This article was written after I had the pleasure of attending a two-day seminar with Dr. Shirley Sahrmann, author of Diagnosis and Treatment of Movement Impairment Syndromes. Throughout the course, and then on the eight hour drive home, I had a lot of opportunity to really think about what I learned and its relevance. This article presents a combination of what I learned from Dr. Sahrmann, as well as some of the thoughts it provoked.
I don’t care how much you don’t move
This was a statement she made repeatedly throughout the course, and reflects the premise that it is usually the place that moves too much that is the problem. This is in keeping with her belief of exercise instead of manual therapy as the best approach for addressing movement disorders, because manual therapy typically addresses shortness.
Further to this, she discussed relative flexibility: That it is repeated movements and prolonged postures that cause movement disorders by causing what she refers to as directional susceptibility to movement (DSM) and relative flexibility. This is an extension of basic physics: movement will follow the path of least resistance. In an ideal body, that path will move in a manner that maintains optimal positioning of joints and involvement of appropriate muscles so that it does not cause wear. In a body that has been changed through repeated movement or prolonged postures, the path of least resistance can lead to suboptimal movement.
In consideration of this new path of least resistance, she notes that it is what moves that hurts, and so to correct the problem, you have to address the movement, not just the limitation. Consider a situation where someone has tight hip flexors that then cause compensatory movement in the lumbar spine. Will lengthening the hip flexors correct the problem? Her answer is that it will not, because the lumbar spine is now too long. Even with lengthened hip flexors, movement will continue to take place in the lumbar spine. You have to prevent the movement to fix the problem. This does not mean that we should forget about the hip flexors; in this example, their tightness was the cause of the problem. It means that once an altered pattern has occurred, fixing the cause is not enough anymore; both the cause and the compensation must be addressed.
Where does the hip end and the back begin?
Where indeed. Dr. Sahrmann spent the first day talking about the spine and demonstrating the assessment she does for patients who present with low back pain. On the second day she spoke about the hips and demonstrated the assessment she does for patients who present with hip pain. The assessment was remarkably similar. She noted that with almost all of her back pain patients, the hip was contributing in some way, and that usually (80-90% of the time) posterior hip pain is from the back.
This should come as no surprise to those who subscribe to the joint by joint training approach.
Glutes are external rotators?
Not always! In hip extension, your glutes do work as external rotators. But with hips flexed, your glutes work as internal rotators! She discussed this finding from “Variation of rotation moment arms with hip flexion“. She also noted that the body has no primary hip internal rotators.
What are the implications, beyond the fact that it is interesting? If we are targeting external rotation in the glutes with the hip flexed, are we? We are working the deep hip rotators, but not the glutes. This has led me to reconsider the validity of exercises like clams for glute medius activation. They are typically done with a hip flexion angle of about 45 degrees, but this is clearly a sub-optimal angle for external rotation for the glute medius. Does this make them a poor exercise choice entirely? Or does it make them an exercise that should be done with the hips at 90 degrees flexion to work deep hip rotators and with the hips in extension to work the glutes? I am currently experimenting with this exercise at both of these positions and a few angles in between. I think there are additional implications of this variation in glute function, but I am still pondering them. For instance what does this mean for exercises that work through a large hip flexion range of motion, like a squat or deadlift? Does it change our interpretation of the meaning of an externally rotated hip at the hip-flexed position of a single-leg Romanian deadlift?
Structural problems of the hip
The concept of “I don’t care how much you don’t move” also extends to treatment by the therapist. Initially this was discussed in relation to Femoroacetabular impingement (FAI), but she continued to mention it in regard to other structural anomalies such as excessive anteversion and retroversion.
Her lesson to therapists: If the range of motion (ROM) is limited and it feels like it is at end range, do not force it. Dr. Sahrmann suggested that up to 50% of people that present with hip problems have a structural anomaly. Assuming this is true, then we need to pay more attention to assessing hip movement before we train our clients. Similarly therapists should give more consideration to how patients move before treatment. Stretching a movement that has structural limitations is going to cause problems. Dr. Sahrmann pointed out that many patients who are diagnosed with FAI are told by their doctor to avoid physical therapy because it can make it worse. She further suggested that this is an unfortunate result of physical therapists trying to increase ROM despite a structural limitation.
My take is that for trainers, this correlates with what Dr. Stuart McGill has said about assessing the hips before having clients squat. Whether it is a supine passive hip ROM assessment or a quadruped rocking test, we have to see where our clients have the best and worst ROM in hip flexion before we decide what position (if any) they should take to squat.
Further to this, Dr. Sahrmann pointed out that she believes it is hip hyperextension that is responsible for many of the hip pathologies she sees, even though the pain is felt in flexion. She also pointed out that the labrum is thinner anteriorly and that labral tears are more common anteriorly. This makes sense considering that hyperextension of the hip can push the femoral head into this thin anterior labrum. She suggested that everyone look at the standing posture of their clients, particularly those who complain of anterior hip pain. Are their knees and hips in hyperextension?
Rotation was also discussed as a significant contributor to labrum injuries. When an athlete plants in a field sport, their cleats are stuck, and since they are standing (hip extension), there is no internal rotator and therefore resistance is provided by either the knee or hip joint. Dr. Sahrmann suggested that we should be teaching athletes to shift their weight to the other foot before they rotate. Interesting thought, but what is the effect on performance? Can a player turn as effectively and push off with as much power if weight is shifted first? I want to learn more about this.
Dr. Sahrmann discussed the relevance of the psoas in hip pathologies, noting that the psoas is not the problem in hip pathologies, but rather a psoas that does not function properly can be a problem. She suggested that psoas tendonitis (or tendinosis) often occurs with hip pathology, but that it is not the cause. The cause is that the hip is being moved wrong.
