Findings in the Clinic
Assessment findings & Roadmap of Treatment + Training
This past week, an NFL athlete coming off an ACL tear and patella rupture and subsequent reconstruction surgery was referred to me for assessment and treatment by another athlete that I have worked with for years. The athlete wanted me to physically assess the leg that he had injured and treat it accordingly - which I did. I want to take you through the process that I took him through, by explaining in detail the findings and the purpose of treatment and training solutions based on those findings.
Athlete Injury History + Current Physical Issues
We have previously discussed how high-level athletes possess significant kinesthetic intelligence. They can often verbally articulate or physically demonstrate their issue to practitioners in a manner that enables effective identification of the problem. Understanding this, I asked the athlete what he wanted to gain from our session. He proceeded to show me a video on his phone demonstrating a sport-specific drill he was currently performing. He explained that when he plants his injured leg and rotates his pelvis around that lower extremity, he feels a sensation in his knee and hip.
To gain a better understanding, I inquired about the nature of the sensation. I asked whether it was a pain, a block, or a stretch? After contemplating my question, he pointed to the front of his hip, in the groin area, and described it as a block. He then pointed to the inside part of his knee, indicating a stretch. He elaborated that the stretch in his knee felt abnormal and uncomfortable, but not painful. I thanked him for the valuable information he shared and suggested proceeding with a physical assessment of his hip to determine the cause of the blockage sensation. Additionally, I suggested assessing his knee to understand the reason behind the stretching sensation. He agreed to proceed with these assessments.
Hip Joint Functional Range Assessment [FRA]
Considering the physical demands of the athlete, who is a defensive lineman, it is paramount for him to possess the appropriate active joint ranges of motion in his lower extremities that enable him to get into his three-point stance to where his connective tissues are appropriately lengthened + loaded so that when the ball is snapped, he can explode out of that stance at the highest attainable speed. Equally paramount is possessing functioning joints - as we have stated prior that joint dysfunction is a limiting constraint on not just performance but also athlete longevity. Due to these specific physical demands, in the assessment, I placed emphasis on assessing bent knee hip flexion and hip internal/external rotation during his local functional range of motion assessment (FRA).
Bent Knee Hip Flexion
During the local physical assessment of the hip joint, he had a closing-angle block at the end range of motion in bent knee hip flexion during passive range of motion assessment. In addition, when I took the hip to end range of motion in bent knee hip flexion while internally rotating the thigh. The athlete pointed to his groin and mentioned feeling a pinch. I asked if this sensation was similar to what he experienced during the sport-specific drills, to which he confirmed it was in the same location but more intense during the drills.
Continuing the assessment, I passively assessed the hip at the end range of motion in bent knee hip flexion and asked the athlete if he felt a stretch in the back of his hip. He stated that he barely felt any stretch in the back, only the block that escalated into a pinch in the front of his hip. Bringing his hip back to 90 degrees, I asked him to describe what he felt first: the block/pinch in the front or the stretch in the back. Slowly returning to bent knee hip flexion, he reported feeling the block in the front first, followed by a very minor stretch.
Internal Rotation [IR]
At 90 degrees of hip flexion, I passively rotated his hip internally through the range of motion to the end range. There was no stretching sensation, only an elevation of the pelvis at the end range of IR. I did not encounter any hip joint capsular barrier, indicating no capsular connective tissue behaving as an absorbing barrier in the hip joint - a huge issue. When asked about his sensations, the athlete mentioned feeling nothing except the block/pinching sensation in his groin. He confirmed not feeling any stretching in his hip and pointed to his medial knee, stating that he feels stretching in that area when I challenge the hip joint at the end range of motion of hip IR. This aligns with the abnormal sensation he experiences during the sport-specific drills.
External Rotation [ER]
Next, I passively assessed the hip's ER range of motion at 90 degrees of hip flexion. The athlete reported a pleasant stretch, specifically in the posterior hip joint capsule. He described the stretch as feeling normal. From my perspective, I detected tissue tension1 consistent with Dr. Chiver’s description of an escalator sensation rather than an elevator. When I challenged the end range of motion, the athlete experienced a more intense and satisfying stretch.
Hip FRA Findings
The physical assessment showed that the hip was in a state of dysfunction. The optimal tissue tension of an escalator that I detected in hip ER did not exist in bent knee hip flexion or hip IR. Passive range of motion assessment of bent knee hip flexion or hip IR did not even elicit an elevator of tissue tension in the connective tissue of the hip joint capsule - there was no connective tissue that was going to length to stop the thigh bone from moving relative to the pelvis, only compensation in the pelvis/lumbar spine or knee.
Additionally, when I challenged the end range of motion of hip IR, the tissue tension he described was elicited in his knee joint - meaning: I am challenging hip IR, and the tissue that is coming online to absorb that force is in his medial knee. Considering his prior injury history, this is not good at all. From a risk perspective, assessment findings are indicating he is at high risk for re-injury to the reconstructed knee joint. Furthermore, assessment of the knee joint capsule detected that the tissue is functioning like an elevator and not an escalator.
What the Findings Mean in Reality
The findings show that the athlete is not at Point B. This is quite sad, as this athlete has no financial or time barriers to appropriate training and treatment. He has a hip that is in a state of dysfunction. One of the negative consequences of this lack of access to joint space is that he also does not possess the reactive strength within his hip joint capsule, which considering the physical demands of being a defensive lineman in the NFL, is going to be a real problem for him - a problem he is already noticing in non-contact sport-specific drills.
Due to the lack of physical capacity (i.e., not being at Point B), he has to compensate for this dysfunction which is more than likely why when he is performing sport-specific drills, he feels a block in his hip and then abnormal stretching in his knee. Not having a physical assessment of him prior to the injury will not enable us to know with certainty, but I would assume with high probability that this dysfunctional hip joint was a major contributor to the injury that he sustained in his knee joint. Meaning: not resolving the joint dysfunction/reactive strength issue will put him at a very high risk for re-injury at worst and, at best, physically constrain (i.e., limit) him from generating high performance.
The Roadmap to Point B
The good news is that the joint function and reactive strength are trainable qualities that are highly plastic to optimal treatment and training work. The roadmap to Point B starts with him performing maximal effort PAILs/RAILs (i.e., Input 1 of the ISM). This training work with be performed 2-3x per week until the joint normalizes. Once the joint normalizes, we will then have access to the hip joint capsular tissue, and at that point, we will put that tissue on the length loading progression (i.e., Input 2-3 of the ISM). Considering the physical state and trainability of the athlete - which is very high, getting him to Point B is something that is very doable. Whether or not the athlete performs the appropriate training work is really the only question.
Video Follow-Up + Questions
We will be doing a video discussion of this case. Any questions you may have, please leave them in the comments below, and we will do our best to answer them in the video. Thanks!
Chivers, M. (2022). Internal Strength Model [Assessing Connective Tissue Behavior: Tissue Tension Technique]. Toronto, Canada: Functional Anatomy Seminars.
Love this in depth break down! Thank you for the time to be extremely descriptive. Not sure about the other's but these types of case studies with assessment, thought process, and programming are very helpful for my way of learning.
Hey John,
In the case of the above mentioned athlete, the first aim is to be able to access capsular tissue of the hip joint. This is achieved through ME PAILs/RAILs. I assume you are choosing a position that biases hip flexion and Int. Rot. - eg. 90/90 - and sticking with that position each time the athlete preforms ME P/R. What if this position does not elicit the outcomes you were looking for? Will you look to change the position the method is taking place in, or will you reassess the athlete to see if something was overlooked?
Thanks