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Functional Assessment, Rehab, and Taping of Musculoskeletal Disorders  

Barton N. Bishop, DPT, SCS, CKTI, CSCS Chief Clinical Officer

Sport and Spine Rehab Kaizenovation Lifestyle

Functional vs. Structural  

•  Structural faults treated with functional treatment  

Functional vs. Structural  

•  Need to treat the deficit appropriately"•  Functional faults require functional treatment"•  Structural faults require structural treatment  

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Structural Deficits  

•  Joint dysfunction"•  Malalignment"•  Fractures  

Functional Deficits  

•  Poor posture"•  Inhibition of a muscle"

•  Phasic Chain"•  Muscle over facilitated"

•  Tonic Chain"•  Inability to do sport, skill, leisure, ADLs"

Treatment Paradigm  

Structural Exam

Structural Treatment

Functional Exam

Functional Treatment

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Janda’s Muscle Imbalance Syndromes  

Treatment Paradigms  

• The traditional, structural approach tends to be more “extrinsic” : Treat what we can see""• The functional approach takes a more “intrinsic” perspective to treat what we can’t see  

Things we can’t see  

•  Proprioception"•  Motor programs"•  Chain Reactions"•  Muscle Imbalances  

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Proprioception  

•  Joint mechanoreceptors"•  Capsules & ligaments"

"•  Muscular receptors"

•  Gamma motor neuron & muscle spindle"

•  Cutaneous receptors"•  Pressure, temperature,

vibration  

Structure vs. Function  

•  Proprioception"•  Hilton’s Law : a nerve that

innervates a joint also tends to innervate the muscles that move the joint, as well as skin and fascia  

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Structure vs. Function  

•  Hilton’s Law example"•  Musculocutaneous nerve

supplies elbow joint with pain and proprioception fibers. It also supplies biceps, brachioradialis, and skin.  

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The musculoskeletal & central nervous systems function as one unit:

The SENSORIMOTOR SYSTEM  

Any lesion within the system is reflected by adaptive changes elsewhere in the system  

Sensorimotor System  

SENSORY INPUT"Visual"Vestibular"Proprioceptive"Exteroceptive

MOTOR OUTPUT"Muscle Facilitation"Muscle Inhibition

CNS PROCESSING CNS

PNS

Chain Reactions  

•  Muscular Chains"•  Slings : continuous connections

through muscle, fascia, and bone"• Synergists & Antagonists interconnected

in closed tensegrity system"•  Integral links for movement"

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Chain Reactions  •  Neurological Chains"

•  Upper Quarter Co-Activation (Janda)"•  Tonic Chain"

•  flexion, internal rotation, adduction, pronation""

•  Phasic Chain"• extension, external rotation, abduction, "supination  

function: prehension, reaching, grasping

Chain Reactions  •  Lower Quarter Co-Activation (Janda)"

•  Tonic chain"• ankle PF & INV, hip flexion, internal rotation & adduction""

•  Phasic chain"• ankle DF & EV, hip external rotation & abduction  

function: creeping, crawling, gait

Upper Quarter Chains  

Tonic Chain !   Phasic Chain

•  pectoralis major"•  upper trapezius"•  levator scapula"•  masseter/lat.

pterygoid"•  SCM"•  Scalenes"•  suboccipitals"•  UE flexors

•  serratus anterior"•  rhomboids"•  middle/lower

trapezius"•  deep neck flexors"•  upper limb

extensors

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Lower Quarter Chains  

gastroc-soleus"tibialis posterior"hip adductors"hamstrings"rectus femoris"iliopsosas"TFL"piriformis"thoracolumbar extensors"quadratus lumborum"

peroneals"tibialis anterior"Vastus medialis/lateralis"gluteus medius/minimus"gluteus maximus"Transverse abdominus"

Tonic Chain Phasic Chain

Muscle imbalance is a systematic and predictable response of the motor system  

Changes in the system will be reflected by adaptive responses within the system  

Tonic muscles are prone to tightness

Phasic muscles are prone to weakness  

Tonics are Too Tight

Phasics Fail to Fire

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Flexors (Tonic)Prone to tightness / shortness  

o  gastroc-soleus"o  tibialis posterior"o  hip adductors"o  hamstrings"o  rectus femoris"o  iliopsosas"o  TFL"o  piriformis"o  thoracolumbar

extensor "  

o  quadratus lumborum"o  pectoralis major"o  upper trapezius"o  levator scapula"o  masseter/lat pterygoid"o  SCM"o  Scalenes"o  suboccipitals"o  UE flexors

