Presented by Activating The Core Slings Learning Objectives

1/7/2013
Learning Objectives
Restoring the
Core Slings:
How to identify
and activate.
EATA 2013 Annual
Conference
Buffalo, NY
Presented by
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Brian Catania, MPT, SCS, ATC (Lead Presenter)
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Site Manager with Christiana Care PT PLUS
Adjunct faculty member of the University of
Delaware’s Athletic Training Program
bcatania@christianacare.org
 Review
anatomy of the core.
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.
 Learn
Numerous studies point out:
The Core Matters
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Travis Ross, DPT (Lead Lab Instructor)
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Staff PT for Christiana Care PT PLUS
tross@christianacare.org
Activating The Core Slings
journal of orthopaedic & sports physical
therapy | volume 41 | number 10 | october
2011 | 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
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“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
Diaphragm – Top of cylinder
 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
Diaphragm
 Noted
in European Medicine since 1930s
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
 Sternal:
Review: Anatomy of the core
cylinder
Pelvic Floor – Bottom of
cylinder
 “Provide
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Top = Diaphragm
Lateral slings
Anterior oblique
slings
Posterior oblique
slings
Deep longitudinal
subsystem
Bottom = Pelvic Floor
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
Female Pelvic Floor
Male Pelvic Floor
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Lateral slings
Common Injuries associated
with disconnected lateral
slings
 Ipsilateral
 Patella
internal
oblique and
Gluteus Medius
 Keystone
attachment =
pelvis
Femoral
Syndrome
 Anterior hip
impingement more
lateral
 Low Back Pain
 Common
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Lab: Anat. of the Lateral Slings
Internal Oblique
Proximal Attachment: lumbar
fascia, iliac crest, and
inguinal ligament
Distal Attachment: linea alba,
pubis crest, 9th-12th ribs and
costal margin
Gluteus Medius:
Proximal Attachment:
gluteal surface of ilium
Distal attachment:
Greater trochanter
Lab: Test for Lateral Slings: Manual
Muscle Test Hip Abduction in correct
alignment
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
internal
oblique and glut
medius
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 Inhibited
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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: Test for Anterior Slings - Manual
Muscle Test Hip Adduction in correct
alignment
Lab: Lateral Slings
Treatment/NMR

STM: to internal
oblique with rotation
and clear TFL/QL
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NMR/Therex:
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Side triceps push-up
Side lying hip
abduction with cross
isometric extension
Anterior Oblique Slings
 External
Oblique
and contralateral
adductors
 Keystone
attachment =
Pelvis
Common Injuries associated
with disconnected anterior
oblique slings
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Groin strain
Oblique strain
Sports hernia
Pubic Ramus stress
fracture
Anterior hip
impingement along
inguinal line

Lab: Anatomy of the Anterior
Oblique
Slings
Adductor Group:
External Oblique:
Proximal Attachment: 5th12th ribs
Distal Attachment: meets
the rectus abdominis via
tendon, anterior half of iliac
crest, inguinal ligament
Proximal Attachment: Pubic
Ramus and pubic symphysis
Distal Attachment: broad
attachment on linea aspera
of femur
 Common
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Hip labral
pathologies
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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
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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
Lab: Test for Posterior Oblique Slings: Manual
Muscle Test Hip Extension in correct alignment
 STM:
to external
oblique with
rotation.
 NMR/Therex:

Side triceps pushup with rotation
toward ground
with hip adduction
Posterior Oblique Slings
Common Injuries associated
with disconnected Posterior
Oblique Slings
 Latissimus
Dorsi with
contralateral
Gluteus Maximus
 Keystone
attachment =
Pelvis and
thoracolumbar
fascia
 Hamstring
Lab: Anat. of the Posterior
Oblique Slings
Treatment strategies for
Posterior Oblique Slings
Latissimus Dorsi
Prox. Attach.: SPs of T7-L5,
thoracolumbar fascia, iliac crest
and inferior 3 or 4 ribs, inferior angle
of scapula
Dist. Attach.: floor of intertubercular
groove of the humerus
strain
back pain
 Shoulder
pain/impingement
 Low
Gluteus Maximus
Prox. Attach.: Gluteal surface of
ilium, sacrum, sacrotuberous
ligament, lumbar fascia
Dist. Attach.: Gluteal tuberosity of
the femur
 Weak/Inhibited
gluteus maximus
 Tight contralateral
latissimus dorsi
 Weak/inhibited
gluteus maximus
hamstring
and
thoracolumbar
fascia
 Tight latissimus dorsi
 Tight
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STM to opposite
lat/thoracolumbar
fascia and ipsilateral
hamstring
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
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STM: to latissimus
dorsi and
thoracolumbar
fascia with arm
reach
NMR/Therex:
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Prone or Q-Ped Hip
Extension with opp.
UE distraction
Child pose with
rotation and reach
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 maximus
recruitment
Deep Longitudinal SubSystem
(DLS)
How to identify and activate a
dysfunctional sling?
 Erector
 Hip
Spinae
 Sacrotuberous
ligament
Femoris
 Peroneus
longus/anterior
tibialis
 Biceps
Common Injuries associated
with overactive DLS
 Ipsilateral
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Injuries
Low back pain
Hamstring strain
Ankle sprain
Knee pain/PFS
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
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Sitting thoracic rotation with ball squeeze
between knees
Standing resisted thoracic rotation with tband.
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
Pitching
Lacrosse
Golf Swing
Baseball
When your slings are
connected-- http://link.brightcove.com/services/player
/bcpid42757819001?bckey=AQ~~%2cAA
AABvaL8JE~%2cufBHq_I6Fnyo5urAiDw0MJ
y4NVIDJred&bclid=1438915275001&bctid=
1427667895001
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References
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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 function
in 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. 352362.
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
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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
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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-1621841nice-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-nlcsgame5-e1287768077736.jpg
http://megliofitness.com/theimportance-of-pitching-mechanics/
http://www.beyondbasicsphysicaltherapy.com/anatomypelvicfloor.shtml
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http://upload.wikimedia.org/wikipedia/commons/e/e2/Anterior_Hip_Muscles_2.PNG
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References
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http://www.audreysmassage.com/images/medical/GluteusMedius.gif
http://www.maxrelax.org/wp-content/uploads/2012/08/internaloblique.png
http://en.wikipedia.org/wiki/Gluteus_maximus_muscle
http://ittcs.wordpress.com/2010/12/10/notes-on-anatomy-andphysiology-slings-at-the-front-slings-at-the-back/
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