 aDepartment of Rehabilitation, Palmer Chiropractic College Florida, Port Orange, Florida Find articles by Trevor Shaw bClinic Affairs, Palmer Chiropractic College Florida, Port Orange, Florida Find articles by Adam Sergent Received 2019 Jan 18; Revised 2019 Dec 9; Accepted 2019 Dec 9. Copyright © 2020 by National University of Health Sciences. To describe the case management of a female CrossFit athlete presenting for a functional movement assessment. She had knee pain after 2 months of training for a competition. After her assessment, it was determined that the patient had difficulty using her gluteus maximus musculature in various positions including standing, lying, and quadruped positions despite being a competitive athlete. It was determined via biomechanical testing that the patient's posterior chain firing pattern was predominantly erector spinae vs gluteus complex and hamstrings muscles. Continuation of reactive neuromuscular training gluteus medius/activation exercise was prescribed to establish motor control, endurance, and preactivation while decreasing erector spinae overload for this patient. This patient was someone with exceptional strength but poor motor control. Regressing back to the most basic activation exercises, we were able to simulate the proper activation and motor control to decrease pain and improve performance. The athlete's function seemed to improve after a course of care that included basic exercises Key Indexing Terms: Patellofemoral Pain Syndrome, Chiropractic Patellofemoral pain syndrome (PFPS) is a common diagnosis among young women presenting with anterior knee pain.1,2 The incidence of knee pain in the general population is about 2 in 100 with women being affected twice as often as men.1 This complaint represents 25% to 40% of the complaints seen in a sports or rehabilitation-driven clinic.1,2 This is a diagnosis of exclusion because PFPS is a clinical diagnosis without pathologic changes that are readily visible, and once anatomic issues such as Q angle are ruled out, as there are no specific exam findings, such as orthopedic tests or advanced imaging. This syndrome can be attributed to possible overuse injuries, instability of the surrounding ligaments of the patella, weakness of the gluteal and quadriceps, and posterior chain firing patterns.2,3 Functional movement screens are greatly used by many sports and rehabilitation-based professionals and have been shown to effectively predict likelihood of an injury.4 These functional movement screens have also been shown to have great inter-rater and intrarater reliability, making them useful regardless of whom applies the test if the individual is trained.4 These movement screens not only show a predictive value of likely musculoskeletal injuries; they are also a great way to access and determine which muscle group may be the one to fail. After a movement screen, the provider should have an idea of which area may fail when under stress. Biomechanical compensatory patterns can present with many different patterns invoking pain at a specific site from another region. The functional movement screens can assess movement quality of an area that may go undetected in a regular physical exam.5 A disruption in the kinetic chain at one location can affect another seemingly uninvolved area. It is well known that overuse injuries, instability of the surrounding ligaments of the patella, lower-extremity dysfunction, weakness of the gluteal and quadriceps, and posterior chain firing patterns can affect the lower back musculature and function 6 Reactive neuromuscular training (RNT) assists in correcting unusual or inappropriate movement patterns. A patient who present with PFPS may be experiencing a dysfunction in motor control of the posterior chain, in which the normal firing pattern is delayed. This delay may be causing the dysfunction and pain. To address this dysfunction of the kinetic chain, closed-chain exercises should be performed to trigger the appropriate firing patterns of the posterior kinetic chain.7 The purpose of this case report was to demonstrate the application of using a selective functional movement tool to determine firing patterns and weakness in muscles that may contribute to pain in seemingly unrelated areas. Traditionally, PFPS is usually treated locally at the knee. A 40-year-old female former competitive power lifter presented with bilateral knee and low back pain after increased training for a CrossFit competition. Upon exam, all baseline vitals, height, and weight were unremarkable. Upon visual inspection, increased Q angle was seen bilaterally, with moderate pes planus pronation bilaterally. Upon palpation, there was bilateral iliotibial band hypertonicity and tensor facia lata, and gluteus medius displayed hypertonicity as well. Muscle testing revealed no neurologic deficits but reduced activation of the gluteus medias. Range of motion revealed decreased active and passive hip extension and ankle dorsiflexion upon visual inspection. No anatomic variances were noted during any of the inspections. Orthopedic testing of bilateral knees anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, lateral collateral ligament, and meniscus were all negative. The patient only