Extensors (Phasic)Prone to weakness / lengthening  

•  peroneals"•  tibialis anterior"•  vastus medialis/

lateralis"•  gluteus medius/

minimus"•  gluteus maximus"•  transverse abdominus  

•  serratus anterior"•  rhomboids"•  middle/lower

trapezius"•  deep neck flexors"•  upper limb

extensors

Muscle Imbalance & Joint Pathology  

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Joint Dysfunction

Unbalanced"

Forces

Abnormal Joint"Biomechanics

Abnormal"movement "pattern

Altered"

motor program

Vicious Cycle of Muscle Imbalance  

Structural v. Functional Pathology  

•  “Dysfunction” (Lund et al, 1991)"•  Characteristic of several types of musculoskeletal pain"•  Neurophysiological model, based on afferent input"•  Muscle Imbalance"

•  Agonists become inhibited"•  Antagonists become facilitated"

•  Normal protective adaptation; NOT the cause of pain  

Typical muscle response to joint dysfunction is similar to spastic muscles

in structural CNS lesions  

Usually develops with muscle inhibition in other muscles, resulting in a muscle imbalance.  

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Presence of Janda’s Crossed Syndromes indicates the

presence of CNS-mediated muscle imbalance  

Requires treatment of the Sensorimotor System  

Janda’s Upper Crossed Syndrome  

WEAK"Cervical "Flexors

TIGHT"Pectorals

TIGHT"Suboccipitals"UpTrap/Levator

WEAK"Rhomboid"Lower Trap

Janda’s Lower Crossed Syndrome  

WEAK"Abdominals

TIGHT"Hip Flexors

TIGHT"Thoraco-lumbar"Extensors

WEAK"Gluteus Max

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Janda’s Layer Syndrome  

•  Combination of both upper and lower crossed syndromes"

•  Marked impairment of the motor regulation"

•  Sign of poorer prognosis due to longstanding dysfunction  

Functional Exam, Rehab, Treatment  Cervico-Thoracic  

Mouth Opening Screen"Instruc(ons  

   

Patient seated or standing comfortably. Patient to open the mouth as wide as possible. Watch the upper cervical spine    

Clinical  Ra(onale  Shows overactivity of suboccipitals

   

Failure   Exercise  Recommenda(ons  Pain or inability to open at least 3 fingers wide. Viewing from side, look for any anterior translation of the occiput = suboccipital over activity

   

Thoracic extension to position c-spine in neutral shutting off suboccipitals; Upright Head Nod; dynamic cervical isometrics – extension

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Upper Cervical Extension Test"Instruc(ons  

   

Perform dynamic cervical extension isometric with a yellow or red Thera-Band – pull from in front of patient

Clinical  Ra(onale  Shows weakness of longus colli

   

Failure   Exercise  Recommenda(ons  Upper cervical extension at any point in the motion – inability to keep head in neutral

   

Deep neck flexion – upright head nod, dynamic cervical isometrics for extension

Deep Neck Flexion Test"Instruc(ons  

   

Patient is supine and ask patient to slowly raise the head from the table and then slowly lower the head back to starting position

Clinical  Ra(onale  Evaluates deep neck flexor strength and over-activity of SCM/scalenes

   

Failure   Exercise  Recommenda(ons  SCM or Scalenes over activity; Shaking; Chin protrusion (not keeping chin tucked to chest at all times)

   

Upright head nod, SCM and Scalenes stretches, dynamic cervical isometrics for extension

Janda Shoulder Abduction Test"Instruc(ons  

   

Have patient start with arm at side and elbow bent to 90 degrees and wrist neutral. Slowly raise arm to side

Clinical  Ra(onale  Evaluates the over-activation of the upper trap for patients with neck pain

   

Failure   Exercise  Recommenda(ons  Scapular hike at any point in the motion; pain.

 

Strengthening of the middle deltoid, supraspinatus, and stretching of the upper traps/levator scapulae

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Thoracic Extension Screen"Instruc(ons  

   

Stand against wall with heels 1-2 inches away from wall; raise arms up (lats) or elbows at 90 degrees (Pecs)

Clinical  Ra(onale  Evaluates thoracic extension which lack of puts the upper cervical spine in extension and the lower c-spine in flexion

   

Failure   Exercise  Recommenda(ons  Inability to flatten TL junction without losing wall contact; Note where tension occurs when performing; Pain

   

W-Vs, Wall Angels, Standing Jacks, Lat Stretches

Push Up Screen"Instruc(ons  

   

In push up position, on toes or knees, lower and rise up, then shift from side to side and shift superolaterally

