compensatory pattern used and the key items that stand out! Let’s first look at a static assessment below.
Figure 1. Static Assessment
Start with analyzing from the ground up the kinematic chain. What do you see? With this particular client example, let’s begin by examining at the foot/ankle complex. The right foot upon observation is slightly more supinated while the left is slightly more pronated.
What does this implicate? It implicates an imbalance that may be due to structural issues, muscle imbalances, pain or all the above.
Clinical effects: A supinated foot will lengthen the peroneal musculature (evertors), lengthen the calcaneofibular ligament (CFL) and place a distractive force on the tibiofibular joint, stressing the lateral femoral condyle and slightly the lateral collateral ligament. While excessive pronation will stress the midfoot and longitudinal arch placing increased stress on the plantar fascia and metatarsal heads. At the knee joint, the client presents with right>left tibial varum (internal rotation of the tibia). Biomechanically, this will create an increased load to the medial joint line (MJL). You also can see both patella (knee caps) are abnormally tracking/placed. The right patella is medially deviated > left upon observation.
You can also see slightly increased muscle girth in right quadriceps and then the left.
Clinical effects: This will place increased load to the patellofemoral and tibiofemoral joints. Leading potentially to Patello femoral syndrome (PFS).
What structures will be tight? Most likely, they will be the right quadriceps, right adductors (gracilis longus) and right hip flexor. The femur is also internally rotated right>left. What does this do to the hip joint? This creates increased compressive loading to the joint, adjacent soft tissue and iliopectineal bursa (which lies between the iliopsoas muscle and the capsule of the hip joint). The client is potentially suffering from patellofemoral syndrome and if the client undergoes continued increased strengthening of the quadriceps, hip flexors and adductors could predispose this individual to femoral acetabular impingement syndrome(decreased mobility of the femur in the acetabulum).
Where should training begin?
- According to Janda and the evidence-based research, stretch the tight musculature and then strengthen the weaker musculature for stability.
- In this clinical example, starting with the ankle complex. Starting with stretching the peroneals, the gastrocnemius, quadriceps, hip flexors and adductors.
- Incorporating stationary bicycle or elliptical machine would be an effective way not only to lengthen these shortened areas but also to improve cardiovascular efficiency — all to improve mobility.
- Next, the patient would also benefit from ITB stretching which can be done via using a foam roller or performed by side lying on the left side while the right leg dangles off a bench with the leg straight. Held for 15 seconds repeated five times is ideal for all stretches.
- Then focus on strengthening glute medius, minimus, maximus with hamstrings to unload the anterior knee and reduce compressive forces to both the hip and knee complex for creating stability.
- Next, targeting the external obliques, transverse abdominis(TVA) anteriorly and quadratus lumborum and multifidus posteriorly will create core stability in the abdominal and lumbo-pelvic complex. These four muscles are the dynamic stabilizers not only per the research, but also in my 12+ year career that are essential when working with any client. Particularly, clients’ with a history of low back pain.
Figure 2. Dynamic Assessment
Start with analyzing from the ground up, examining the entire kinematic chain. What do you see? Ankle: pronating Knee: slight IR Hip: adducting with some IR Pelvis: (L) anterior rot Lumbar: SB to right.
What does this implicate? It implicates an imbalance that may be due to structural issues, muscle imbalances, pain, weakness or all the above.
Clinical effects: A left-pronated foot will place a load on the midfoot and plantar fascia, which will overwork the plantar flexors (gastrocnemius). Adduction of the hip with slight internal rotation creates lengthening to the ITB, distractive force to the hip joint and places stress on glute medius/minimus. This has the potential to lead to overactivity tendonitis. There is a left-forward rotated pelvis that will create a shortening of the left hip flexors and quadriceps. Left sidebending of the lumbar to the left, will create muscle imbalance in the obliques, paraspinals and QL from a soft tissue perspective while creating slight compressive loading to the facets in the lower lumbar on the left.
Where should training begin?
- Like any fitness assessment whether it is static or dynamic or both, the first thing is to educate the client.
- Teach the client what you see and the potential implications cannot only be valuable to the client to understand their bodies better, but prevent injury from developing.
- Addressing pronation begins with teaching the client what is subtalar neutral and demonstrating using the hands.
- Examine the muscle length of the adductors and quadriceps. ITB should next be examined and compared bilaterally. Most likely, the muscles are tighter and shortened and therefore as stated previously be stretched via educating the client and passive stretching.
- Teach the client what is neutral spine and how to maintain this position statically in positions such as standing which then can be progressed to bridging and then dynamic movements such as an in place lunge.
- Finally, strengthen the weaker phasic muscles (glute medius/minimus/max) and hamstrings.
Progress core strengthening from static exercises such as planks, side planks, trunk rotation with equipment to dynamic strengthening using physioballs and compound movements such as traveling lunge, then lunge with trunk rotation, while progressing accordingly.
Assessing and examining a client for the first time can be challenging, particularly if the client has an extensive medical history, or is difficult to work with. By conducting a thorough static and dynamic assessment, you will gain more information about the clients’ posture, movement patterns and most of all, where their imbalances are. Correcting imbalances can reduce present or future pain, restore symmetry and help a client achieve their highest potential.
By understanding the science behind movement, the personal trainer will possess the fundamental knowledge, skills and abilities to work with any client providing training that is safe, functional and most of all, based on human movement that is scientifically and research based!
In part two, we will review some common dysfunctions of the ankle, knee and spine injuries, post rehabilitation guidelines and effective exercises to teach your clients.
About the Author
Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, CPT is the President of Pinnacle Training & Consulting Systems, a consulting and educational company that provides advanced continuing education material and live seminars to personal trainers. The Synergy of Human Movement is the only course that examines how human movement occurs. For more information visit www.pinnacle-tcs.com or email to [email protected].