complained of knee pain while bending or with squatting-type motions. A low back exam revealed unremarkable strength, reflexes, and sensory motor testing. Low back orthopedic tests Slump, Kemp, straight leg raise, and Flexion, Adduction, Internal Rotation were all negative. Sacroiliac joint (SIJ) referral patterns were concluded as negative using Laslett's criteria, which is a cluster of 5 tests to determine SIJ dysfunction.8 She was being treated at the site of pain with the standard soft-tissue mobilization, kineso-taping, shockwave therapy, and adjustments to the SIJ using drop technique with no true relief of pain measured on the numerical pain scale or improved function. She was then screened using the Selective Functional Movement Assessment (SFMA) screening tool, which revealed excessive effort in the toe touch pattern, bilateral valgus collapse of the knees during the squat pattern, and bilateral positive Trendelenburg in the single-leg stance. The movement screen revealed difficulty maintaining a neutral lumbar spine during activity, and the gluteus medius and maximus were not contributing to the load management as much as needed, as evident by bilateral valgus collapse of the knees upon single-leg stance and squat. It was determined that this lack of gluteus medias activation was the causative factor in the bilateral valgus collapse of the knees that was causing the patient's knee pain. There is no way to specifically say the cause was gluteus medius other than possible needle electromyography studies. The patient was treated with specific corrective exercise to reestablish normal firing of the gluteus medius and to correct her valgus deformity, which in turn was able to decrease her knee pain. The exercises selected consisted of RNT squats (Fig 1), lateral monster walks (Fig 2), and gluteus medius bridges (Fig 3). The first exercise that was chosen was RNT squats because for this athlete the squat pattern was very important and part of her daily training regimen. We wanted to see if this pattern was immediately correctable, and with RNT we found that it was. The RNT squats serve as an additional test as much as a corrective exercise. Once we were able to get an immediate pattern correction, we had an area of suspected weakness to focus on. The second exercise selected was lateral monster walks for the purpose of adding additional strength and endurance to the lateral hip. Lateral monster walks with the band placed above the knees will increase stress at the lateral hips and gluteus medius, exactly the area of focus. Our third exercise was gluteus medius bridges; this exercise was selected because it layers more load onto the already fatigued gluteus complex while demanding the patient maintain a neutral spine, an issue she had trouble with earlier on as well. This patient experienced immediate in-session relief of her knee pain using the numerical pain scale as a 0 of 10, showing promise that between-sessions pain would decrease. Common treatment for an athlete presenting with anterior knee pain often consists of soft-tissue mobilization, ultrasound, interferential muscle stimulation, chiropractic adjustments, or any number of other passive therapy options. This can be seen as problematic because the patient can then become reliant on the doctor for treatment and management of pain. Defaulting to an active care paradigm allows the clinician to make the patient have an ability to self-treat by performing the prescribed exercises given. The SFMA represents a powerful paradigm shift in clinical rehabilitation. This model allows us to find the source of dysfunction, which may be perpetuating or provoking the patient's pain syndromes. This study showed the effectiveness of using a systematic movement analysis to evaluate the movement patterns associated with this athlete's knee pain. It is common for clinicians to treat the site of pain when an athlete presents with a specific complaint; however, as demonstrated by this patient, the cause of pain was not at the site of pain but due to improper and poor movement above at the hip joint. The utilization of the SFMA screen allows a reliable, reproducible approach to examining movement in patients to determine areas of dysfunction and can be used between various examiners with reliable outcomes.6,9 The SFMA system consists of 10 primary movement patterns, which are then broken down further into standard orthopedic exams. The idea is that when a faulty pattern is found, you then change positions and retest actively vs passively. The presence of bilateral knee valgus collapse and excessive lumbar effort in the squat pattern, along with a positive Trendelenburg in the single-leg stance position, were strong indicators that corrective exercise may be needed.7 Once the faulty movement pattern was discovered and diagnosed as weak gluteus medius and maximus muscles, the focus of the visit switched to active corrective exercise over passive modalities. We used RNT to reeducate the faulty movement pattern. Reactive neuromuscular training is a reflexive activation technique that allows the patient the opportunity to fix faulty patterns by feeding the dysfunction to self-correct. The idea behind this is that external cues are more