Clinical  Ra(onale  Evaluates the activation of the serratus anterior and lower and middle traps

Failure   Exercise  Recommenda(ons  Scapula wings (unilateral more significant); Inability to perform

   

Depends on failure – medial border: serratus ant and mid trap exercises; inferior angle: lower trap vector, scap/sagittal flex-bar oscillation

90/90 ER With and Without Retraction"Instruc(ons  

   

Have patient stand naturally, abduct arm to 90 degrees and externally rotate. Measure range. Redo motion after doing scapular retraction

Clinical  Ra(onale  Have patient stand naturally, abduct arm to 90 degrees and externally rotate. Measure range. Redo motion after doing scapular retraction

Failure   Exercise  Recommenda(ons  Range  should  be  more  than  85  degrees  with  retrac6on.  Without  retrac6on  it  should  be  at  least  90  degrees  of  external  rota6on

   

Scap stab strengthening – lower trap vector, rows, serratus progression, Y-I-T. External rotation, sword. ER stretching

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Functional Examinations and Appropriate Rehabilitation Exercises  Low Back/Lower Quarter  

Overhead Deep Squat Test"Instruc(ons  

   

Have patient hold bar over head, feet shoulder width, toes straight and squat down keeping bar over head and heels on ground

Clinical  Ra(onale  Evaluates hip, ankle, and thoracic spine mobility as well as core strength

   

Failure   Exercise  Recommenda(ons  Pain, Inability to break horizontal with thighs, weight shift, or bar comes forward. Knee valgus during any part

   

Depends on Failure: Core strengthening, hip mobility, ankle dorsiflexion mobility, glute med/max strengthening, thoracic extension mobility

Single Leg Squat"Instruc(ons  

   

Have patient stand on one leg and perform a squat. Have them do repeatedly. Stand on 6-8 inch stepand touch the heel of other foot to floor

   

Clinical  Ra(onale  Evaluates activation of the gluteus medius, maximus, quadriceps, and soleus length    

Failure   Exercise  Recommenda(ons  Knee pain, valgus of knee, excessive foot pronation, trendelenburg, body lean, Heel lifts

Clams, fire hydrants, step down, running man, bowler’s squat, single leg stance activities, soleus stretching    

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Step Down Test"Instruc(ons  

   

Stand on 6-8 inch step. Step down and touch the heel of the other foot to the floor

Clinical  Ra(onale  Evaluates activation of the foot instrinsic musculature

   

Failure   Exercise  Recommenda(ons  Pain, Heel raises up, Valgus knee load, Trendelenburg

   

Soleus stretch, glute med strengthening, quadriceps/VMO strengthening

Forward Lunge Screen"Instruc(ons  

   

Patient performs forward lunge    

Clinical  Ra(onale  Evaluates activation of the gluteus medius, quadriceps, and hip mobility

   

Failure   Exercise  Recommenda(ons  Valgus knee load, excessive knee flexion (knee anterior to ankle), knee pain, inability to maintain upright trunk

   

Depends on failure – glute med/max strengthening, core stabilization, quadriceps strengthening    

Single Leg Stance Test"Instruc(ons  

   

Stand on one leg, look straight ahead, opposite leg ideally at hip height and not touching stance leg. Get balance with eyes open, then close eyes    

Clinical  Ra(onale  Evaluates balance, core stability, and glute medius stability  

Failure   Exercise  Recommenda(ons  Trendelenburg (loss of height), gain of height, inability to maintain balance for minimum of 15 seconds  

Depends on failure – glute strengthening, core, or balance training    

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Lat Length Test"Instruc(ons  

   

Patient stands with back against wall with feet forward. Raise arms up to touch thumbs to walls. Move supine to table and repeat if unable to perform. Then flex knees to chest.

Clinical  Ra(onale  Evaluates lat dorsi length as well as thoracic extension and diaphragm weakness

   

Failure   Exercise  Recommenda(ons  Pain, inability to touch walls with thumbs with head to sacrum touching wall    

Lat stretch, thoracic extension exercises, diaphragmatic breathing exercises/retraining

Thoracic Rotation Test"Instruc(ons  

   

Hold bar in front of body and rotate to each direction while sitting. Then Hold bar behind back through arms and rotate again

Clinical  Ra(onale  Evaluates the mobility of the thoracic spine in rotation

   

Failure   Exercise  Recommenda(ons  Pain. <50 degrees rotation with bar in front, <45 degrees with bar behind, loss of >20 degrees from front to back

   

Thoracic rotation strengthening (if active insufficiency); Assisted thoracic rotation; Scapular stabilizer exercises

Vleeming’s Active and Resistive SLR Test"Instruc(ons  

   

Have patient lift one leg 20 cm off table keeping it straight. Switch sides. Then perform again and provide resistance. Finally, do again after asking patient to brace.

