LUMBO-PELVIC-HIP COMPLEX: TESTING, ASSESSMENT, AND PROGRAMMING
Lumbo-Pelvic-Hip Complex: Testing, Assessment, and Programming
Featured Speaker: Derrick Mc Bride LAc, CSCS
As an Acupuncturist, low back pain is likely a common complaint you treat. You likely have your tried-and-true ways of treating it, whether it’s deep needling of the Huatuojiaji points, Master Tung points, or something else. You also likely have impressive success stories using these techniques to solve problems that other practitioners could not solve. This is a tremendous feat that I’m sure those patients are grateful for.
What I will cover in the first session of my lecture, Lumbo-Pelvic-Hip Complex: Testing, Assessment, and Programming, will be straightforward and easy to implement orthopedic and muscle tests to better understand the nature and anatomy of the common pain syndromes afflicting the lumbopelvic region. Being more proficient in our anatomy and ability to stress anatomical structures for a more concrete orthopedic understanding of the patient’s pain is always a valuable endeavor. After all, our bodies are biomechanical machines, and our pain syndromes often present themselves within the machinery. They are obviously much more than this, but a working diagnosis from this context is a great step towards an actionable treatment plan. For instance, if I can produce 3 or 4 positive tests for the illusive sacroiliac joint pain, I feel strongly that my plan should include direct treatment to the SI joint. That’s a solid anatomical starting point. From there, we can branch off to holistic treatment of the entire person in front of us, knowing we are stepping from solid ground.
If we want to take a step further and consider ourselves sports medicine practitioners, we need to understand how these injuries occur on a deeper level. Going back to being biological machines, there are often parts of the machinery that are dysfunctional but not generating pain. They aren’t holding up their end of the deal movement wise and shuttling unnecessary stress into the painful areas that are now crying out for help. *Insert any of your favorite cliches about the problem not being where the pain is. I tend to favor Ida Rolf’s “where you think it is, it ain't.” * To use our SI Joint case as an example: Are the anterior trunk muscles supporting the posterior structures? Are the hips able to effectively extend? Are the hip flexor muscles inhibiting the hips’ ability to extend? Or are the hips not efficient at extending?
This leads us down many possible paths that will require different solutions. A lack of ability to extend from the hips could either be a hardware problem of the hip flexors not allowing the range or a software problem of the hips and trunk not orchestrating the movement pattern. If it’s the latter, you can stretch your hip flexors till your heart’s content (and many patients do) and you will never solve the problem of the hips and trunk communicating properly to produce the movement pattern efficiently. As acupuncturists, we have the mental operating system already programmed within us to understand these possible differences. We understand that a deficiency in Spleen Qi could come from Fire not creating Earth or from Wood overacting on Earth and that these patterns of disharmony need different therapeutic interventions. The same holds true for patterns of disharmony within movement.
The second session in my lecture will cover the assessment tools and treatment programming to deal with these problems.
And this leads me into a case study I’d like to share that demonstrates the importance of both tool sets I’ll be covering. I was working with a 28-year-old male professional MMA athlete. He was experiencing crippling low back pain that was preventing his ability to train. If he took some time off, the back pain would improve but never fully go away. Most of the time he described it as achy, dull, and limiting his ROM. First thing in the morning he described it as stiff. If he sat for long periods of time, it would stiffen up as well. If he tried to train, it would start radiating into the hip and down the hamstring into the calf. At times this pain was sharp and stabbing. He did not report a loss of strength although the pain would limit his strength.
When he first came in, I performed the Straight Leg Raise Test and Crossed Straight Leg Raise Test to determine if there could be possible nerve entrapment coming from his lumbar spine. These tests were negative for producing radicular symptoms down the leg and at the low back. The patient just reported “tight hamstrings'' despite hitting a functional range of motion of 80 degrees of passive hip flexion. What tested positive were: Right sided muscle tests for the gluteus medius, gluteus minimus, and transverse abdominus. Limited ROM of less than 50 degrees of hip external rotation and less than 30 degrees of hip internal rotation on the right side. As well as palpable tenderness within the right quadratus lumborum and gluteus medius muscles. So, now we had a treatment plan.
