A Language to Diagnose
Join Kelly Starrett, owner of San Francisco CrossFit and creator of MobilityWOD, as he teaches coaches and their athletes how to diagnose dysfunction.
In Part 7, Starrett makes a plan of action. First, he looks for motor-control issues expressed in positioning faults.
"Let’s fix the movement pattern first," he says. "When you correct mechanics, things stop hurting."
Next, he looks for connective-tissue or sliding-surface problems that can arise from dehydration, stiffness and matted-down tissues.
"What we need to do is shear and restore motion through those tissues," he says.
After evaluating connective tissue, Starrett looks for a joint issue. For athletes and coaches to improve joint mobility, he suggests using a band "to encourage the joint to be going in the right direction."
Finally, Starrett looks for muscle-length issues causing dysfunction. To address these issues, he suggests muscle manipulation such as PNF stretching.
"You can see that it’s working, and any time there’s a nice positive feedback loop, we tend to see behavior changes," he says. "This whole project is observable, measurable and repeatable."
Is it a Motor Control Issue?
And now we've got this basic kind of coaching plan about spine movement, seeing movement efficiency. Now I'm like, Here's my action plan. On the bottom, making the base of this is what? more control man? You're just not externally rotating. You're just in a bad position. You're just breaking your head. Let's fix the movement pattern first, you know, and that's where I started my physical therapy practice, I try to fix the movement first, then I see what the resultant restriction is afterwards and then combine the two so that the first thing that happens is that my patient or athlete goes back into their community, into their gym, and to their home, their life, Knowing what the good mechanics is, I put my energy there first, you know, make sure they know how to treat it and then I treat them third, it's the last thing turns out to work very well. When you correct mechanics, things stop hurting. It's very strange that way, right? I think my neck hurts when my neck hurts. I don't know. Stop doing that.
Is it a Connective Tissue Issue?
Second piece, Connective tissue. What's another word for connective tissue? You guys remember? sliding surfaces. and that can, you know, because technically there's connective tissue. Your muscles and your joints are connective tissue, but what we're talking about here specifically is all the interface of how all these layers slide over one another. Are you dehydrated, are you stiff? Are you just a matted down warrior? You know, right now you're sitting in an awesome position and especially if your professional athlete, (sing, and good job sitting up I see you), you say you're an adult male, you weigh 200 pounds, it's about 100 pounds on each cheek, what happens when you take layers of of tissue, and you put them under high pressure and they're under high temperature, 100 degrees? So you create what? laminate! ass lamination is going on right now. That's what that is. You're taking layers of wet, soggy cheese and sticking them together. Oh, my God forbid you just did a whole bunch of cleaning jerks and you're all injured and stuck together now. So the problem is we do a lot of sitting, a lot of these tissues, just get it adhered down, especially after the fact of lots of muscle damage, a lot of soreness. You know, I'm dehydrate a little bit, a little bit inflamed and so this is a good primer. If I have a layers of a laminate, like a grilled cheese sandwich, do you think the most effective way to fix that is to put a nail through that? No, if you drive a lacrosse ball into your laminated tissues, you probably going to vomit. It's probably not going to change anything. What we need to do is shear and restore motion through those tissues. And that's why we always try to roll on the foam roller. We try to create shear, we twist on the foam roller. We try to pull tissues, past the ball, We use the spiky foam roller, the rumble, the tumble roller, all those things, because we just don't need to put a nail through this laminate tissue. So we need to restore that motion. And that's what this connective tissue is. We see this with skin, we see it with muscles. In fact, I was in the southeast and this guy does this very complicated thing. He's from a school of mashers down there, the southeast. What they do is they take a walker and they straddle you with the walker and they mash you. So what it is, they take your shoes off and they stand on you and break up your muscle fibers and all your connect tissue with huge pressures, but diffuse huge pressures from the foot. And it's it's a miraculous getting mashed is pretty awesome and isn't it how simple it is what do you call this. High pressure compressive fashion release or mashing. Yeah. Call it What it is, it's matching. not not fancy, but you get the idea. We have parallel bars at home and we match each other.
Is it a Joint Issue?
