Miss B is a 26 year old female who initially presented to Physio Connection on January 23, 2019 with right medial knee pain and swelling. The right knee pain started 3 days earlier when she was at the gym. She was doing a stretching session and twisted her knee as she stood up from the floor. During this movement she also felt her right patella sublux for a brief moment. This was a familiar feeling for Miss B as she had a significant right patella dislocation 8 years prior and has not been confident with her right knee and leg since.
Following the initial patella dislocation 8 years ago, Miss B had approximately 10 sessions of physiotherapy over 3-4 months. The focus of this treatment was to improve the strength of the quadriceps and gluteal muscles. There was an initial improvement in her condition but then she plateaued and did not fully recover. There were no investigations, for example an MRI, conducted to identify a reason for this lack of progress. Since then she has had ongoing problems with strength and confidence. She feels like the leg and knee just cannot do certain things, for example: running or lifting a higher load in the gym with squats. Miss B identified these as goals she would eventually like to achieve.
Past Medical History
Miss B had significant childhood asthma between the ages of 7 and 14. Her asthma improved with age, now it is mild and she only occasionally uses salbutamol for symptom relief. Associated with this, Miss B also had episodes of acute bronchitis at the ages of 13 and 17.
At the initial assessment, Miss B had two main concerns:
- Acute right patella subluxation resulting in: mild patellofemoral swelling, significantly reduced range of motion (80 degrees knee flexion, full extension), significantly reduced right quadriceps activation (Grade 2 strength) and reduced ability to weight-bear through the right leg.
- Long term (over the last 8 years) weakness and reduced confidence with her right knee and leg. She also reported an associated right anterior ankle tightness and restriction into dorsiflexion with squatting.
At Miss B’s initial treatment session her knee symptoms were too acute to begin addressing the long term picture of her condition. Therefore, this session was focused on:
- Addressing Miss B’s immediate concerns outlined above.
- Gaining Miss B’s trust in order to have her invested in the longer term rehabilitation process.
The following treatment was employed in the first session:
- Release with awareness of the right tensor fascia latae (TFL) and right gluteus maximus.
- Release with awareness of the right genu articularis.
- Home exercise program: gentle knee active range of motion within pain limits; right quadriceps muscle activation (static and inner range).
By the second treatment session 7 days later, the acute symptoms had settled. We could now address long term goals and develop a plan to achieve those goals.
Miss B thought she had a moderate reoccurrence of the right knee injury that she sustained 8 years ago. Due to her ongoing difficulty with high loads she thought she would never return to higher level physical activity. Also, her mother has long term knee problems and she thought that she inherited it.
Over the past 8 years she has continued to go to the gym to maintain her fitness and functional capacity, albeit at a lower level than she would like. Even though she did not think there was much that could be done to improve her condition, she was willing to try a new approach to working with her whole body.
Miss B identified two tasks which she would like to return to, with confidence:
- Squats with weights
Based on these meaningful tasks, the following screening tasks were chosen to assess:
- Standing postural screen
- Right one leg stand (OLS)
- Standing trunk rotation
Standing Postural Screen
A standing postural screen is required to establish the starting position of each body segment for the screening tasks of squat, right OLS and standing trunk rotation.
Miss B had no awareness of symptoms during the standing postural screen.
Findings for the Standing Postural Screen:
Functional Unit #1 (FU#1) = 3rd thoracic ring to hips
Pelvis: Left transverse plane rotation (left TPR) with a congruent left intrapelvic torsion (left IPT).
Hips: Right femoral head (FH) anterior relative to the right acetabulum. This was congruent with the pelvis position.
Thorax: Lower thorax was left rotated – 7th thoracic ring (TR) right translated / left rotated. Upper thorax was right rotated – 3rd and 4th TRs left translated / right rotated.
Lumbar: L5 rotated left. This was congruent with the pelvis position.
Driver for FU#1: No driver found for FU#1 as this was a starting screen.
Functional Unit #2 (FU#2) = cranium to 2nd thoracic ring
Cervical spine: C7 left translated / right rotated.
Upper thorax: 2nd thoracic ring (TR) right translated / left rotated.
Shoulder girdle: Intra-shoulder girdle torsion (ISGT) right.