Clinical  Ra(onale  Evaluates core stability via activation of the transverse abdominus or obliques

   

Failure   Exercise  Recommenda(ons  Pain or pelvis rotates in any part of the motion on either side. Unilateral failure is more significant.

   

Ab Bracing; New Abs; Multi-Planar Vertical Stabilization; Abdominal activation via posterior weight shift with band (all depends on patient’s ability to stabilize after activation

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Janda Hip Extension Test"Instruc(ons  

   

Patient prone on table, keeps leg straight and extends hip. Palpate hamstrings, glute max, and contralateral lumbar paraspinals

Clinical  Ra(onale  Evaluates activation of the glute max, paraspinals, and hamstrings

   

Failure   Exercise  Recommenda(ons  Delay of glute max and excessive firing of lumbar paraspinals and/or hamstrings; early anterior pelvic tilt

   

Glute max strengthening – 4-way hip, glute squeezes, running man, squats

Janda Hip Abduction Test"Instruc(ons  

   

Patient sidelying on table. Expose waist and have patient abduct leg. Watch for the belt line to stay in place

Clinical  Ra(onale  Evaluates activation of the gluteu medius to create hip abduction

   

Failure   Exercise  Recommenda(ons  Belt line moving toward ribs (activation of QL), external rotation of toes or flexion of hip

   

Glute med strengthening – 4-way hip, clams, monster walk, running man, bowler’s squat

Single Leg Bridge Test"Instruc(ons  

   

Patient supine on floor (not table if possible) and performs a bridge (arms on chest or up). In bridge, one leg is kicked straight. Hold this position for 10 seconds

Clinical  Ra(onale  Evaluates glute max activation over hamstring and lumbar paraspinals

   

Failure   Exercise  Recommenda(ons  Pelvis drops to ground, hamstring cramps, pelvis rotates, lower back pain, can’t hold for 20 seconds

   

Glute max activation – bridges, glute sets, 4-way hip, hip hinging running man, bowler’s squat

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Vele’s Reflex"Instruc(ons  

   

Patient standing in bare feet and they fall forward until they start to fall. Ask the patient to catch his/herself. Watch the toes for gripping into the ground.

Clinical  Ra(onale  Evaluates activation of the foot instrinsic musculature

   

Failure   Exercise  Recommenda(ons  Delayed firing of the foot intrinsics (unilateral is worse)

   

Ski jumpers, Janda short foot, rolling towel, marble pick up, brushing sole of foot with a comb

Common  Glute  Exercises  

MSSE  2013  TRAC  Preceedings  2013  

 

Glute  Max  Ac6va6on  

0  

20  

40  

60  

80  

100  

120  

Clams  

Clams  TB  

Prone  Hip  Ext  

Stand  Hip  Ext  TB  

S/L  Hip  ABD  

Stand  Hip  ABD  TB  

Quad  Hip  Ext  

Quad  Hip  Ext  TB  

Bridge  

Bridge  TB  

FireHydrant  

FireHydrant  TB  

Lunge  

Lunge  TB  

RunningMan  

RunningMan  TB  

Gmax  Healthy  

Gmax  LBP  

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Glute  Med  Ac6va6on  

0  

10  

20  

30  

40  

50  

60  

Clams  

Clams  TB  

Prone  Hip  Ext  

Stand  Hip  Ext  TB  

S/L  Hip  ABD  

Stand  Hip  ABD  TB  

Quad  Hip  Ext  

Quad  Hip  Ext  TB  

Bridge  

Bridge  TB  

FireHydrant  

FireHydrant  TB  

Lunge  

Lunge  TB  

RunningMan  

RunningMan  TB  

Gmed  Healthy  

Gmed  LBP  

Fire  Hydrants  

Clams  

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Running  Man  

Principles  of  Propriocep6ve  Taping  

•  Not  all  tapes  are  the  same  •  Tape  the  area  that  you  exercise/massage  •  Tape  for  the  pain  AND  the  cause  of  the  pain  •  Think  globally,  act  locally  (and  globally)  

Taping to Inhibit Internal Rotators

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Taping to Facilitate Posterior Cuff

Taping to Facilitate Posterior Cuff

Taping to Facilitate Lower Traps

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 bbishop@ssrehab.com  

@drbartonb  

Thank you!