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Restoring the Core Slings: How to identify and activate.EATA 2013 Annual Conference

Buffalo, NY

Presented by Brian Catania, MPT, SCS, ATC (Lead Presenter)

Site Manager with Christiana Care PT PLUS Adjunct faculty member of the University of

Delaware’s Athletic Training Program bcatania@christianacare.org

Travis Ross, DPT (Lead Lab Instructor) Staff PT for Christiana Care PT PLUS tross@christianacare.org

Activating The Core Slings

Learning Objectives Review anatomy of the core. Learn the major core slings. Learn common injuries associated with

each sling. Learn how to test the core slings. Learn manual and neuromuscular

techniques to improve specific core sling activation.

Numerous studies point out: The Core Matters journal of orthopaedic & sports physical

therapy | volume 41 | number 10 | october2011 | 767

JULIE A. HIDES, PhD1 • CASSANDRA T. BROWN, BPhty (Hons)2 • LACHLAN PENFOLD, BHMS3 • WARREN R. STANTON, PhD4

“Screening the Lumbopelvic Muscles for a Relationship to Injury of the Quadriceps, Hamstrings, and Adductor Muscles Among Elite Australian Football League Players

Sampling of Conclusions “An association between multifidus muscle size (relative to

age, height, and weight) and preseason injury suggests a way to identify players at risk of severe HGT injuries.

“Small multifidus muscle size at L5 through MRI predicted 5 of 6 players who incurred a more severe HGT injury, but No relationship was found the ability to contract the transverse abdominis muscle through the drawing in of the abdominal wall.”

“People with LBP have delayed recruitment of the Transversus Abdominis with upper and lower extremity movement.”

“Hides et al does note that a previous report showed AFL players with groin pain also had delayed activation of Transversus Abdominis.”

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Identifying the true core weakness The core slings are

our window into where the core is actually weak, typically it is not the entire cylinder, especially if you catch the injury in its early stages.

Muscle Slings according to “The Janda Approach” text Noted in European Medicine since 1930s “Provide movement and stabilization

across multiple joints!” Facilitate rotation Transfer forces through the trunk Interconnected – one muscle insertion is

connected to the next muscle’s origin via a common keystone structure.

Fixation points = stability for the chain

Review: Anatomy of the core cylinder

Top = Diaphragm Lateral slings Anterior oblique

slings Posterior oblique

slings Deep longitudinal

subsystem Bottom = Pelvic Floor

Diaphragm – Top of cylinder

Diaphragm Sternal: two muscular slips from the back

of the xiphoid process. Costal: the inner surfaces of the cartilages

and adjacent portions of the lower six ribs on either side, interdigitating with the Transversus abdominis.

Lumbar: aponeurotic arches, named the lumbocostal arches, and from the lumbar vertebrae by two pillars or crura

Pelvic Floor – Bottom of cylinder

Female Pelvic Floor Male Pelvic Floor

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Lateral slings Ipsilateral internal

oblique and Gluteus Medius

Keystone attachment = pelvis

Lab: Anat. of the Lateral SlingsInternal Oblique

Proximal Attachment: lumbar fascia, iliac crest, and inguinal ligamentDistal Attachment: linea alba, pubis crest, 9th-12th ribs and costal margin

Gluteus Medius:Proximal Attachment: gluteal surface of iliumDistal attachment: Greater trochanter

Lab: Test for Lateral Slings: Manual Muscle Test Hip Abduction in correct alignment

Common Injuries associated with disconnected lateral slings Patella Femoral

Syndrome Anterior hip

impingement more lateral

Low Back Pain

Common Reasons: Tight TFL Excessive hip IR Overactive

Quadratus Lumborum

Inhibited glut med and internal oblique

Treatment strategies Most techniques mentioned and shown in

lab can be found at:http://www.youtube.com/cataniahesc406

Treatment strategies for Lateral Slings Tight TFL/QL Inhibited internal

oblique and glut medius

STM to TFL/QL/rectus femoris

Correct innominate dysfunctions of inflare and anterior rotation

NMR for glut medius and internal oblique

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Lab: Lateral Slings Treatment/NMR