Driver for FU#2: No driver found for FU#2 as this was a starting screen.
Functional Unit #3 (FU#3) = extremities
Knees: Right medial tibiofemoral (TF) joint mildly compressed.
Feet: Normal alignment.
Driver for FU#3: No driver found for FU#3 as this was a starting screen.
The squat screening task was chosen as this is one of the tasks Miss B identified she would like to improve her confidence with in the gym. An optimal squat strategy is one that has normal alignment, biomechanics and control (ABCs) within each region and between each region of the body: both innominates should remain posteriorly rotated with respect to the sacrum (sacroiliac joint (SIJ) control); the pelvic should remain neutral in the transverse plane and anteriorly tilt as a unit; the femoral heads (FHs) should remain centered in their respective acetabulum; all lumbar vertebrae should remain neutral; there should be not any TR translations / rotations; and all lower limb peripheral joints should move symmetrically with respect to the opposite side. Ideally it should also feel smooth and easy for the subject to perform.
During the squat, Miss B felt she was not able to maintain even weight-bearing through both legs. While there were no right knee symptoms, she did not feel completely confident with her right leg. She also reported a tightness and restriction in the anterior right ankle joint.
Findings for the Squat Task:
Pelvis: Left TPR increases at 20% into the squat. Loss of control of the right SIJ 40% into the squat.
Hips: Anterior right FH translation maintained throughout squat. Medial compression and internal rotation of the right FH occurs at 20% into the squat.
Thorax: Lower thorax – 7th TR translation right / rotation left increases at 20% into the squat. Upper thorax – 3rd and 4th TR translation left / rotation right increases at 10% into the squat.
Lumbar: L5 rotation left increases at 20% into the squat.
Drivers for FU#1: Manual correction of the 3rd and 4th TRs resulted in some improvement (but not full correction) of the ABCs of the pelvis, right SIJ, right hip and L5 in the squat task. Miss B also felt the squat was a little smoother and easier to perform. Therefore, the thorax was the primary driver for FU#1 in the squat screening task, TR 3 and 4 being the primary segments impaired.
Cranium: not assessed as it was neutral in the standing postural screen.
Cervical spine: C7 translation left / rotation right increases at the initiation of the squat.
Upper thorax: 2nd TR right translation / left rotation was maintained throughout squat.
Shoulder girdle: Intra-shoulder girdle torsion (ISGT) right increases at the initiation of the squat.
Driver for FU#2: Manual correction of C7 improved both the 2nd TR and the shoulder girdle ABCs in the squat task. Correction of the 2nd TR made C7 and the ISGT worse. Correction of the ISGT did not improve C7. Therefore, the neck (C7) was the driver for FU#2 in the squat screening task.
Knees: Right medial TF joint compression is maintained throughout the squat. There was also non-optimal biomechanics of the femur and tibia (screw-home mechanism) through the squat task: the femur did not externally rotate relative to the tibia as Miss B went into knee flexion.
Feet: Increased compression through the anterior aspect of right talocrural joint. The tibia had a reduced glide anteriorly over the talus.
Driver for FU#3: Decompression of the medial TF joint improved the anterior compression of the talocrural (TC) joint and subjective awareness of anterior ankle tightness through the squat task. Therefore, the right knee is the driver for FU#3 in the squat screening task.
Relationship between drivers of the functional units: comparing corrections of FU#1, 2 and 3 (3rd and 4th TRs, C7, and right knee).
- Correction of C7 improved the 3rd and 4th TRs (but not completely) and the right SIJ, hip and knee (almost completely). Correction of 3rd and 4th TRs improved C7 a small amount, but not the hip, knee and ankle.
- Correction of both C7 and then the 3rd and 4th TR resulted in complete correction of the right SIJ, hip, knee and ankle with the squat task.
- Miss B also reported correction of both C7 and the 3rd and 4th TR resulted in the best feeling of ease and improved confidence with the squat task.
- Therefore, the neck (C7) is the primary driver and the thorax (3rd and 4th TRs) are the secondary driver for the squat task.
Right One Leg Stand (OLS)
The one leg stand screening task was chosen as Miss B wants to return to running. A prerequisite for running is the ability to stand effectively on one leg. Miss B was less confident and found it more difficult to stand on her right leg compared to her left.