Is it a joint problem? Is a joint capsule problem? And what we're what I'm talking about here is the dense sack of connective tissue. Many of the patterns of dysfunction we see are related to a capsule restriction or a capsular pattern, and you have to account for the capsule. When we do a lot of mobilization with the band, for example, and you'll notice on the mobility WOD that we're always using the band whenever we can. Early on we don't use the band, but I'm a big fan of the band for athletes, particularly because it helps me to kind of make sense and accommodate for this thing called passive accessory motion of the joint. So as you move your limb through a range of motion, of physiologic range of motion, putting my arm up in my head, putting my arm into extra rotation, the joint has some small motions that go along with it. What doesn't happen is there's not a pin going through my head of my humerus in my arms and just rotating around the humerus pin. Basically, the joint has multiple axes of rotation. It rolls, slides and glides. It's a complex movement. So as the shoulder comes up and not only that, but it rolls down, it slides, it'll rotate, it'll twist, locking into tighter position. And so there's a lot of complex movement going on, and I need to account for that movement. As a physical therapist, we work on passive accessory motion. As a chiropractic physician, you're working on passive accessory motion. As an athlete and coach, what do I do? How do I improve a range of motion or physiologic movement? Well, I use a band and I try to encourage the joint to be going in the right direction. Is it like taking a sledgehammer on a peanut a little bit, sort of the wrong tool. But it's very effective and I think it makes mobilizing two or three times more effective, especially since your hip capsule is capable of generating huge amounts of force, is very thick. If I just go ahead and stretch my hamstring, what can I hip flexion here and my hip capsule is stiff. Well I may capture some of the things that need to be stretch here, but what really needs to be stretched is the capsule. It's that stiff, dense fiber cartilage sac that holds the whole joint together. Does That makes sense? So if this this is a joint this is a really ugly joint. But this joint is rotating about a single axis. You can see it's rotating this direction. But because it essentially has more than one kind of axis, as it drops down, it's going to roll, slide, and glide. And so one of the things I can do is as a therapist, I would add a force this direction and then I would encourage that motion. I could feel that restriction. as an athlete, if I can't put a force on or what do I do, put a band to distract the joint or encourage the joint to move into the right range of motion. So as my hip comes up, what the joint has to drop to the back of the socket and down to move effectively. And this is one of the problems that we see when that hip is forward in the socket, then we end up impinging hip on femur. Now have a mechanism for femoral acetabular impingement syndrome. I've impinged myself. My shoulder is living in the front of the socket and I've tipped my scapula over on top of my arm and I raise my arm up. Bam! take that! I'm just having a collision between my humerus, my arm and my shoulder blade. So how do I improve that position? Well, I make sure that the shoulders in a good position and organized, And then there's some things that I can do as an athlete to get that shoulder to the drop to the back of the socket. So any time we can add a band to a stretch or to mobilization, you get, I think a more force multiplies by a factor of like three or four. It's really effective, especially for my thick, strong athletes. Your capsules are so strong. Make sense? You got to have a band. I wish I had stock in jump stretch bands, but I don't.
Is it a Muscle Length Issue?
You usually look at muscle length as one of the last issues. And it's super important. We get tight short muscles and muscles that are tight and short have to be stretched. But we need to do so in an educated manner, in a manner that makes it so that my muscles in just like dead meat, but as part of a complex neuromuscular system, So if I get my brain involved with this whole process, using a process like Proprioceptive Neuromuscular Facilitation or P and F like model, where i use a Contract Relax or Hold Relax system, And I get much better outcomes. I just don't need to hang on the soft tissue that's that doesn't work and leads to a whole host of problems. The PNF stretching, my personal biases is my school was tied into the world center for PNF training if you've heard PNF it's Kaiser Vallejo and my all the senior instructors there were my senior instructors and then my school actually would go as beginner students to the World Center for PNF and perform this kind of rehab on people with brain injuries when people in spinal cord injury, So now that this is my personal bias and I think it works very well for athletes and what I like about this is that you can see that it's working and any time there's a nice positive feedback loop, we tend to see behavior changes. So I don't really care what mechanism or model of soft tissue work or grassin or take a stick or break a chicken neck and wave it over your head, or you take a Chinese soup spoon called boysha and you rake yourself. If it works where' in, it's in, it's in the plan. And what's nice about that is it's all inclusive. Does acupuncture work? You bet your butt it works. you know does Mr. Miyagi weird Chinese therapy hands know Chee work if you deadlift more it works you know that's it. So that's a nice way to think. Is it work or not work. Which leads us to this idea that this whole project is observable, measurable and repeatable, that it's not gonna just work one time, it needs to work every time, and that if you can't see change, there's no change. If you didn't notice a position or increase the quality of range of motion or change your work output, then it's not really working ,It's just sort of subjective mumbo jumbo. I think I feel better, you know. Are you better? Yes. Better, same, worse or is same worse? I don't know. I really like my acupuncturist. No, my physical therapists are good friends. Well, I'm like, Yeah, but you're still missing all the range of motion, your knees and your hips. So what's going on? Muscles are like obedient dogs. Tissues are like obedient dogs. If you give them consistent input, they will change and turn around. We see kids with flexion contractures will cast them at end range. Wait two days, take them out, range them, exercise them, cast them in and range cast of an end range. And in a week warm bodies like Dude, you need that range, I got your back. So if you're saying to yourself, let's sit in the chair and get all short time, your body's like, I got your back, bro. We can do that. You want to get short? We got short, we got to get along, got long. It's about consistent pressure and consistency. And this is where we kind of come in. the Mobility WOD is set up, for example, as an example of how this can work 10 minutes a day at the end. I feel like that consistency of 10 to 15 minutes work extrapolated time seven is an hour plus of mobilization. I mean, it's a significant amount of mobilization. 70, 80 minutes a week is a lot of time treating tissues. And just like we can't train the whole athlete every day, I don't think we need to mobilize the whole athlete every day. I think you hit your problem areas and more importantly, we always give mobilization context. People don't understand why am I doing these ten things? What do I do? Okay, I guess it's working. But if I'm like, We're going to fix your deadlift for improving deadlift today and we go after the deadlift mobilization, then we understand our app and start to see the relationship between cause and effect, between better positioning and their experience.