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“Thin Slicing” Expertise and a New Case Study

Filed under: Case Studies — Tags: , , — Shon @ 10:27 am May 31, 2011

In my last post,I mentioned my friend Shane Pratt, a multi year veteran of Penn Relays competition.  As we were watching the races at this year's Penn Relays from our vantage point in the stands, we also had a clear view of the paddock, where competitors were setting up for the third leg of the 4 x 100 meter relay.  As the men's heats were progressing, Shane would casually note which team he thought would win the heat just by observing the competitors in the paddock area.  I started to take notice after he had been correct five times in a row. When I pressed him on his prediction, he couldn't really answer how or why, only that he had an instinct while watching each athlete in the paddock (BTW it turns out by the end of the day he was spot on 80% of the time).

How could he have been correct so much of the time just observing an athlete stand in a confined space prior to a race?  Shane is not an active coach currently.  He doesn't have a degree in movement science, and hasn't competed or coached in over 15 years.  I was dumbfounded  until I recalled an anecdote from Malcolm Gladwell's excellent book, Blink.


In Blink, Gladwelltalks about the ability to make quick decisions with "thin slices" of information; the few important details that come when previous experiences meet rapid cognition, leading to a correct conclusion.  One  example was how the world class tennis coach, Vic Braden, could call a player's second "double fault" almost instantly, while 1) watching the match on TV and 2) having never met, coached or seen the player prior to the serve.  When asked how he knew the faulty serve was coming, he couldn't answer-he only knew it was inevitable (it turns out > 90% of the time). 

I believe this is how Shane was able to predict heat winners based on quick observations in the paddock.  His own high level of innate skill (10.32 FAT will not be seen in Pennsylvania high schools for a long time!), his years of waiting, watching and competing at the Penn Relays, as well as countless other championship events (youth, high school and collegiate), and his continued passion for the sport as a fan have given him the ability to "thin slice"- that is take a little bit of information at hand and arrive at an appropriate conclusion. 

Extrapolating forward, I also believe this is how excellent physical therapists, athletic trainers and strength& conditioning coaches are able to make decisions for their patients, clients and athletes quickly and seamlessly-the culmination of multiple years of experience, the quest for continuous improvement and refinement of skill, as well as just "paying attention" (in a Patrick Jayne/"Mentalist" kind of way).

I can't believe I actually referrenced this guy in my blog-but he really is a great example of "thin slicing"!


Case Study 3- Hamstring Strain in a High School Speed/Power Athlete

In the spirit of  the state high school track and field championships here in Pennsylvania this weekend, I'll review another interesting case that again wasn't what it initially seemed.  Part 1 will detail our treatment, while part 2 will outline a training program we implemented during the athletes indoor track season after additional information was gathered regarding the athlete's true impairment.


My patient was a high school junior who played running back as well as defensive back on an elite 4A team in  Southeastern Pennsylvania.  In conversation withhis father, he had strained his right hamstring at the origin in spring practice, approximately 5 months earlier.  His pain resolved with rest, but through summer conditioning, the pain never fully abated.  In pre-season "2-a-days", he re-injured his hamstring; 10 days later, we saw him in the clinic.  At this time, he was not actively practicing/ participating.

The athlete's main complaint was proximal hamstring pain near the origin at the ischial tuberosity.

Key Findings

Functionally, the athlete had pain only withascending 2-3 stairs at a time, with symptom reproduction in the region of the ischial tuberosity.  Level surface walking was pain free and non-antalgic (sidebar: for non-PT's, antalgicsimply means"avoiding pain"; if he had antalgia, he would have had an altered gait pattern to avoid aggrivating his hamstring.)


Straight leg raising was measured at 60 degrees on the injured side vs.  75 degrees on the non-injured side.

No, not me, and definately not my athlete, but motion was this poor!

Additionally, hip flexion was limited to 125 degrees on the right (130 degrees left).  Anterior hip tightness was not significant when observed in "figure 4" prone lying.  Thomas' test/ Ober's test were negative for IT band, rectus femoris and/or illiopsoas tightness.


Hamstring strength (measured via hand held dynamometry) was noted to be 35 lb. right withpain on resistance, as compared to 69 lb. left.  Hip extension withknee extension (to elicit hamstring contraction) was 38 lb. right vs. 57.6 lb. left.  Hip extension with knee flexion ( testing gluteus maximus with significantly less hamstring involvement) was pain free on the right side.  Adductor strengthwas pain free on the right, withstrengthgrossly equal as compared bilaterally.  Remaining right lower  extremity strength was grossly equal and did not cause pain/symptom reproduction.


Point tenderness was significant near the hamstring insertion near the ischial tuberosity.  The belly of the hamstring muscles (medially-semimembranosus and semitendinosus, and laterally biceps femoris) were not significantly tender.   