Findings for the right OLS screening task:
Pelvis: Left TPR is maintained and there is loss of control of the right SIJ at 40% into the right OLS task.
Hips: Right FH maintains right anterior translation relative to the acetabulum.
Thorax: Lower thorax – 7th thoracic ring maintains translation right / rotation left in the right OLS task. Upper thorax – 3rd and 4th TR translation left / rotation right increases at 10% into the right OLS task.
Driver/s for Functional Unit #1: The 3rd and 4th TRs were the first segments to display non-optimal ABCs. Manual correction of the 3rd and 4th TRs resulted in restoration of the ABCs of the right SIJ and right hip in the right OLS task. Miss B also felt the squat was easier to perform and she improved confidence. Therefore, the thorax (3rd and 4th TRs) was the primary driver for FU#1 in the right OLS screening task.
Cranium: not assessed as it was neutral in the standing postural screen.
Cervical spine: C7 translation left / rotation right increases at the initiation of the right OLS.
Upper thorax: 2nd TR right translation / left rotation was maintained with the right OLS.
Shoulder girdle: ISGT right increases at the initiation of the right OLS.
Driver for FU#2: Manual correction of C7 improved both the 2nd TR and the shoulder girdle ABCs in the right OLS task. Correction of the 2nd TR made C7 and the ISGT worse. Correction of the ISGT did not improve C7. Therefore, the neck (C7) was the driver for FU#2 in the right OLS screening task.
Knees: Right medial TF joint compression is maintained with the right OLS.
Feet: not assessed as was neutral in the standing postural screen.
Driver for FU#3: The right knee is the driver for FU#3 in the right OLS screening.
Relationship between Drivers of the Functional Units: comparing corrections of FU#1, 2 and 3 (thorax, (3rd and 4th TRs), neck (C7), and right knee).
- Correction of C7 improved the 3rd and 4th TRs (but not completely) and the right knee (almost completely). Correction of the 3rd and 4th TRs improved C7 a small amount, but not the right knee.
- Correction of both C7 and then the 3rd and 4th TR resulted in complete correction of the right knee in the right OLS task.
- Miss B also reported correction of both C7 and the 3rd and 4th TR resulted in the best feeling of improved confidence and balance with the right OLS task.
- Therefore, the neck (C7) is the primary driver and the thorax (3rd and 4th TRs) is the secondary driver for the right OLS task.
Summary Point: The drivers are the same for both the squat and the right OLS task.
Standing Trunk Rotation
Standing trunk rotation is a useful screening task for two reasons:
- Trunk rotation is necessary for optimal biomechanics in running. The trunk needs to counter-rotate with respect to the pelvis and lower extremity. If the trunk cannot rotate optimally in either direction there may be adverse consequences in any part of the body, especially load-bearing regions.
- It provides another feedback mechanism for patients to feel when there body is and is not moving optimally.
When attempting standing trunk rotation, Miss B was not able to feel any limitations of movement nor any differences in quality between rotating right or left. For this reason, we used seated rotation as a screening task.
Seated Trunk Rotation
Miss B had reduced left trunk rotation (60% of full rotation) compared to right trunk rotation (80% of full rotation). Miss B also found it more of an effort to rotate left compared to right. For this reason, left rotation was the primary focus in this task. In addition, left trunk rotation is also necessary for an optimal right OLS, which Miss B also has difficulty with.
Findings for the Left Seated Trunk Rotation Screening Task:
Pelvis: Pelvis maintains left IPT and left TPR.
Hips: Right hip maintains anterior translated.
Thorax: 3rd and 4th TRs maintain their relative left translation / right rotation position throughout the left seated trunk rotation task.
Driver for FU#1: Manual correction of the 3rd and 4th TRs was more difficult in sitting, so they were corrected in standing and then Miss B sat down to assess the impact of the correction on left trunk rotation.
As stated above with the squat task, correction of the 3rd and 4th TR improves (but didn’t completely restore) the pelvis and right hip alignment and biomechanics. This was also the case with sitting down onto the treatment table. While maintaining the correction of the 3rd and 4th TRs, both left and right trunk rotation improved to approximately 90% of full rotation. Therefore, the thorax (3rd and 4th TRs) was the primary driver of FU#1 for left trunk rotation in sitting.
