Last Updated on May 2, 2014 by Jimson Lee
This is part 7 of the Freelap Friday Five Series, Season Three. To review the past 37 interviews, click here.
Part 1 was Jeff Cubos, Chiropractor and Performance Therapist
Part 2 was John Godina, World Athletics Center founder & Elite Shot Putter
Part 3 was Questions & Answers from Peter Weyand’s Research
Part 4 was Dr. Thomas Lam, focusing on Movement Based Sports Science
Part 6 was Gabe Sanders, Assistant T&F coach of Boston University
I feel today’s therapist must have a working knowledge of Chiropractic, Active Release Techniques (ART), Biomechanics, Video Analysis, Rehabilitation, Functional and Corrective Exercises, Taping, and Sports Medicine… and so on.
Dr. Jessica Greaux is one of those people, along with Dr. Jeff Cubos.
She is the founder and owner of Innersport Chiropractic, graduated from Brown University (1995) and Magna Cum Laude from Life Chiropractic College West (2001) specializing in sports injury management and extremity adjusting techniques.
Dr. Greaux is an Active Release Techniques® certified instructor, the highest level attainable by an ART practitioner. An ART® provider goes through a rigorous credentialing process that includes in-depth knowledge of muscular skeletal structures in the entire body. She has completed her biomechanics certification, which allows her to observe the entire body for dysfunction while it is in motion. She has also been invited to become an assistant ART® instructor.
Interview with Dr Jess Greaux, on Rehab, Biomechanics and Beyond
(Q1) Injury prevention with running is essential and one of the assessments you do includes using video analysis to see key milestones of running gait. Could you go into how forefoot strike sprinters can learn about the value of a good general running shoe when running on the grass during conditioning? We forget as sprint coaches that running volumes add up and slower running has some carry over to speed with some areas of mechanics. With the barefoot debates and recent research showing not everyone can tolerate running without shoes or minimalism approaches, could you share how you screen athletes with actually running technique and how foot ware relates to this?
Dr. Jessica Greaux: First, thank you for interviewing me. I’m delighted to share what I know with the sports rehab community. I’m glad it is recognized not everyone can tolerate barefoot or minimalist shoes. Biomechanical screening is very important, including big toe flexibility and Flexor and Abductor Hallicus strength, a stable tripod base (1st and 5th met heads and calcaneus) in single leg stance, step down, and single leg squat, and hip flexibility.
However, just as important, if not more, are the runner’s lifestyle and previous injuries. For instance, has the runner spent most of his/her day sitting for years? What shoes do they wear when they are not running? Any major injuries or surgeries? Have they had recurring injuries on one side of their body? Do they have a history of stress fractures? Lastly, we argue that barefoot or minimalist running does not fix all biomechanical and technique errors. I believe we see an increase in injuries such as 5th metatarsal stress fractures because the shoe (or lack there of) does not correct the cross-over strike in which the runner will have a more supinated foot at initial contact, increasing stress on the lateral foot.
(Q2) You perform both manual therapy and surface EMG with your clients. What seems as a research tool is more mainstream now in clinical practice. Could you go over injuries to runners, besides the “weak glutes and knee problems” such as low back and hamstrings so we can learn the value of objective data?
Dr. Jess: Yes, I do ART and Graston and we use sEMG for all of our running analyses as well as many of bike fits/analyses. I’ve found ART to be one of the most useful tools to evaluate the quality of tissue movement. Having our hands on athletes while they move gives us insight into which tissue may have less tensile capabilities during a range of motion or sometimes we can feel two muscles adhered together, causing a snag or hiccup in movement. In addition, we watch an athlete perform a movement such as a squat (or running, cycling, etc.) and learn quickly which muscles are fibrotic, causing the squatter to move in the path of least resistance.
After performing ART, we re-test the squat and observe better movement. I feel a combination of soft tissue evaluation, FMS (Functional Movement Screen), and biomechanical assessments are more mainstream. However, sEMG takes our evaluation one step further. Glutes are definitely a big issue when it comes to muscle activation and sequence, but we can’t always look at strength or amount of firing. We are paying closer attention to the quality of muscle activation, sequencing, and muscle rest. We are starting to find some muscles are basically constantly active. For instance, we have a runner with left greater trochanteric pain. We found the ipsilateral glute max to fire 3-4x more than the other side, but more importantly, it never relaxed during the running gait cycle.
To determine why, we have to put her through a more diagnostic process such as the SFMA and start looking at oblique, thoracic rotation, and lumbar stability using sEMG and video. sEMG takes the guessing out of observing movement. I’ve learned athletes are exceptional cheaters, meaning they can mimic impeccable technique and form. However, sEMG has allowed us to determine how they achieve that perfect movement. We find hidden asymmetries and poor sequencing, which can lead to injury or suboptimal performance. For instance, we had an NBA player with chronic patellar tendonitis for 3 years do a depth jump. We found he activated one glute max on the way down and the other glute max on the way up, all along with good technique… observing the squat with a naked eye most likely would have not exposed this asymmetry.
(Q3) With the Northeast being freezing and many runners cross training with biking, could you get into your experience with cyclists to share that just because the bike is low impact doesn’t mean the training modality is scot-free of problems? A lot of coaches complain about bike routines causing imbalances or problems if used too much, any tips on bike fitting you can share?
Dr. Jess: The coaches have a valid complaint. In addition to our sitting lifestyles, bucket seat cars, and poor posture, cycling can cause tight hip flexors and a more quad dominant, less glute dominant movement pattern. Not to mention that cyclists typically have rounded shoulders, increased thoracic kyphosis, shortened intercostals anteriorly and abdominal muscles and poor dissociation between shoulders and pelvis. Frankly, I like swimming for runners as it stretches the body out, encourages pelvic rotation and oblique activation, and forces the runner to establish good rhythmic breathing, However, if one must bike, follow the cycling session with good hip extension exercises, split stances with rotation, and glute activation exercises.