My Thought Process in Treatment

1) The "strain" was high, and was therefore more likely a hamstring insertional tendonitis/tendonopathy.  Straight leg raising, while not great was not significantly limited on the right side vs. the left, and pain was not in the muscle belly of the hamstring at end range.  Additionally, tenderness was at the insertion point on the ischial tuberosity, with no significant muscular point tenderness. 

2) Lack of active hip flexion mobility was a significant issue.  This was my hypothesis before even evaluating the athlete.  His father had described the history of injury to me at least 1 week before I had evaluated him; my initial thoughts centered around what I thought he would present with when he came to the clinic. My intuition served me well in this case.  Without "reserve" hip mobility passively and actively into hip flexion, the athlete was not allowing his hamstring to lengthen at the ischialtuberosity appropriately as his distal leg moved through swing phase during his various activities at football practice.  Microtrauma developed over time at the hamstring attachment in the ischial tuberosity, leading to the tipping point of dysfunction that brought him  to see me.

3) So as the Hip Goes, the Hamstring Goes.  My focus was on restoring hip flexion mobility through joint mobilization as well as increasing dynamic hip mobility in multiple planes using  progressive hurdle circle drills I devised.  The net result is a "flossing"  action of the hamstrings; the adductors and hip rotators get to "go along for the ride" as well. 

4)  Hamstring Yielding Isometrics/ Static Contraction  in Open Chain Rather than Eccentrics in Open Chain.  My bias is static contraction/ yielding isometrics for strengthexercise in the clinic for most pathologies.  I feel time under tension is a variable I can control along with load and position, so I chose this vs. eccentric OKC training for the athlete.  We also utilized Romanian deadlifts (RDL's) as part of treatment, so eccentric strengthening wasperformed,  just in a closed kinetic chain.  I also feel with an RDL, motion is dictated by the athletes' unique mobility/ biomechanical profile using free weights vs. using eccentrics in OKC on a leg flexion machine where whole system mobility options are limited.

Treatment/ Outcomes    

The athlete was seen for 10 visits over a 1 monthperiod.  Treatment emphasized hip joint mobilization with an emphasis on techniques to increase hip flexion passively and actively.  Ultrasound was used prior to mobilization for the first five visits to increase tissue temperature at the injury site and allowing my manual techniques to be more comfortable initially.  Manual therapy was followed by my hurdle circle/ hip mobility progression, progressing from a 12 inch height to ultimately a 24 inch height without pain.  Static knee flexionwas initated on the second visit, with a 30 second contraction/time under tension  Hip hinging/ box squatting  were initiated after 3 visits, RDL's on the fourth visit.  Weights, repetitions and time under tension was progressed every visit.  Full practice was resumed after 5 visits.  At  the 6thvisit, the athlete noted pain only with activities that involved decelleration at practice.  After 10 visits, he self discharged, just prior to a formal re-assessment, as he was symptom free in both practice and scrimmage activity.  He finished the season without re-exacerbation/ re-injury, fully returning to starting positions on offense and defense.

What I Would Do Differently Today

Le me preface this section by saying that I was pleased with the outcome above.  All long term goals were met in a timely manner, with a great long term result.  The athlete is now in a Division 1 program and projected to start in the defensive secondary next year, and has not had a single instance  of pain/ symptoms since he was seen in 2007.  That said, there is always room for improvement.  Some things I would have considered:

1)  Assessment of single leg function sooner.  You noticed I said sooner?  That's because after the football season, I trained this athlete  10 weeks during the winter, while he was running indoor track.  I had assessed his right  single leg  squat ( the involved side) after I noted a valguscollapse on the right with relatively light training weights in the box  squat and trap bar deadlift.  At a height of 23 inches, technique was poor, with the athlete barely able to complete 1 repetition without losing balance, compared to 19 inches for 5 excellent quality repetitions on the left side.  Over the course of the next 10 weeks, we were able to get to a point where he could single leg squat a a pair of 20 lb. kettlebells from 17 inches for sets of 5.  Not so coincidently, his best indoor 200 meter time dropped by 0.8 second  in the same time period.




2)  More agressive soft tissue work at the injury site.  At the time, my treatment bias was on re-establishing hip mobility and static hamstring strength.  Again the outcome was favorable, but I believe I could have expedited this even more sowith the use of soft tissue manual therapy, especially tool assisted soft tissue massage  , as tendonopathy responds well to this manual therapy intervention. 

3)  Assessing trunk strength and stability.  A stable torso is  important for a strength/power athlete in allowing force transmission through the lower quarter; if anterior/ posterior and lateral muscular forces aren't held accountable, then lower quarter muscular forces aren't fully transferred  through the trunk.  Making sure that trunk stability was in check would have been prudent as well.