effective than internal cueing for movement correction, and that by getting the patient to self-correct without verbal coaching, we can teach more authentic reproducible movement.10, 11, 12, 13 The corrective movements that were then selected consisted of RNT squats, a pattern designed to allow the patient to self-correct movement without verbal cueing by the doctor. This exercise was performed with a band placed around the knees to further facilitate the valgus collapse. Without verbal cuing to correct the knees out, the instruction to push against the band was given and the patient's squat pattern immediately corrected to knees over toes. The next exercise performed was lateral monster walks with the band around the superior knee. This exercise was selected because of its ability to create hip abduction and hip lateral stability while building strength and endurance. Finally, gluteus medius bridges were selected in an effort to retrain neutral spine position while activating the gluteus maximus musculature. This was chosen because it was another area of dysfunction noted in the patient's movement screen.14 Traditionally PFPS is usually treated locally at the knee. This application of using a selective functional movement tool to determine firing patterns and weakness in muscles that may contribute to pain in seemingly unrelated areas suggested muscle and firing patterns not necessarily in the knee. We can draw no firm conclusions from this case report, although it does suggest that in this particular patient, the use of SFMA was an effective tool in assessing the patient. There were also aspects of the exam that should have been better evaluated, such as a true measurement of the Q angle and evaluation for anteversion and retroversion of the hips. No funding sources or conflicts of interest were reported for this study. Concept development (provided idea for the research): T.S., A.S. Design (planned the methods to generate the results): T.S., A.S. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): T.S., A.S. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): T.S., A.S. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): T.S., A.S. Literature search (performed the literature search): T.S., A.S. Writing (responsible for writing a substantive part of the manuscript): T.S., A.S. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): T.S., A.S. Practical Applications
1. Petersen W, Ellermann A, Koppenburg A. Patelofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264–2274. [PMC free article] [PubMed] [Google Scholar] 2. Fontenay B, Esculier J, Bouyer L. Hip kinematics during functional tasks in females with patellofemoral pain: modification following rehabilitation and correlation with clinical improvement. Phys Ther Sport. 2018;32:7–14. [PubMed] [Google Scholar] 3. Barton C, Lack S, Hemmings S, Tufail S, Morrissey D. The “best practice guide to patellofemoral pain”: incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med. 2015;49(14):923–934. [PubMed] [Google Scholar] 4. Bonazza N, Smuin D, Onks C, Silvis M, Dhawan A. Reliability, validity, and injury predictive value of the functional movement screen: a systematic review and meta-analysis. Am J Sports Med. 2017;45(3):725–732. [PubMed] [Google Scholar] 5. Hyunsoo K, Jun S, Seeley M, Hopkins T. Kinetic compensations due to chronic ankle instability during landing and jumping. Med Sci Sports Exercise. 2018;50(2):308–317. [PubMed] [Google Scholar] 6. Dolbeer J, Mason J, Morris J, Crowell M, Goss D. Inter-rater reliability of the selective functional movement assessment (SFMA) by SFMA certified physical therapists with similar clinical and rating experience. Int J Sports Phys Ther. 2017;12(5):752–763. [PMC free article] [PubMed] [Google Scholar] 7. Dorrel B, Long T, Shaffer S, Myer G. The functional movement screen as a predictor of injury in National Collegiate Athletic Association Division II athletes. J Athl Train. 2018;53(1):29–34. [PMC free article] [PubMed] [Google Scholar] 8. Glaws KR, Juneau CM, Becker LC, Di Stasi SL, Hewett TE. Intra- and inter-rater reliability of the selective functional movement assessment (SFMA) Int J Sports Phys Ther. 2014;9(2):195–207. [PMC free article] [PubMed] [Google Scholar] 9. Pascua LA, Wulf G, Lewthwaite R. Additive benefits of external focus and enhanced performance expectancy for motor learning. J Sports Sci. 2015;33(1):58–66. [PubMed] [Google Scholar] 10. Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: the OPTIMAL theory of motor learning. Psychon Bull Rev. 2016;23(5):1382–1414. [PubMed] [Google Scholar] 11. Wulf G, Shea C, Lewthwaite R. Motor skill learning and performance: a review of influential factors. Med Educ. 2010;44(1):75–84. [PubMed] [Google Scholar] 12. Cambridge ED, Sidorkewicz N, Ikeda DM, McGill SM. Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises. Clin Biomech (Bristol, Avon) 2012;27(7):719–724. [PubMed] [Google Scholar] 13. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49(2):89–97. [PubMed] [Google Scholar] 14. Voight ML, Hoogenboom BJ, Prentice WE. 3rd ed. McGraw Hill Medical; New York, NY: 2007. Musculoskeletal Interventions: Techniques for Therapeutic Exercise. [Google Scholar] |
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