Regarding fit, the cyclist will have to find the middle ground of pelvic flexion as too anterior or posterior can inhibit the glutes. We’ve found a 60 degree anterior pelvic tilt (not hip flexion or trunk flexion) to the horizontal plane to be a good starting point. If the crank arm is adjustable or changeable, err on the side of a shorter crank and just like in running, work on a higher cadence between 90-110 on flat and mild climbs. If on a big climb, attempt to stay around 70-80 RPMs.
(Q4) Foot mechanics are important and sometimes difficult to gage just on a medical table. You have experience with inshoe pressure and clinical techniques and have decisions ranging from orthotics to manual therapy. With so many factors, ranging from foot anatomy and injury history, how do you approach decision making with improving function.
Dr. Jess: We use the in-shoe pressure sensors with cycling as we have not yet ordered the running pressure sensors (hopefully coming soon). So, I can address how we approach the decision making process with cyclists. This is a great question and one in which we are constantly learning and experimenting. First, we make sure the bike fit is perfect using the saddle pressure sensors, sEMG and then determine the correct saddle. A poor fitting bike can cause changes in the foot pressure and forces.
Next, we can either go in two directions depending on what the off-the-bike examination revealed. We can do treatment and prescribe exercises to see if we can correct the foot pressure sensors, or we can start playing with cleat placement, wedges, shims, over-the-counter orthotics. Custom orthotics are our last option typically, as we want to correct what is happening above the foot first. An example where we went to the foot first: We had a patient missing 2 toes with pain on the first met head while cycling. We used the foot pressure sensors to determine the best option (shims, wedges, orthotics) for him. As it turned out, a custom orthotic by a podiatrist gave us the best result on the pressure sensors and gave him the biggest relief at the big toe.
One important note: cycling and running are very different when it comes to pronation control. A cyclist is not absorbing the same ground reaction forces as a runner, and we PREFER to have a rigid foot and shoe to transfer forces more efficiently. Most types of running requires pronation to attenuate the ground reaction forces and thus, we are even more cautious with orthotics, first addressing hip, pelvis, and trunk control. The hip tells the foot where to land and all too often we see a cross-over strike causing excessive pronation. I haven’t seen an orthotic correct the cross-over strike.
(Q5) Many therapists are focusing on hip down and foot up with the kinetic chain. How do you evaluate what is causing what with ground reaction forces from the feet up and the coordination and range of motions of the pelvis during the recovery of the stride. This sounds like a chicken and egg thing but I am sure you have more insight to enlighten the readers that it’s a thought process, not just trial and error.
Dr. Jess: Yes, it is a chicken and egg thing especially when the foot and hip communicate constantly with each other. I wish I could give you an A + B = C answer, but since the body is so dynamic and we come to each evaluation with so many previous injuries and lifestyles, each case is not treated like a textbook. First and foremost, we delve deep into their history of injuries, athletic and daily lifestyle activities. Typically, a good history will give us a place to start such as a previous ankle sprain that was not rehabbed adequately.
We are finding little evidence in the literature regarding pelvic rotation and pelvic translation and how this either influences the foot or is influenced by the foot. However, through our own experience we have found runners with an unstable tripod in the foot have a lateral translation of the pelvis. We see this on the step down and single leg squat or even single leg stance. I think the gluteus medius gets a bad rap and is not always the culprit. Sometimes we find a patient cannot create a stable tripod at the big toe, thus the theory is the weight shifts laterally, putting the center of mass over the more stable part of the foot.
So, does a weak glute medius cause the foot to cross the midline or does the brain know the foot cannot take the load on the medial side of the foot and thus shifts the pelvis so it appears the hip is doing the adducting. Is the hip adducting or is the pelvis translating? Is the hip internally rotating excessively or NOT internally rotating or is the pelvis not rotating on the hip? Unfortunately, just because one sees excessive hip adduction and internal rotation, doesn’t mean the hip is weak or the glute is under utilized. Via slow motion video, we observe WHAT is happening WHEN and combine this with our sEMG findings, functional movements and ROM exam. A case in point: At mid stance, a runner shows a cross-over strike where the foot crosses the midline of the body and excessive pronation at the ankle. However, the hip stays neutral or abducted, putting the knee in a valgus position or even creates a valgus thrust.
More often than not we go back to the pelvis and observe mechanics during the recovery stage of running, the step down and even check active and passive ROM of the hip and find that the pelvis will not rotate over the hip and the hip lacks internal rotation. As the pelvis is supposed to rotate on the hip during mid stance, if there is a restriction, the femur stays neutral or slightly abducted, giving the knee a valgus posture. The body will not allow the foot to land far away from the center of mass, so the foot will still cross the midline of the body, causing excessive pronation.
Or sometimes a lack of internal hip rotation during terminal stance on the right side can cause limited rotation of the pelvis and thus causing the left hip to adduct during recovery, knee to have a varus posture, and foot excessively pronate so the center of mass stays over the most stable part of the foot. Trunk and spinal rotation can also influence pelvic rotation.
Unfortunately, it is difficult to measure pelvic rotation in a clinical setting without a 3D lab so we have to rely on slow motion video, biomechanical tests, and active and passive range of motion tests.
Editors Note: Noraxon does provide a 3-D system that is portable, marker free, and wireless , something coaches and clinicians can use. More information can be found at www.noraxon.com