What I learned from the Great Ones- Sahrmann diagnosed

In the summer of 2009, one of my goals as a trainer and coach was to develop a better understanding of why injuries and pain occurs. After attending my first FMS workshop in April of that year, I was mesmerized by the way Gray Cook and Lee Burton had spoken so eloquently of movement and seemed to pick apart complex problems (including my own) in minutes through simple observation.

One quote which seemed to sum up their mantra was the concept of “Thin Slicing” which dictates that expertise (not experience) is defined not so much by high level technical skill as it is by advanced pattern recognition. While novices become distracted by details, experts categorize and recognize individual issues as the sum of collective dysfunction.

This assessment certainly summed up my early utilization of the FMS, as I screened everyone I could, collected spreadsheets of information and spent hours toiling over how to address the many multitudes of issues. While I understood that the Active Straight Leg Raise pattern and Shoulder Mobility were most important, I could not get over the need to fix someone’s squat or ability to lunge—though fixing these two patterns often does just that.

My conclusion was that to successfully integrate such corrections in to my programming, I required a better understanding of how to do so and why. With this in mind, I scoured my go-to resources on the topic of corrective exercises and came away with three epic works which have changed the way I view the body:

1. Kendall’s Muscle Testing + Function- Florence Kendall + CO
2. Diagnosis and Treatment of Movement Impairment Syndromes- Shirley Sahrmann
3. Ultimate Back and Performance (Book + DVD)- Stuart McGill

While I could thousands of words to what I learned from each author, what I will try to do in this series of blogs is sum up the five ah-ha moments from each book which have brought me to my present view of the body. Suffice to say, the one thing I can say about each writer is that great minds think alike.

Cracking the pages of Sahrmann’s Diagnosis and Treatment of Movement Impairment Syndromes, I knew this would not be a light read. In fact, I must admit it took me one month to actually get past page one (I had to psych myself in to reading cover to cover) and another month to finish chapter 1-2, but copious amounts of notes and re-reading gave me a thoroughly improved understanding of why movement impairments occur and how to distinguish between mobility and stability issues.

To keep things simple, I have broken down my key learning points and practical applications below:

1. Relative flexibility- Put simply, relative flexibility is the idea that the least stiff segment will move first in a series of joints. Along the lines of Mike Boyle’s joint by joint approach, this means that if the lumbar spine for example is more mobile than the hips, compensatory motion will occur in this area. For me, this principal acts as a roadmap along with the joint by joint theory to determine exercises and progressions for clients with back, neck, shoulder and knee pain.

2. Motor control versus stiffness- When muscle stiffness is a contributing factor to compensatory movement, compensatory movement only occurs when the muscle is passively stretched. By contrast, this motion occurs during active motion, but not passive motion, it is a motor control issue. An example of a motor control issue would be the foot turning outward during an active straight leg raise, but remaining straight when the muscle is passively stretched by a partner. This is a huge distinction when we consider our approach to treatment.

3. Synegistic Dominance- In the presence of injury and/or poor posture, certain muscles become dominant over others and cause compensatory movement in the direction of this dominance. Consider an individual who constantly experiences hamstring strains, yet tests strong in this muscle. Because the hamstring is being forced to extend the hip in place of a weak gluteus maximus (butt), it falls victim to strain and overuse.

4. Why Core Stability?- Possibly the most influential statement for me was as follows: "During most activities, the primary role of the abdominal muscles is to provide isometric support and limit the degree of rotation of the trunk which, as discussed, is limited in the lumbar spine While I have never been a huge advocate of crunches, this statement summarizes why we need core stability and how it is obtained (isometrically). The solution? Groove stability in postures which increasingly challenge posture-- such as quadraped, half kneeling, tall kneeling, bi-lateral standing and single leg stance.

Practical applications:

1. Directional movement assessment- Once again using the lumbar spine is an example, the next question is which motions of the spine are most flexible. If the answer is flexion, the spine will be restricted in extension. In this case, rockbacking back on the heels is a motion which can be utilized as an assessment by taking the client through both extension and flexion. The question is which motion causes the client pain? Which motion is restricted? Do compensatory movements occur during movement (for example, does the pelvis rotate while rocking back)?

2. Passive Muscle testing- As mentioned above, distinguishing between mobility and stability issues comes down to testing the muscles in both passive and active ranges of motion. Check out this fantastic primer on table assessments with Bret Contreas and Keats Snideman

3. Classification Thinking- In Sahrmann’s system, most pain and movement disorders can be classified in to the direction of compensatory movement. The key to diagnosis is to determine the specific movements and sustained daily postures. This can often be traced to patterns of the clients lifestyle (flexing over a computer or rotating during the day to watch television) and assessed via a series of questions on occupation, lifestyle, etc.

4. Floor to standing core progressions- While I had long prescribed planks to improve “stability”, the reality is these movements can often be too stressful for entry level clients. By contrast, Sahrmann’s floor based progressions train the motions of hip extension and shoulder flexion (aka Floor slides) in a supported environment while teaching abdominal engagement and endurance. This concept of transitional posturing seems a reoccurring theme in giants in this field such as Gray Cook and Vladimir Janda. For de-conditioned clients, a floor based phase of activation sequence can be seen as a precursor to integrated such as squatting, stepping, overhead pressing and planking.

Keep in mind, this only skims the surface of this amazing resource and I would be interested to learn what other took from this classic. Feel free to add your thoughts below!