Cranium: not assessed as it was neutral in the standing postural screen.
Cervical spine: C7 translation left / rotation right was maintained through the movement.
Upper thorax: 2nd TR right translation / left rotation was maintained through the movement.
Shoulder girdle: ISGT right was maintained through the movement.
Driver for FU#2: As for FU#1, C7 was corrected in standing before sitting down and testing left trunk rotation. Correction of C7 improved both the 2nd TR and the shoulder girdle. It also improved left trunk rotation approximately 10-15%. Therefore, the neck (C7) is the primary driver of FU#2 for left trunk rotation in sitting.
FU#3 was not assessed for the trunk rotation in sitting task as correcting C7 and the 3rd and 4th TRs cleared the medial TF joint and anterior TC joint compression in standing and during the squat task.
Relationship between Drivers of the Functional Units: comparing corrections of FU#1 and 2 (thorax (3rd and 4th TRs) and neck (C7)).
- As stated above, correction of C7 improved the 3rd and 4th TRs (but not completely). Correction of 3rd and 4th TRs improved C7 a small amount. However, correction of 3rd and 4th TRs improved trunk rotation better (subjectively and objectively) than C7. This implies the thorax is the primary driver and the cervical spine is a secondary driver for the task of trunk rotation.
- Correction of both C7 and the 3rd and 4th TR resulted in full restoration of trunk rotation to the left and right. Miss B also reported correction of both C7 and the 3rd and 4th TR resulted in the best feeling of ease and range of motion left trunk rotation task.
- Conclusion: the thorax (3rd and 4th TRs) is the primary driver and the neck (C7) is the secondary driver for the left trunk rotation task.
Screening Tasks Summary
The results of the above screening tasks provide us with the most ideal part of the body to investigate further. A primary driver is defined as the area of the body that, when corrected, yields the best response in the ABCs of the other areas of the body. Ideally this also leads to a subjective improvement in pain, ease of movement or strength. Similarly, a secondary driver also improves other areas of the body, but not as much as a primary driver. There are also scenarios where two areas of the body equally improve ABCs in other areas of the body. These are called co-drivers.
A summary of Miss B’s findings so far are:
- Squat: primary driver = cervical spine: C7, secondary driver = thorax: 3rd and 4th
- Right OLS: primary driver = cervical spine: C7, secondary driver = thorax: 3rd and 4th
- Seated trunk rotation: primary driver = thorax: 3rd and 4th TRs, secondary driver = cervical spine: C7.
Now that the primary and secondary drivers for the meaningful tasks had been identified, further assessment of the drivers was required to determine the type of system impairment (neuromuscular, visceral, myofascial or articular) that was causing non-optimal ABCs. This assessment includes interpretive reasoning of:
- Active mobility
- Active control
- Passive mobility
- Passive control.
A vector analysis was conducted during active and passive mobility testing to determine direction, length and location of the vector/s that caused the non-optimal ABCs.
Further Assessment of C7
- Active mobility: C7 was restricted into left cervical spine rotation and had no limitation into right cervical spine rotation.
- Passive mobility: when correcting C7, vector analysis revealed a short inferior anterolateral vector on the left side. This vector was identified as the scalenus minimus muscle (also known as the transverse pleural ligament). It originates on the pleural dome, runs against the anterior scalene and inserts into the transverse process of C7 (and sometimes C6). This anatomical entity is a blend of both visceral (part of the suspensory apparatus of the pleura) and neuromuscular systems (a cervical spine muscle). A further confirmation of this vector was achieved by observing the response of C7 with a breath hold on inspiration. With this manoeuvre, C7 was unable to be corrected. Therefore, this is a blend of visceral and neuromuscular system impairments.
- Active control test: is used to evaluate the force closure mechanism provided by the chosen motor control strategy, which is known to be individual and task specific. It was not tested at this point as the alignment of C7 was non-optimal. It will be tested at a subsequent treatment sessions with the identified screening tasks of squatting and right OLS.
- Passive control tests: evaluate the form closure mechanism (the ability of the passive components (capsule, ligaments) of the joint to resists shear forces). This was not tested as there was no indication from the history (ie. no trauma) that passive control components of C7 would be compromised.
