How to identify non-painful movement dysfunction

It’s clear that a client needs a physical therapist when they’re in pain. But just because they don’t feel pain doesn’t mean there isn’t dysfunction in their movement.

As personal trainers increase their understanding of the way movement should take place, they have a great opportunity to help clients prevent pain before it occurs — and ultimately help their clients improve performance.

“Some people learn to compensate and never attempt, say, an overhead lift for fear of hurting their neck,” says Omi Iwasaki, senior vice president of field operations at EXOS. “But avoidance isn’t going to fix anything.”

At least in those cases the client recognizes the problem. Of greater concern is when a client has no pain despite movement dysfunction and continues to perform, risking serious injury in the future. In those instances, trainers must recognize the dysfunction and take action.

“A client might say, ‘My neck doesn’t hurt. Why go to physical therapy?” says Stefan Underwood, continuous improvement director at EXOS. “It’s our responsibility as professionals to understand what functional movement should look like and recognize dysfunction even when it doesn’t hurt.”

Iwasaki notes that it can be challenging enough to get a client experiencing pain to seek physical therapy, let alone one not feeling pain. It helps when a trainer and a physical therapist have an ongoing relationship and can refer clients back and forth. “Ideally you’d want them both to speak the same language and use the same methodology,” he said.

Underwood says there are five areas a trainer can focus on when it comes to identifying non-painful movement dysfunctions. These aren’t necessarily all-inclusive, he says, but “it’s a terrific starting point.”

1. Weight shift

How is the client engaging with the ground? Have they created a strong base of support? With a squat, are the heels coming off the ground, causing a quad-dominant squat? That’s incorrect. So too is telling the client to drive through the heels, turning into a low-back dominant squat. The weight should be over the mid-arch with the big toe, little toe, and heel creating a stable platform.

“If the client isn’t engaging the ground with their feet and doesn’t have the appropriate weight shift with their base and center of mass, then everything else is going to be worse,” Underwood says.

How a client moves might not be hurting them, yet. But movement dysfunction can cause problems down the road.

Avoiding movements due to pain isn’t going to fix anything.

2. Pelvic tilt

If you can identify anterior or posterior pelvic tilt, you can identify movement dysfunction with the lumbar spine. Underwood likens it to having buckets of water positioned alongside the hips. Can the pelvis tilt without spilling the water in either direction?

The key is that the lumbar spine is neither flexing nor extending. “We don’t want an excessive arch, but we don’t want an excessive posterior tilt either,” Underwood says. “We just want clients to extend their hips with a neutral spine position.”

3. Cervical spine

EXOS founder Mark Verstegen has spoken for years about watching people in airports and noticing how few are properly aligned from head to toe. It’s most evident in the head position, where the ears often are in front of the shoulders, a result of too much sitting and too little movement.

This can be aggravated in the weight room, Underwood says, when clients squat either by looking at the ground (rounding their backs) or by looking up and placing tension on the cervical spine.

“This might not be painful, but it’s still incorrect form that will lead to pain in the future,” Underwood says. “It’s your job to recognize that the spine should be neutral and the eyes forward.”

4. Thoracic hinge

The thoracic spine often goes overlooked since the neck and lower back produce so many more injuries and pain. But a dysfunctional thoracic spine can contribute to pain along the kinetic chain.
Clients attempting a bench press often take a cue from power lifters, who flare out their ribs in order to shorten the distance the bar must travel. That’s an effective strategy for power lifting, though even those clients are putting extreme stress on their bodies.

“As a trainer dealing with a general population, I need to recognize that they’re rib flaring and putting stress where we don’t want it,” Underwood said. “It’s not painful, but it’s dysfunction.”

Having a good referral relationship with a physical therapist can help your clients feel like they're getting a more holistic experience.

When a trainer and a physical therapist have an ongoing relationship, they can refer patients back and forth.

5. Knee collapse and scapular rhythm

One common dysfunction that often doesn’t produce pain is when the knee dives in during movement instead of tracking with the toes. Likewise, when the knees stay in place as the feet get wider during a squat, the knees aren’t tracking with the toes, causing undue stress.

If a client is holding a plank or pushup position and the shoulders are “winging” to the point where it would be possible for a trainer to lift them like a suitcase, Underwood says, that’s another telltale sign of dysfunction. Ideally the shoulders should be moving in a fluid rhythm along the rib cage. “If we ignore this, we’re setting them up to go from non-painful to painful dysfunction,” he said.

Though the five areas mentioned above don’t cover everything, Underwood says, it covers a high percentage of compensations. “If your clients are engaging the ground properly with a neutral spine, neck in neutral position with hips ‘keeping the water in the bucket,’ ribs tucked away, knees tracking with the toes, scapulas moving in a fluid rhythm along the ribcage, you’ve taken considerable steps in the right direction.”

Bad movements bringing your clients down? Here’s what to do.

About the Author

Pete Williams

Florida-based writer Pete Williams is a longtime editorial contributor to EXOS.

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