STM: to internal oblique with rotation and clear TFL/QL

NMR/Therex: Side triceps push-up Side lying hip

abduction with cross isometric extension

Anterior Oblique Slings External Oblique

and contralateral adductors

Keystone attachment = Pelvis

Lab: Anatomy of the Anterior Oblique Slings

External Oblique:Proximal Attachment: 5th-12th ribsDistal Attachment: meets the rectus abdominis via tendon, anterior half of iliac crest, inguinal ligament

Adductor Group: Proximal Attachment: Pubic Ramus and pubic symphysisDistal Attachment: broad attachment on linea asperaof femur

Lab: Test for Anterior Slings - Manual Muscle Test Hip Adduction in correct alignment

Common Injuries associated with disconnected anterior oblique slings Groin strain Oblique strain Sports hernia Pubic Ramus stress

fracture Anterior hip

impingement along inguinal line Hip labral

pathologies

Common Reasons: Tight adductors Weak external

oblique Rib 5-12

dysfunction Restricted

diaphragm Limited thoracic

rotation

Treatment strategies for Anterior Oblique Sling dysfunction Inhibited external

oblique (EO) Tight adductors Anterior hip

impingement

Correct key rib dysfunction from 5-12 and STM with NMR

STM to adductors along with NMR for EO

STM along inguinal line with posterior glide of femoral head with single knee to chest

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Lab: Anterior Oblique Slings Treatment/NMR

STM: to external oblique with rotation.

NMR/Therex: Side triceps push-

up with rotation toward ground with hip adduction

Posterior Oblique Slings Latissimus Dorsi with

contralateral Gluteus Maximus

Keystone attachment = Pelvis and thoracolumbar fascia

Lab: Anat. of the Posterior Oblique Slings

Latissimus DorsiProx. Attach.: SPs of T7-L5, thoracolumbar fascia, iliac crestand inferior 3 or 4 ribs, inferior angle of scapulaDist. Attach.: floor of intertuberculargroove of the humerus

Gluteus MaximusProx. Attach.: Gluteal surface of ilium, sacrum, sacrotuberousligament, lumbar fasciaDist. Attach.: Gluteal tuberosity of the femur

Lab: Test for Posterior Oblique Slings: Manual Muscle Test Hip Extension in correct alignment

Common Injuries associated with disconnected Posterior Oblique Slings Hamstring strain Low back pain Shoulder

pain/impingement

Weak/inhibited gluteus maximus

Tight hamstring and thoracolumbar fascia

Tight latissimus dorsi

Treatment strategies for Posterior Oblique Slings Weak/Inhibited

gluteus maximus Tight contralateral

latissimus dorsi

STM to opposite lat/thoracolumbar fascia and ipsilateralhamstring

STM to contralateral lat and correct any rib dysfunctions from 6-12

NMR for glut max activation and decrease overactive hamstring

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Lab: Posterior Oblique Slings Treatment/NMR

STM: to latissimus dorsi and thoracolumbar fascia with arm reach

NMR/Therex: Prone or Q-Ped Hip

Extension with opp. UE distraction

Child pose with rotation and reach

Deep Longitudinal SubSystem(DLS) Erector Spinae Sacrotuberous

ligament Biceps Femoris Peroneus

longus/anterior tibialis

Common Injuries associated with overactive DLS Ipsilateral Injuries

Low back pain Hamstring strain Ankle sprain Knee pain/PFS

Treatment strategies for overactive DLS STM to overactive structure (i.e. biceps

femoris, sacrotuberus ligament, erector spinae)

Manipulate or mobilize Lumbar dysfunction

Restore normal gluteus maximusrecruitment

How to identify and activate a dysfunctional sling? Hip abduction weakness = ipsilateral

internal oblique Hip adduction weakness = opposite

external oblique Hip extension weakness = opposite

latissimus dorsi or overactive ipsilateral DLS

Therex: Taking it to function Sitting thoracic rotation with ball squeeze

between knees Standing resisted thoracic rotation with t-

band. Diagonal Lifts/Chops from ½ kneeling to

standing Lunges in different planes with twist Side plank with rotation TRX single leg squat w/ t-band on lateral knee

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Slings in action

Lacrosse

Baseball

Pitching

Golf Swing

When your slings are connected--- http://link.brightcove.com/services/player

/bcpid42757819001?bckey=AQ~~%2cAAAABvaL8JE~%2cufBHq_I6Fnyo5urAiDw0MJy4NVIDJred&bclid=1438915275001&bctid=1427667895001