Further Assessment of the 3rd and 4th TRs
- Active mobility: left seated trunk rotation was used to assess the active mobility of the 3rd and 4th Active listening for vectors (part of vector analysis) during left seated trunk rotation revealed the same vectors as noted below during passive mobility testing.
- Passive mobility: when correcting the 3rd and 4th TRs, vector analysis during correction revealed two medium length parallel vectors which originated from the lateral aspect of the TRs and towards the medial border of the scapula. These vectors were identified as the left serratus anterior, confirmed by palpable hypertonic muscle fibres. The correction of this neuromuscular system impairment was difficult to attain, however, by correcting slowly, incrementally and with the breath, the local region did relax and it was possible to correct most of the malalignment.
- Active control: was not tested at this point as the alignment of the 3rd and 4th TRs were non-optimal. It will be tested at a subsequent treatment sessions with the screening tasks of squatting and right OLS.
- Passive control: this was not tested as there was no indication from the history (ie. trauma) that passive control components of the 3rd and 4th TR would be compromised.
Further Assessment of the 3rd and 4th TR after Treatment of Serratus Anterior
- Passive mobility: after the serratus anterior fibres were treated with a ‘release with awareness’ (RWA) technique, another vector was revealed with passive mobility testing which was attached to the posterior elements of the 3rd and 4th
- The vector went deep into the center of the thorax. It was a short to medium vector that created a ‘stickiness’ when a correction of the 3rd and 4th TRs was attempted. This vector was identified as the inferior part of the vertebropericardial ligament. The vertebropericardial ligament blends into the endothoracic fascia and the anterior longitudinal ligament.
- This is a visceral system impairment.
Further Assessment between C7 and the 3rd and 4th TRs
- Passive mobility: after the vertebropericardial ligament was released, another vector was identified between C7 and the 3rd and 4th This vector felt like it created a slight compression between the two drivers and they were not able to move completely independently of each other. This vector originated anterior to C7 and connected within the 3rd and 4th TRs. This anatomical entity was identified as the prevertebral layer of the deep cervical fascia at the C7 level and the endothoracic fascia at the 3rd and 4th TR levels. These two layers of fascia are continuous with each other. This is a myofascial system impairment.
Miss B’s difficulties with her right knee and leg started 8 years ago with a right patellofemoral dislocation. Even though she spent 3-4 months attempting to rehabilitate the injury, her strength and confidence never fully returned. Consequentially she just modified her activities to stay within her loading capacity and comfort zone.
My hypothesis is that the non-optimal ABCs of the various areas of the body outlined so far (primary driver: cervical spine with C7 neuromuscular / visceral impairment, secondary driver: thorax with 3rd and 4th TR neuromuscular impairment, pelvis, right hip, right knee and right ankle) had existed before the injury to varying degrees. While it is not possible to definitively say, they may have even contributed to the initial patellofemoral dislocation 8 years ago. The primary and secondary drivers may have been related to the history of asthma and bronchitis. Infections, persistent coughing and increased work of breathing could cause the restrictions found in the muscles and ligaments connecting between the pleural dome and C7; the pericardium and the 3rd and 4th TRs; and the fascia connecting between C7 and the 3rd and 4th TRs. They would also increase the likelihood of hypertonic serratus anterior and pectoralis minor fascicles.
A treatment plan was developed using the principles of the Integrated Systems Model (ISM): first release and align the primary and secondary drivers, then teach strategies to connect with and control these drivers, and finally integrate these new ABCs into the meaningful tasks identified by Miss B. The treatment plan for the second treatment session was:
- Primary driver – cervical spine with C7 neuromuscular / visceral impairment: left scalenus minimus technique*.
- Secondary driver – thorax with 3rd and 4th TR neuromuscular impairment: release with awareness of left serratus anterior muscle fibres connecting between the medial border of the scapula and the lateral aspect of the 3rd and 4th ribs; inferior vertebropericardial ligament technique*.
- Stack and breathe C7 and 3rd and 4th TR: to release of common posterior fascial line of the deep cervical prevertebral fascia and endothoracic fascia.
- Primary driver – cervical spine with C7 neuromuscular / visceral impairment: an effective cue was “float C7”.