She also noted that she thinks psoas-release surgery is not a good idea. She pointed out that often people believe hip popping or snapping is the result of hip flexors that are too tight. She went on to note that typically the hip popping occurs during extension from active flexion, but that it usually occurs well before full extension, which suggests the problem is not psoas length. Additionally, it typically does not occur with passive movement. In fact she noted that typically if iliopsoas is tested, it is usually not short. She believes that the psoas is not firing rapidly enough so it jumps laterally and ends up catching on the pubic ramus.
Her suggestion to address this is along the same lines as her recommendations for all problems: retrain the muscles that are not functioning properly.
Everyone should move the same way?
Another important message that Dr. Sahrmann tried to make clear was that it is important to realize that there are differences in hip structure. She suggested that structural variations should direct activity. As an example, she suggested that women who have femoral anteversion should not do ballet. This is similar to suggestions by Dr. McGill that if someone wants to be a competitive cyclist, they need to have the right parents so their back is flexion tolerant.
This relates back to Dr. Sahrmann’s belief that approximately 50% of hip pathologies involve a structural anomaly. She supported this claim with a graph of medial hip rotation results from “Lower-extremity rotational problems in children. Normal values to guide management”. The results were extremely varied, with many being outside the 2 standard deviation range. She pointed out that assuming everyone’s hips move to the standard is like assuming that all women in North America are 5’4″ because that is the average.
This is a critical element of her approach, and one that causes a big question mark for me in terms of impact to my training approach. She stated that she does not think that everyone should move “normally”, because many people are not “normal”, and she went on to point out that situations where we correct “abnormal” movement can cause problems. This was specifically noted in relation to the variations that are seen in hip structure. Does this contradict the Functional Movement Screen (FMS) overhead squat requirement that feet stay pointed straight ahead? I have read that this test position is set for a standard, and that this is not necessarily the optimal squat stance, but that everyone should be able to perform a squat this way. Given the difference in our hip anatomies, is that a valid claim?
Are we sure about belly breathing?
Dr. Sahrmann noted that for people with back pain, one of the things she looks at is how well they move in the thoracic region. This fits nicely with the Joint by Joint Training philosophy proposed by Michael Boyle and Gray Cook, and that many quality strength coaches espouse. For Dr. Sahrmann, however, she is looking to see if people move their ribs when they breathe. She places a measuring tape around the ribcage at the bottom of the sternum, and then measures it at the end of exhalation and again at the end of inhalation. She would like her patients to have this diameter increase by at least 3 inches.
I asked her how this relates to the concept of belly breathing over chest breathing, to which she responded that she doesn’t really understand belly breathing. A brief discussion ensued, with talk of using the diaphragm more, and she acknowledged that those who breathe by pulling in the abdominals are moving incorrectly. Her main point is that she wants to see a longer torso, particularly in the older population where she finds the compression on the spine is too much. This led me to re-evaluate my training focus on belly breathing instead of chest breathing, because I now believe we want diaphragmatic breathing with chest expansion.
Sahrmann and the strength & conditioning specialist
Sahrmann presented her movement systems syndromes (MSS) approach. At the very core is the need to take an active versus passive approach to fix disorders, which means exercise. She noted that the best way to treat movement systems is with movement. This is why she does not treat anyone. She identifies the problem through a very thorough assessment and then the patient does the homework she gives them.
She further noted that movement disorders and abnormalities often precede pain, which is not a surprising claim. In my view, these two points – treatment through exercise and recognition that disorder precedes pain makes Dr. Sahrmann an excellent resource for strength and conditioning specialists. Physical therapists see patients once they are in pain; we see them without pain. So who is in the best position to address movement dysfunction?
I actually think she would disagree with this suggestion. In fact she noted a wish that people would come to the physical therapists when they want an exercise program, instead of going to the “pilates instructor”. I had the impression that the “Pilates instructor” was meant to include personal trainers and strength coaches.
Diagnosis and Treatment
Dr. Sarhmann spent a significant portion of the seminar sharing with us the assessments that she uses for her clients. To go through all of the assessments is far too in-depth to cover in this article, and to cover only a portion would be counter to her assessment concept: that it is critical to really understand all of the details of how someone moves before providing a correction. I had previously read the movement assessments in her book, along with the tables showing the correlations to the movement impairment disorders and treatments, but I did not really appreciate the extent of their inter-relationships. This is particularly true with impairments of the hip, where the variety of potential structural anomalies (coxa vara, coxa valga, retroversion, excessive anteversion, femoroacetabular impingement) combined with the number of contributing muscles each with primary and secondary functions, results in many, many possible outcomes.
This became a bit of a quandary for me. Dr. Sahrmann is teaching a complex series of simple assessments that produce a complex series of simple solutions. They are intended for physical therapists, and they are intended to address painful movement patterns. The quandary is that diagnosis and treatment of painful movement is outside my scope of practice as a strength & conditioning coach. But is performing a system of simple assessments? Is recommending exercises to encourage proper movement?
It became very clear to me that if I was a physical therapist, that I must spend more time studying and practising the assessments in her book, and get comfortable with combining the results of them all into a corrective exercise program. But I am not a physical therapist. I am a strength coach. Clients hire me to help them move better, to be stronger, and to be fit. Becoming practised at this science of movement systems would allow me to do those better. But there is a voice in the back of my head that questions if this would be crossing a line that should not be crossed. Somehow I do not feel that screening my clients with the Functional Movement Screen (FMS), or with additional tests from Kendall and McGill cross that line. I will forge ahead with more studying, and I hope the more I learn, the more clarity I will have on how to apply this knowledge.
Elsbeth Vaino, B.Sc, CSCS is a personal trainer with a particular interest in hip anatomy as a result of personal experience with FAI, labral tearing, and arthritis.