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References Page, Phil. Frank, Clare. Lardner, Robert.Assessment and treatment of muscle imbalance:

the Janda approach: 2010 Benchmark Physical Therapy Inc. Houglum, Peggy A. Therapeutic exercise for musculoskeletal injuries, 3rd ed. 2010 Human

Kinetics. “Screening the Lumbopelvic Muscles for a Relationship to Injury of the Quadriceps,

Hamstrings, and Adductor Muscles Among Elite Australian Football League Players.” Journal of Orthopaedic & Sports Physical Therapy. Volume 41. Number 10. October 2011;767-773.

Hides, J., Hughes, B., and Stanton, W. “Magnetic resonance imaging assessment of regional abdominal muscle functionin elite AFL players with and without low back pain.” Manual Therapy. 16(2011). Pg. 279-284.

Kolar et al.“Postural Function of the Diaphragm in People with and without Low Back Pain.” Journal of Orthopaedic & Sports Physical Therapy. Volume 42. Number 2. April 2012; pg. 352-362.

Brumitt, Jason, and Dale, R.B.“Integrating Shoulder and Core Exercises When Rehabilitating Athletes Performing Overhead Activities.” North American Journal of Sports Physical Therapy. Volume 4, Number 3, August 2009 pg. 132-138/.

Jackson, R. and Porter, K. “The Pelvis and Sacroiliac Joint: Physical Therapy Patient Management Utilizing Current Evidence.” Independent Study Course from Current Concepts of Orthopaedic Physical Therapy, 3rd Edition, Orthopaedic Section, APTA, inc.

Cervical-Thoracic Integration course by Tim Crunk, PT, MS, OCS, CFMT March 18-21, 2004 Clark, Michael; Lucett, Scott C.; et al. NASM Essentials of Personal Fitness Training: Chapter 2 -

pages 24-28. 2011 Lipponcott Williams and Wilkens. Primal Pictures Ltd. 2008

http://b2cfitness.com/cpt_blog/wp-content/uploads/2012/02/DLS.png

References http://en.wikipedia.org/wiki/Transversus_abdominis_muscle http://en.wikipedia.org/wiki/Latissimus_dorsi_muscle http://en.wikipedia.org/wiki/Diaphragm_(anatomy) http://fantasyknuckleheads.com/wp-content/uploads/2010/03/albert-pujols.jpg http://www.brooklandssportsclub.co.uk/tour/lacrosse.htm http://nokoatemaildotco.blogspot.com/p/lacrosse.html http://therapyprotocols.webs.com/Oblique%20muscle%20slings.jpg http://fantasyknuckleheads.com/wp-content/uploads/2010/03/albert-pujols.jpg http://www.brooklandssportsclub.co.uk/tour/lacrosse.htm http://nokoatemaildotco.blogspot.com/p/lacrosse.html http://therapyprotocols.webs.com/Oblique%20muscle%20slings.jpg ittcs.wordpress.com http://i.istockimg.com/file_thumbview_approve/1621841/2/stock-photo-1621841-

nice-swing-softball-player.jpg http://www.pgatour.com/2007/mygame/08/09/one/ http://www.anatomytrains.com/uploads/rich_media/locomotor_slings.pdf http://www.google.com/search?q=pitching+pictures&hl=en&rlz=1R2GPEA_en&prm

d=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=CpEwT_-vGOLq0QG0x4jSBw&sqi=2&ved=0CCoQsAQ&biw=1024&bih=545

http://phillysportscentral.com/wp-content/uploads/2010/10/roy-halladay-nlcs-game5-e1287768077736.jpg

http://megliofitness.com/theimportance-of-pitching-mechanics/ http://www.beyondbasicsphysicaltherapy.com/anatomypelvicfloor.shtml http://upload.wikimedia.org/wikipedia/commons/e/e2/Anterior_Hip_Muscles_2.PNG

References http://www.audreysmassage.com/images/medical/GluteusMedius.gif http://www.maxrelax.org/wp-content/uploads/2012/08/internal-

oblique.png http://en.wikipedia.org/wiki/Gluteus_maximus_muscle http://ittcs.wordpress.com/2010/12/10/notes-on-anatomy-and-

physiology-slings-at-the-front-slings-at-the-back/