Making a case for the Joint-by-Joint approach and understanding the differences between mobility and flexibility
Quite often, when we evaluate our patients, we need to ask ourselves two main questions: What is the problem and where is it coming from? If we don't think about anything else but these two things then we have a system to start with. For example, lets use a patient who complaints of anterior knee pain. On paper, we already know what the problem is: anterior knee pain. But is that really the problem? If we assume that the patient's knee pain is the problem then we have already set ourselves up to miss something. Let me explain.
Anatomically we have the fat pad, patella tendon, reticular fibers, bursa, tibial tuberosity, etc. Now if we assume that the anterior knee pain is the problem then we might think one of those anatomical structures is the pain generating source. However, if we open up our minds then we realize that its never that simple. This is where the joint by joint approach can be beneficial. Lack of dorsiflexion at the ankle alone could influence the patient's knee pain. Or lack of strength in the hips. Or lack of core control. Or the patient's everyday activities (stairs vs jumping, etc). Or maybe it's flexibility issues causing dysfunctional positions. Or maybe its a biomechanical mobility issue. See where I'm going?
While I'm here lets make sure we understand the difference between mobility and flexibility because there still seems to be a lot of confusion out there. Flexibility for all intensive purposes means length of the muscle while mobility means how a joint moves. Understanding this is what separates physical therapists from personal trainers who might assume stretching the calves will correct loss of dorsiflexion without realizing it may be a mobility issue. But thats another article for another day.
So lets review the joint by joint approach that Gray Cook and Mike Boyle have both spoke about. In this expansion of Cooks Movement book, he discusses some of the common myths about the joint by joint approach. His explanations and examples really help you understand this approach.
Now that my sports residency has come to an end I have been doing a lot of reflecting lately. I've thought about what I learned this year and what I still want to learn. More importantly though, I've thought about what makes evaluating and treating an athlete different than other orthopedic patients. On the surface, it may seem that an athletes' evaluation is easier because they are more "functional" and can do more. However, I can safely say that is not always the case. In fact, sometimes an athletes' evaluation can be MORE complicated than our typical orthopedic patients. Here's why.....
Scenario: You are evaluating a professional lineman today. He is s/p L ankle debridement. He hasn't played in over 10 months and had surgery 1 month ago. He reports that he had surgery due to significant pain and decreased motion. You learn that he broke his ankle a few years ago and rushed back to play after going through a few courses of "therapy" that consisted of modalities, a few stretches, and strengthening movements. Additionally, you learn that his past medical history is significant for: R ACLr, L & R ankle sprains (multiple), and separated L shoulder. He tells you he plays defensive end.
Other than your basic subjective and objective examination what should you start thinking about?
1. Psychological state. How does he feel about his current situation? He hasn't played in 10 months, is he under contract or a free agent? How is this affecting his state of mind?
2. Physical Conditioning: Is he currently in shape or overweight? Is he using joint supplements, weight loss supps, etc?
3. What are his goals? Does he plan to play this upcoming year? Are teams contacting him about his status?
4. Who is his agent? Coach? Strength coach?
5. What has his experience in therapy been in he past? What is his "current" routine? More importantly, what does he need to be doing to reach his goal?
6. What are the biomechanics of his position (aka what positions does he need to get into)? What energy systems come into play? What drills does he need to perform in the future to prepare? How does his past medical history change his plan of care?
* These are just some of the things to start thinking about when evaluating a professional athlete. Part 2 will explain why you want to think about these things and how they affect your plan of care. *