I used electroacupuncture on the right QL and gluteal muscles and gave the patient corrective exercises to address the limited hip ROM (90-90 stretch) and lack of transverse abdominis activation (dead bugs). I used multiple tests to rule in and rule out possible pain generators and came up with a clear and concise treatment plan. The patient’s pain reduced immediately, and he was very happy with the treatment. I was pretty happy with the treatment and with myself.
The patient returned a few days later to report he felt great for the rest of that day, went back into training the next day feeling hopeful. He began with a warmup. got into some drill work, then transitioned to the heavy bag. He went to throw his first kick and noticed he had no power and the back pain immediately returned. I went through my assessment again and came across the same positive tests. I thought to myself, maybe it was just too much too soon? However, this patient had a fight coming up and needed to get back to training. He didn’t have time to wait. Did I miss something? Yes. Yes, I did.
The first appointment I assessed the patient’s main pain areas. The low back and the hip. I found positive tests for pain generators, and I found limitations in movement abilities. However, I didn’t assess the joint above. I was so focused on the low back and hip that I didn’t think to consider the way the thoracic spine was moving. In general, when there is an injury or pain, the areas you want to assess are the injured joint and the joints above and below. I then performed my thoracic spine extension and rotation assessment (that I will cover in this lecture) and noticed a dysfunctional and painful test to the left sided thoracic spine extension and rotation. This patient was lacking the ability to coordinate thoracic spine extension and rotation on the left side and that was contributing greatly to his pain. Here we found a movement pattern at a joint segment above and on the opposite side from where the patient was experiencing the pain. This should come as no surprise to us, but we can often overlook these things.
With the new information, I treated the patient as I did before except this time, I added left sided transverse abdominis and internal oblique electroacupuncture that I learned from my good friend, Dr. Jenny Neiters. It immediately improved the thoracic spine extension and rotation assessment and the pain. I followed it up with an exercise (half kneeling windmill) to integrate the new movement pattern and to get the treatment to “stick.”
I worked with this patient for years after this and the pain never came back. The day after the treatment, he was able to hit the heavy bag with full force without pain for the first time in months. His fight name is “THUD” because of the way his kicks land on his opponent. His teammates reported that he was back to his namesake self.
I use this example because it demonstrates how I used both sets of tools I will be going over in this year’s lecture. I used orthopedic and muscle testing to create a precise and simple treatment that directly targeted the patient’s main pain generators while (sort of) ruling out more serious injuries involving the nerve roots of the lumbar spine. I used movement assessments to assess the function of the joints above and below the pain generators to determine dysfunctional movement patterns that were contributing to the injury.
With that, we not only treated the patient but educated and empowered the athlete to continue treatment at home with corrective exercises to fully rehab the injury back to a functional level and allow him to continue with his training.
While I may have missed the full picture on the first session, I was able to go back to my systems and quickly catch a problem that was disguising itself and had been overlooked for months until that point. My ultimate goal for my sports medicine practice is to simply, precisely, and comprehensively address my patient’s pain and to help them rehab their dysfunctions to a fully functional level. I hope to share these tools with you all during this year’s conference and I look forward to all becoming better through our shared time together.
Derrick McBride has over a decade of experience as a strength and conditioning coach working in sports medicine and performance facilities. After becoming a Licensed Acupuncturist, he set out to bring the worlds of movement and acupuncture together. Derrick works with many professional athletes alongside his private practice in Pittsburgh, PA. Derrick has worked as one of Whitfield Reaves' teaching assistants, teaches doctorate classes at Colorado Chinese Medicine University, presents at conferences, and runs weekend workshops on testing and programming. He specializes in bringing orthopedic testing, muscle testing, movement assessments, and corrective exercise programming to Acupuncturists in a systematic, digestible, and clinically effective way.