Leaky Roof Syndrome

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To begin, yesterday, I had just finished my training session when Eric walked up to me and said, “you’re 12:30 eval is here; she’s waiting in the office.”   Oops – twenty minutes early.  I head over to the stereo to turn-off the Wu-Tang (not exactly a great first impression when M.E.T.H.O.D Man is blaring through the speakers), pound my protein shake, and change shirts really quickly before I head out to greet Paula.

Upon quickly glancing at her health history, I notice something that jumps out and grabs my attention – she noted that she had been suffering from a chronic hamstring strain for the better part of the last two years.  Hmmm, interesting.  Almost immediately a light bulb goes off in my head and I start to stroke  my evil strength coach beard (but more on that in a bit).

Anyways, whenever a new client walks into the facility, we always try to sit down for 5-10 minutes to better ascertain what it is (s)he is looking to do.  Generally speaking, this is the time where we try to dig a little deeper, discuss training background, goals, injury history, etc.  The form sitting in front of me was otherwise blank, so without even blinking an eye, I ask about the hamstring.

Paula smiled, took a deep breath and let it rip.  Without going into too many details, she explained how she had always been an athlete (she was a sprinter in college) and had always lead an active lifestyle – she even did some personal training on the side a few years ago, and really enjoyed it.  For all intents and purposes – she’s the epitome of a fitness junkie.

Giving full disclosure, however, she openly admitted that she’s her own worst enemy, and sometimes has a knack for not knowing when to hold herself back.  When she first hurt her hamstring, she waited a few weeks, and once it started feeling better, she hightailed it to the track and did some sprints – only to re-injure herself, again, and again, and again.

After what was seemingly her umpteenth hamstring strain, she finally decided to seek some professional expertise and visited a local physical therapist near her hometown.   And for many of you, I think you know where this story is going.

To say that a ham sandwich could have done a better job than this physical therapist would be the understatement of the century.  Based off of what Paula told me, this therapist did nothing other than give her ultrasound and electric stimulation for a few weeks and then sent her on her way.  Incidentally, there was no real formal assessment of her movement quality.  Basically, Paula walked in, said “my hamstring hurts,” and the therapist treated the hamstring. 

I guess in the grand scheme of things, this isn’t necessarily wrong.  For instance, when one of our baseball guys shows up and says his shoulder hurts, as traditionalists, we usually end up looking at the shoulder first and work out way out crossing things off as we go:  things like, scapular positioning, thoracic mobility, contralateral hip mobility, soft tissue restrictions, to name a few. 

But there’s the rub – WE DON’T JUST LOOK AT THE SHOULDER.

And this is where I feel this particular physical therapist (and the countless other health professionals whom Paula visited) missed the boat entirely.

Leaky Roof Syndrome strikes again!!

It’s akin to someone complaining about a leaky roof in their house, and hiring someone to come in and place a patch over the leak itself – when in fact, the root cause of the leak is coming from somewhere else entirely.  Placing a patch over it is just a temporary fix in the long run, and will do nothing but delay the inevitable.

So, fast forward to yesterday and Paula getting visiably emotional while telling her story.  Who could blame her?  I mean, up until this point, no one had really taken the time to listen and to actually offer any concrete resolution to her problem.  All she’s been told is that she has “tight hamstrings,” (which, as I’ve noted in the past, is a bullshit excuse more often than not), and that she just “needs to take it easy.”

All this great advice for a $25 co-pay?  Sign me up!

Bringing this to a close, here are a few points of interest from yesterday that I found:

  • By and large, whenever someone mentions the word “strain,” you can usually (not always) chalk it up to something called Synergistic Dominance. Translating for the non-nerds out there, Synergistic Dominance is defined as a condition when a muscle in a group of muscles, that share similar actions, become more dominant and in turn, another less dominant.
  • In Paula’s case, during her assessment, I found that she had little (if any) ability to activate her glutes, which is kind of a problem – especially given they’re a very powerful hip extensor.   If her glutes are unable to fire, then that means her hamstrings (also hip extensors) have to work overtime to pick up the slack.  And, when you put two and two together (poor glute function paired with hamstrings throwing you the middle finger), you get chronic strains.

  • Furthermore, after taking her through some more tests, I found that she had very little ankle dorsiflexion.  Actually, that’s just being nice.  She had NO ankle dorsiflexion.  She lives in planar flexion from wearing high heels all the time.  Is it any wonder, then, that whenever she tries to sprint, she ends up hurting herself?
  • And finally, as I alluded to above, all the therapy in the world won’t make a bit of difference if people continue to move like shit.   Renowned physical therapist, Gray Cook, has popular saying

“fix the pattern, and the muscles take care of themselves.” 

  • It’s so simple, that it’s brilliant.   I took Paula through some basic movement drills, and it was readily apparent that her lunge pattern needed some work – her foot externally rotated and knee caved in on each step, and even worse, her hip would collapse; all indicative of really poor hip stability.  Sorry, but ultrasound isn’t going to fix that.

In closing, it’s things like this that make my job so awesome – cause here’s a woman that came to us as a last resort, and she left yesterday feeling hopeful that we’d be able to help.

