Who Are These Experts?

Last week I was in my friends house when he handed me the newspaper and said "this will piss you off"! It was a small section in the paper about Dublin senior footballer Bryan Cullen's ongoing low back problems.

In the paper Pat Gilroy is quoted as saying "we thought the problem might go away with rest"!! Cullen has supposedly seen several 'experts' at this stage and yet no one has been able to help him!

The following is what I would do if I was to rehab Bryan Cullens Low back.

1. Ask about job and lifestyle, and a static postural assessment.
2. Breathing Pattern
3. FMS
4. Look at Hip Mobility, and thoracic spine mobility
5. Look at hip flexors, rectus femoris to see if they are stiff/tight/short
6. Look at Core Endurance


Job and Lifestyle, and Static Posture Assessment
First things first. Nobody and I mean nobody should be getting non-contact injuries!! Hamstring strains, quad strains, back pain, shoulder pain, non-contact ACL etc. If you were not hit by something (oppontent, object), you should not be getting injured.

I would ask Bryan what does he do for a living? How long would he sit for at one time? How does he sit. What brings on the pain - flexion, extension, side flexing, rotation.

I would ask him what is current Strength program is, and ask is any exercises affect his back pain. I would proceed to look at his technique at all his exercises. As Eric Cressey once said "Its not what you are doing, its how you are doing it"!

I would also pay close attention to what Bryans Hip hinge pattern is like. Can he dissassociate low back flexion from hip flexion?

In this initial interaction I would also assess Bryans posture. I would look at things like feet, pelvic alignment, spine, neck etc. I know that static postures assessment cannot give you a total picture of what is going on, as they don't tell you how the body functions when moving dynamically, but there are still a good tool to have in the tool-box.

Breathing Patterns
Like a lot of things in our industry (stability balls, foam rollers, workout muse, hip thrusts), breathing patterns seem to be the in thing at this moment in time. There is no doubt though that breathing patterns are a huge factor in pain and disease.

I would look to see if Bryan can effectively use his diaphragm, or does he use his upper chest to breath. If he breathes in his upper chest, instead of his diaphragm, his rage cage will not articulate how it should with each breath, and this in turn can lead to thoracic spine mobility issues. Allows listening to Pavel Kolar, we now are also starting to realize that proper diaphragm function is cruical for spine stability also.

FMS
Does Bryan have mainly a mobility issus or a stability issue, or both? Truth is one effects the other anyway.

The FMS is great brang for your buck assessment tool. I know that it is not the end all and be of assessments. I also know that it is not actually an assessment its a screen, but for the sake of this blog post I am going to call an assessment.

With the FMS I get a chance to see Bryan's feet as his perfroms some of the screens. The feet can tell you a lot about whats going on up the chain. I would look at things like a stiff 1st metatarsal joint, which can lead to a decrease in hip extension, which can lead to less glute strength on that leg, and more compensation in the low back and hamstrings to extend the hip when running, sprinting.

I would be interested to see Bryans shoulder mobility test (for thoracic spine mobility), and active straight leg raise (for hip disassociation, and to see if his in using his hamstrings to stabilze his pelvis instead of his core). Also a look at his trunk stability push up (to see if he can avoid hyperextension), and his rotary core test (to see if his can stabilize his spine effectively). These four assessments are known as the little four.

With the big three I would look for the usual's. Overhead squat - ankle mobility, hip mobility, t-spine mobility. If he can't get a 3/3 on this is it a mobility or stabilty problem. This is where the little four above come in to help with the decision making process.

Hurdle step - How well can he bring the leg over hurdle? Can he disassociate hip flexion and extension? Does he have a stiff hip flexor on the stance leg?

In-line Lunge - Looking for symmetrical stability on both sides. Are the hip flexors stiff and inhibiting the core from keeping the intregity of his posture and spine position. Can he extend his 1st metatarsal joint of his foot? Can he keep his head, upper back and sacrum in contact with th stick.


Look at hip and Thoracic Spine Mobility
99.9% of Low Back Pain (LBP) is not caused by the back. The LBP is the symptom, but it is not the cause. Linda Van Dillen has done research proving that a lack of hip internal rotation can lead to low back pain.

We know from the Joint by Joint model by Boyle and Cook that if the is pain in a joint or segment look above and below the joint for the cause (eg. LBP, look at hip mobility, and thoracic spine mobility).

Perform a Thomas Test
The Thomas Test is another Bang for your buck assessment. The assessment tells you many things about the hip flexors (psoas, illiacus, TFL), the adductors, rectus femoris, piriformis, ITB.

From reading the work of Shirley Sahrmann and listening to Bill Hartmann. I would then have to decide from the thomas test if Brian has stiffness issues or shortness in the muscles mentioned above.

Look at Core Endurance
People with LBP, generally have very poor core endurance. I would have Brian perfrom a plank, side plank, and an isometric hyperextension for time to get an idea of how long and how well he can stablize the spine.

Well there are the main things I would be looking for with Bryan Cullen. There are other things to look at and assess. You could also look at glute function in isolation, but if Bryan has Breathing issues, and a stiff/short anterior hip region (hip flexors, quads), I would already know that there is no way he can be effectively using his glutes to extend his hips, and that his core is not functioning optimally.

Hope you found this interesting. Bryan if reading (very doubthful), give me a call!

Stay Strong,
RB