- Secondary driver – thorax with 3rd and 4th TR neuromuscular impairment: an effective cue was “relax and float the left scapula”.
- As the correction of C7 and the 3rd and 4th TR with release and align resulted in optimal control of the right SIJ, hip, knee and ankle, no connect cue was necessary at this stage.
- Integration of the align cues with whole body movement progressions, as able:
- Right OLS
- Progress to right single leg squat (small ranges to simulate running)
The above ‘move’ exercises became her home exercise program. Each exercise was to be performed 3 sets of 10 repetitions, twice a day. Miss B was engaged and responded well to the ISM approach. She realised how important it is to have focused attention while integrating align cues and whole body movement.
Over the next two sessions the relationship of the drivers started to change:
- Treatment session 3
- Primary driver: thorax with 2nd TR neuromuscular impairment – vector from right pectoralis minor.
- Secondary driver: cervical spine with C7 visceral impairment – vector from right pleurovertebral ligament*.
- Treatment session 4
- Primary driver: thorax – articular system vector from 4th left costochondral joint.
- Active control of the 4th TR: As Miss B improved, the difficulty of each task was progressed with repetition, weight and speed. When adding these complexities, it was noted that Miss B was not able to maintain an optimal alignment of the 4th Palpation of the deep thoracic multifidus at the 4th TR revealed a deficit in the muscle bulk at that level. Therefore, a connect cue was incorporated into the treatment plan to increase the capacity of the deep thoracic multifidus to control the 4th TR in high load tasks.
* This case study utilises three techniques from the Barral Institute’s Visceral Manipulation
- Scalenus minimus technique (also known as the transverse pleural ligament technique)
- Inferior vertebropericardial ligament technique
- Right pleurovertebral ligament technique
- After the 4th session, the focus of treatment was on 2 main elements:
- Restoring optimal active control of the upper thorax.
- Releasing non-optimal activation habits of the muscles attached to the upper TRs.
- This was difficult for Miss B as her job required long hours sitting at the computer.
- Miss B was encouraged to continue retraining her postural patterning as she could now:
- Squat smoothly with even weight-bearing. She now felt confident to gradually load more at the gym.
- Start to build up her running – I referred her to a running coach who also incorporates whole-body and specific segmental cuing to optimise running patterns. We’re very lucky to have such a coach in Canberra who utilises cues which are very similar to ISM movement training!
- Miss B was encouraged to continue retraining her postural patterning as she could now:
Mr. S is a cyclist who has a meaningful complaint of left superior SIJ pain. The pain started after a fall with cycling 3-4 years ago, where he had a displaced fracture of his left clavicle. Now his main aggravating activity is cycling. The left SIJ pain is generally aggravated at around 30km into a ride, or when cycling faster with a higher load.
Video 1 (2:18) demonstrates:
- A brief introduction to the case of Mr. S.
- The assessment to determine the primary driver (3rd TR) in the screening task of squatting to the bike position.
Video 2 (4:07) demonstrates:
- Further assessment of the 3rd TR including vector analysis in the meaningful task of cycling.
- Patient education regarding the left pectoralis minor vectors causing the non-optimal ABCs of the 3rd
- Teaching a relax cue for the left pectoralis minor affecting the 3rd
- Palpation of thoracic multifidus and noting of atrophy at the 3rd
- Patient education regarding the active control deficits of the 3rd TR and the consequences on the rest of the body.
Video 3 (5:45) demonstrates:
- Correcting and then taping of the 3rd TR on the left posterior rib.
- Correcting and then taping of the 3rd TR on the right posterior rib.
- Teaching hook (connect) cue for the thoracic multifidus.
- Positive feedback when teaching a new cue in the meaningful task.
- Improved subjective (patient) performance of the screening task of squatting to a low bike position.
Clinical Mentorship in the Integrated Systems Model
Join Diane, and her team of highly skilled assistants, on this mentorship journey and immerse yourself in a series of education opportunities that will improve your clinical efficacy for treating the whole person using the updated Integrated Systems Model.
We will come together for 3 sessions of 4 (4.5) days over a period of 6-8 months with lots of practical/clinical time to focus on acquiring the skills and clinical reasoning to put the ISM model into practice. Hours of online lecture and reading material and 12 hours of in-person lecture are...More Info