Traditionally when our clients/patients have come in to see us with sore spots we’ve assessed the sore spots and treated the sore spots to make them go away. This assumes that the cause and the symptom are one in the same, an assumption that this article will show, is not one we can make.

I’ll use two patients to demonstrate the point that where it hurts isn’t where the problem is.

The first patient AC is a high level rugby lock who presented with a lumbar spondylolysis and shoulder impingement (links). AC’s injuries had caused him problems in the previous season resulting in him missing the last third of the season. His goal was to prepare for the following season 4 months away.

The assessment showed that AC had very limited in shoulder flexion and immediately went into lumbar extension when raising arms to create the illusion of raising his arms. Note the limited scapula movement. The scapula had 23?of upward rotation (60? is ideal). The hips remained in anterior rotation with the arm raise resulting in more lumbar extension. The thoracic spine didn’t extend with shoulder flexion. During a jumping movement (AC jumps in the lineout) there was rapid lumbar extension. In a scrummaging position there was also high degree of lumbar extension.

AC showed depressed scapula and reduced upward rotation.  The red dot marks the inferior angle.  This should move to the mid-axillary line in shoulder flexion.

The faulty movement patterns, repetition and high loads in these movements were the likely cause of ACs injuries. If movement can’t occur in the thoracic spine or the hip, the movement is shunted to another area. In this case the lower back was moving excessively without control, and injury occurred.  The reduced scapula upward rotation and thoracic extension shunted movement to the shoulder joint causing impingement and pain.

ACs previous treatment had targeted theraband rotator cuff conditioning for the shoulder injury and floor-based abdominal strength and back conditioning work to target his back pain. In one month AC had made little progress despite improving his strength in the exercises. His revised programme included thoracic mobilisation, hip extension mobilisation, and abdominal conditioning to control lumbar extension. We also included some low level multifidus activation work to help AC gain segmental control at the site of injury. Squat and specific scrum training was used to teach AC to control the lumbar spine during these movements.

Thoracic mobilisation and extension work Hip extension mobiliser - shoulder flexion was added with established core control

The lumbar curve is maintained against the pull of the hip flexors and latissimus dorsi.  This exercise was progressed to a level so that AC could perform this on his toes with fshoulder flexion.  A high level of lower abdominal strength was developed.

Over the next 2 months pain on activity reduced and AC was able to be loaded in shoulder flexion, squat and scrum movements. AC returned to sport the following season pain free.

Our second example is Mr D who presented with lumbar and knee pain. Mr D is a keen recreational golfer but has been experiencing severe pain after playing and was referred by his concerned golf coach. Mr D’s assessment showed reduced hip flexion, abduction and hip rotation. With reduced rotation through the hips, Mr D shunted movement to the knee and also to the lumbar spine with painful results.

A restriction in left hip internal rotation shunts movement into the knee/ankle and also into the lumbar spine.

Key exercises included hip rotation and abduction mobilisation work. The supported deep squat and sitting work were key exercises to restore hip flexion and external rotation. I also worked closely with Mr D’s golf coach to shorten the swing to improve results and reduce the risk of injury.

The hip swing mobilizer.  The right thigh swings over the planted left foot.  This mobilizer was kindly borrowed from Ian O'Dwyer

A spikey ball is placed underneath the right adductor promoting external rotation in the right hip.

Supported deep squat stretch on CrankIt straps

Sitting cross legged.  An effective stretch or archetypal posture (Beach, 2010). At this stage Mr D requires a raised platform to sit.  This will be progressed until Mr D can sit on the ground effectively.

Mr Ds golf swing and scores have improved. His pain has reduced significantly and he is able to self manage both his warm ups and conditioning and just as importantly, put his socks on more easily.

In conclusion, where it hurts is just, well – where it hurts. By understanding the importance of mobility through key areas of the body – the ankle, hip, and thoracic spine and the strength and stability requirements of the movements required, specific mobiliser and strength exercises can be prescribed that address the cause of the problem.