Dysfunctional Definitions

Q: I just listened to the Fit Cast episode with you (and glad to know you will be a regular contributor, you were great) and was wondering how to find a therapist that can help with imbalances. I'm most certain I have more than your average bear (I've had ACL replacement on both knees - when I squat, my right foot turns out almost 45 degrees, but my knees and thighs are parallel. That's imbalance, right? ;)

Anyway, what are some good resources to find a good pro? My therapist for recovery was great, but she's not that kind of trainer.

A: Hey AT, thanks for the question. It was a busy couple of weeks (funny how that keeps happening in your last semester of grad school...go figure!), but I definitely wanted to respond to your excellent question!

Unfortunately, most often a physical therapist is chosen by a patient not because of his/her qualifications or experience but whether or not that therapist accepts the patient's insurance and how close the office is to the patient. Finding a qualified and expert physical therapist (just like finding a great trainer, physician, massage therapist, etc) can be difficult depending on your location and/or your particular needs, but there are definitely some things that you can look for to help.

There are unfortunately very few resources on the internet which actually rate physical therapists, such as Angie's List. However, Angie's List is also a pay site, requiring either a monthly or annual fee for access. If you're willing to pay for it, you might find this service helpful.

Other than that, it's pretty similar to finding any good health-care professional: look at their credentials and experience!

Although it's not a requirement of practice, it's not a bad idea to seek out a physical therapist that chooses to enrich his/her knowledge by earning additional credentials beyond their degree. Of course, a good place to start would be looking for the Certified Strength & Conditioning Specialist credential, the CSCS. Other credentials include the Sports Certified Specialist (SCS) and the Orthopedic Certified Specialist (OCS), which indicate a therapist that has achieved advanced clinical knowledge and skills, being recognized by the American Physical Therapy Association as a board certified expert.
Of course, Certified Athletic Trainers (ATC) can also be a great option, and a number of physical therapists have their ATC as well. Other credentials following a PT's name that indicate expertise in manual therapy, such as CMPT or MPT (Certified Manual Physical Therapist) or the prestigious FAAOMPT (a Fellow of the American Academy of Orthopedic Manual Physical Therapists) are also good indicators of a highly experienced and expert practitioner.
Finally, I would be remiss if I didn't also mention Active Release Techniques (ART) here as well. Although I would not consider ART to be a complete system of treatment by itself, it is a very effective complimentary skillset when used properly as an adjunct treatment. An experienced therapist that has this credential is often very good at properly diagnosing and treating dysfunctions.

After narrowing your search, take a look at who the therapist has worked with (athletic populations in performance enhancement would be my first choice) and how long he/she has been practicing in orthopedics/sports rehabilitation. Experience goes a long way, of course, but make sure that you're getting a therapist with the the right kind of experience.

Finally, a word on education: at this point in PT training, there are a number of different degrees that a PT might have earned. You may find therapists that practice with an undergraduate degree in physical therapy, a Master's degree (MS or MSPT), or the Entry-Level Doctorate (DPT). In addition, there are a number of Terminal Degrees that a therapist may have earned as well, including the EdD., ScD., and of course the PhD. While it might be tempting to simply assume that a PT with the most educational letters behind his/her name is also going to be the best therapist, this might not always be the case. The terminal degrees are research-related and therefore do not necessarily translate into better clinical skills, and the difference between a DPT and a therapist with his/her Masters or even Bachelor's degree isn't as great as you might expect, either. The major difference between these entry-level degrees is primarily the amount of time in school, with the DPT student taking an expanded curriculum when compared to the other degrees. However, this doesn't mean that the DPT is a better clinician, which is even acknowledged by the American Physical Therapy Association itself.

In this case, I would recommend experience and additional qualifications over simply the type of education when looking at a PT's abilities. As an aside, the DPT is now the standard entry-level degree of all new physical therapists, and most programs have already switched over from the MSPT to the DPT, so as the profession of physical therapy continues to move forwards, there will be fewer therapists that are practicing without the DPT (at this point, bachelors programs no longer exist by themselves, although there are some programs that offer undergrads the option of entering an accelerated 4+2 year bachelor/doctorate degree).