This isn’t to say that we don’t hava a lot of work to do – we do!  On top of building some basic strength, and correcting some motor patterns, she’s going to need quite a bit of soft tissue work done.  I gotta say, though, that it definitely frustrates me when I hear stories like this, and do nothing but show how “broken” our primary care system is (at times) in this country. And,let me just say that this post wasn’t meant as a “dig” to all physical therapists, chiropractors, physicians, or orthopedic surgeons out there that may be reading. 

I understand that with any profession, there are those that do their job very well, and others that, well, don’t.  And I am in no way saying that what I found is altogether right or wrong. I But this is one instance where I was pretty fired up about the lack of “giving a shit” this physical therapist had.  We can do better than that!

PS:  If you found this article useful, or just liked it’s general awesomeness, please do me a favor and “like” it, or maybe re-tweet it.  Any way to get the word out there is very much appreciated!

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  • Adam

    How do you test someone's ability to activate their glutes? Is it through a specific test or a result of the overall assessment?

  • Chris

    Hey Tony,

    Great post and a case I think is fairly common, at least as far the inactive glutes and poor ankle dorsi-flexion, not necessarily the recurring hamstring issues. Love to hear your approach to correcting the movement patterns and weak links in Paula.

  • For testing glute activation I like to put someone in quadraped position to see if they can actually just get the glute to fire. If they are able to, I put them into floor bridge and single leg bridge positions and see how far into hip extension they can get and how well they can actually feel their glutes activating. But I am sure Tony has some other methods as well.

  • Mitch

    Tony,

    Great post! I've been through this myself with some low back issues and going to to a PT who didn't even think to look at my hip. AAARRRGH! I'd love for you to make this a continuing series/case study of posts or articles to see what you've found and how you plan to go about fixing it. That would be as awesome as the next Harry Potter movie should be!

  • Laura

    Great post. I wish I lived in America and could come and see you to fix me! I have seen so many 'professionals' and not one has sorted my problem out (lateral hip instability), it would be great to have some confidence in the person treating you and know the work you are putting in will pay off. It's a bit depressing when most of the chiros/physios I see blame strength training as the main cause or just treat the point of pain and don't look for the root cause.

  • Domenic

    Tony,

    I love these cases. I find physical therapists and orthapedic surgeons think they are so superior to personal trainers and strength coaches.

    But when you break it down, its simple. Most orthapedic surgeons and physical therapists don't understand the way the body works. Simple as that.

  • R Smith

    Tony,

    Hate to be the typical Cressey Performance suck-up that I always am, but Paula was fortunate to have found you guys. Yes, there are other great trainers/coaches across the U.S., but I have friends who have visited some of the less-than-stellar facilities, and what they get told is borderline stupid. Not to mention the orthopedic surgeon who told my friend that her chronic knee pain would be cured with more cushiony running shoes. Hu…what?

    I tell all of my friends that If they are not going to get an assessment at one of a handful of facilities, then buy Assess & Correct and self-assess.

  • JB

    There's an Irish proverb that sums this up nicely:

    It does no good to carry an umbrella if your shoes are leaking.

    It would be interesting to see some case studies from some of your clients.

  • Pete K

    TG, remember a couple of posts ago where I questioned your wording on “best exrc for upper back”, but then gave you props for being “freaking brilliant”.

    Yeah, this post is why. Sensational.

  • so funny, one of the legends of the pilates field (and an amazing anatomist) says “if you put the bones in the right place and call for movement, the muscles will automatically do the right thing”

    i love how we're all starting to say the same things… how it's all coming together. go sane movement!

  • Tony Gentilcore

    Adam: there are a few ways, actually.

    1. Have them perform a basic supine bridge and “palpate” the the glute to see if it fires.

    2. I like to have people lie prone, and then lift their leg into extension – ideally, the glutes should fire first, then the hammies, then the opposite erector (spiral line – ie, Thomas Myers). When someone has weak glutes, you'll almost always notice that their hammies fire first

  • Tony Gentilcore

    @ Ronell: Yeah, that's unfortunate that your friend paid all that money to see a specialist only to be told to wear more cushiony shoes. Absurd!

  • Great post Tony. Found the article from a linkedin discussion. I look forward to reading more of your stuff!Do mind if i link your blog to mine? thanks, talk to you soon.

    Chris Tolisano

  • Stone

    Kickass post!!!

  • fotis

    Tony that was a really good post that I am gonna like and share!I have a question

    Other than Gray Cook and Eric,do you have any other sources to recommend on finding and correcting problems with muscles and movement patterns?

    Thanks a bunch buddy!

  • Tony Gentilcore

    @ Christopher: absolutely, feel free.

    @ Fotis: I'd recommend Shirley Sahrmann's Diagonsis and Treatment of Movement Impairment Syndromes and/or Kendall's Muscles and Testing text (both of which can be found in my recommended resources page).

  • I followed Chris from linked in discussion to here and agree that learning and understanding Sahrmann's philosophy of fascilitated/inhibited muscles leading to movement impairment syndrome is so important.The workshops spoke to me many years ago. Shirley and Florence (Kendall) are the true foundations to analyze posture and locomotion and intervene as needed. Also find anything you can on Vladimir Janda.