Now that you (hopefully) understand physical therapy a little better, let's take a look at what you're describing as your problem: a turned-out foot when squatting. This isn't actually an imbalance. It's a potential dysfunction or movement impairment. That means that there is a departure from what would be considered the standard, or normal, position or motion of part of the body during an activity. This is not, however, an imbalance by itself.

An imbalance refers to the interaction between either opposing muscle groups (such as the quadriceps on the front of your leg and the hamstrings on the back of your leg) or muscles that work together as synergists, such as the actual muscles that make up the hamstrings: the semitendinosus, semimembranosus and biceps femoris muscles. When the natural relationships between muscles are changed and one or more muscles become weaker or shorter than the other(s), this is called an imbalance. For example, the normal and healthy strength ratio between the quadriceps and the hamstrings has been examined quite a number of times in the literature, such as in this study from the journal Physical Therapy. Most of these studies find a natural strength ratio somewhere around 2:1 quadriceps:hamstrings, depending on the study and the methods.
As you might expect, these two concepts are, of course, related. Our current model for the cause of chronic injury/pain is based on muscle dysfunctions and imbalances. If we take the example of the 2:1 strength ratio and change it to make the quadriceps much stronger than the hamstrings, for instance (perhaps 2.5:1 or 3:1), this will change the forces occurring at the knee and the way that we move, which can lead to chronic issues. However, the terms imbalance and dysfunction do not describe the same concept, but rather two aspects possibly having an effect on the same overall issue.

The truth is, the reason that your foot turns out even if your legs and knees appear to be lined properly could be happening for a number of reasons, some of which would be structural (meaning that the actual alignment of the bones and joints are to blame) while others could be functional (meaning that there are adaptations to your muscle lengths, strength and movement that causes this to occur). To make it a little more complicated, there is very rarely any single cause for a problem, and it is far more likely that you are dealing with both issues to some degree: there may be muscle strength and length issues that have resulted in structural changes (imbalance leading to dysfunction), or you may have structural issues that have contributed to changes in your muscles that are contributing further to the problem (dysfunction leading to specific imbalances).

Usually, dysfunctional movements such as the kind that you're describing can be improved if not entirely corrected, but understanding what is actually contributing to the problem is just as important as being able to identify the problem in the first place. For example, I would take a guess and suggest that what is actually occurring when you are squatting is probably a relatively common issue such as an over-pronation of your right foot. This can be caused by a number of issues including structural changes in the foot itself due to muscle weakness and/or shortness in the hip extensors, leading to changes in the kinetic chain from the ankle up to the low back and even beyond.

In this example, muscle weakness and subsequent poor dynamic control of the knee leads to compensatory strategies in the lower leg, foot and ankle. Normally, the biceps femoris muscle acts as a strong lateral stabilizer of the knee, preventing your leg from falling inwards (adducting) during a squatting motion. In your case, there are a number of reasons that would lead me to suspect that this might not actually be happening. Although I don't know how you actually injured both of your ACLs, muscle weakness in the hip extensors such as the biceps femoris can be one of the causes for such injuries, especially in non-contact ACL injuries. I'm also assuming that your ACL injuries were in fact non-contact (meaning no direct trauma to the knee itself) since bilateral ACL ruptures would be a pretty rare thing...even for a football player! Non-contact ACL tears occur 2-4x more in female athletes than they do in males, based on the sport and activity, which also leads to my assumption concerning the mechanism of your injuries.

If there is a weakness of your lateral (outside) hamstrings, the biceps femoris specifically, we would normally expect to see a dynamic valgus where the knees fall inwards towards one another. However, in order to prevent this, your particular strategy may be to laterally rotate your tibia (turn the shin/lower leg outwards), resulting in an improvement in the biomechanical ability of the biceps femoris muscle to exert force and maintain the position of your knee, disguising the actual weakness that exists. Because of this, there would be an increased pressure on the outside of the foot (the little toe and the "fifth ray"). This is not how we would normally walk or place pressure on our feet, so in order to balance out the contact forces of the foot your body has responded by pronating your right foot, allowing contact to once again be placed closer towards the inside of the foot (big toe and "first ray").
Of course, I could be completely wrong, too! But by putting the details together like my attempt above, coupled with a complete physical examination and evaluation of movement, a good therapist will be able to "read" the signs of your body and correct the issue.

Thanks for the great question, and thanks for listening to me ramble on the FitCast! I'm glad that you like it.

-Jonathan