For Non Medical Blog Readers

*** Please note the following blog contains information for both medical and non medical personnel. Please read this paragraph and the next one, view the pictures and skip to the last section of the blog if you are the average, non medical blog reader.

Sometimes we have patients and findings in the office that just make don’t make sense. Sometimes these patients have been to other health care professionals and had treatment without success. You then scratch your head and wonder, “What was missing or what could have been overlooked?”  Sometimes the obvious was ignored. The obvious was ignored for 2 years in a recent patient in our office with lofty aspirations of making the NFL. From the pictures below, the obvious was moderate to severe tension in the thigh muscles affecting the athlete’s ability to stand, walk, run, balance, jump, land, change direction and other things necessary for a professional athlete. The blog traces the case from the 1st session to discharge at the 6th session. Our treatment focus was on the obvious (thigh tension). ***

For Medical Personnel Blog Readers – History

We recently saw a patient in the office with a 2 year history of chronic knee pain that started late in his senior season of collegiate football. The athlete was provided palliative (pain relieving) care with ice and electric stimulation and told that he should take NSAID’s (non steroidal anti-inflammatory medication such as Motrin, Aleve, Naproxen, etc.) as needed to get through the season. This strategy initially helped; however, the knees continued to bother him. The team physician ordered a MRI after the season. The MRI was clean showing no structural damage to the knees. The athlete was told to manage the symptoms with a regimen of ice, electrical stimulation, training modification and oral medication as needed. Seems harmlesss enough right?

Fast forward 2 years when he comes into our office. The knee pain was no longer during football related activities. Pain occurred at rest. Activities like prolonged sitting, standing and even resting (laying down for periods of time) would aggravate the knees. Stairs were painful. Squats were painful. Lunges were painful. He had difficulty with running, jumping, and with change of direction. These are all inherent qualities needed to play high level football.

We failed to mention that the knee pain hampered his ability to train for the NFL Combine for the past 2 years. We also failed to mention that he performed poorly at several NFL individual tryouts (most recently with the Dolphins) and at Regional NFL Combines because of the knee pain. What seemed harmless clearly progressed into something that affected this young man’s potential livelihood.

Making an NFL practice squad is valued at approximately $5,700/week. That contract is worth approximately $96,900 (NFL Practice Squad Salary) over a 17 week NFL season. The minimum rookie salary if he makes an NFL roster is approximately $435,000 for the season (NFL Rookie Salary). It is true that NFL contracts are not guaranteed, but the point here is that the knee pain seriously hindered his ability to compete at the highest level. The pain impaired his the chance to live his dream of playing in the NFL. The pain hampered his chance at a ridiculously nice salary.  Seems like a little problem, just became a big one!

Initial Presentation

We won’t bore you with all the details. We will just highlight the key findings:

  • + L Mod Thomas: Moderate-Severe Tension in L Rectus Femoris and Quad Musculature, Moderate L Adductor Tension
L Initial Mod Thomas Test

L Initial Mod Thomas Test

  • + R Mod Thomas: Moderate-Severe Tension in R Rectus Femoris and Quad Musculature, Moderate R Adductor Tension
R Initial Mod Thomas

R Initial Mod Thomas

  • Heel to Buttock’s Test for Quadriceps Length: Difficulty bilaterally getting to 90 degrees of passive knee flexion (R Angle 95 and L 90). The normal measurement is approximately 135-145 degrees of passive knee flexion.
  • + Clarke’s Test/Patellofemoral Grind Test: R and L patellar compression with active quad contraction increased knee pain.
  • + Patellar Compression Test:  Pain with compression of the knee cap with active knee flexion and extension.
  • – Knee Othopedic Tests for Pain/Instability:  Lachman’s, Anterior and Posterior Drawer, McMurray’s, Patellar Apprehension, Apley’s Compression, Apley’s Distraction, Varus and Valgus Stress Test’s at 0 and 30 degrees
  • + Prone Hip Extension Test: Limited hip extension bilaterally with increased hamstring tone, knee flexion bilaterally, anterior pelvic roll bilaterally
  • + Sidelying Hip Abduction Test: Pelvis/Hip Anterior Roll bilaterally, Decreased B Hip Range of Motion
  • + Squat Screen: Pain noted with squat maneuver to 0-70 degrees bilaterally (loss of depth), with B heel rise (mild-moderate), lumbar flexion at 70 degrees, and loss of thoracic extension (torso rounding forward in the squat), pain and loss of coordinated movement returning from the depth of the movement.
  • + Lunge Screen: Pain noted with maneuver 0-70 degrees (loss of depth), loss of thoracic extension (forward lean), pain and loss of coordinated movement returning from the depth of the movement.
  • – MRI Findings: No abnormal MRI findings.


Caption Says It All

Caption Says It All

The patient had a scheduled tryout with a Canadian League Football team less than 2 weeks after the initial session. We had to work quickly to reduce the pain, improve the knee range of motion, improve the soft tissue extensibility/flexibility and improve movement patterns. So what do you address first? Remember you have limited time to work with this athlete.

We picked the “Texas Sized Dysfunction.”  A “Texas Sized Dysfunction” is a dysfunction so big and so obvious, you couldn’t miss it. The most obvious finding was the soft tissue extensibility/flexibility of the quadriceps muscles. Don’t believe me? Just check the pictures above again. Normally, the knee should bend to 90 degrees in the Modified Thomas position. Clearly, the knees are nowhere close to 90 degrees. Normally when bending the heel to the buttocks, the heel should be in rather close proximity to the butt; however, the heel was nowhere close in our patient. Our treatment plan was 3 sessions/week for 2 weeks and consisted of:

1). Soft Tissue Mobilization/Manipulation: IASTM (Implemented Assisted Soft Tissue Mobilization) utilizing the FAKTR (Functional and Kinetic Treatment with Rehab) Concepts with the Edge Mobility Tool 8-10 Minutes On Each Side

Implemented Assisted Soft Tissue Mobilization (IASTM) with the EDGE Tool

Implemented Assisted Soft Tissue Mobilization (IASTM) with the EDGE Tool

2). Rehab Exercises:

  • Kneeling Ankle DF 1 set of 30 reps on each side
  • Foam Rolls 1 set of 20-30 reps on each side (Quads, Hamstrings, ITB/TFL, Calves,Groin)
  • Post Hip Capsule Stretch 3 sets of 20-30 seconds each side
  • Hip Extension from Prone Press Up Position with Breathing Overpressure/Ant Hip Capsule Self Mob 1 set of 20 reps on each side
  • Hip Airplanes 1 set of 20 reps on each side (Forward/Backward/Internal & External Rotation)
  • Triplanar Quad Stretch 1 set x 3 positions x 20 reps

3). Manipulation (As Needed):

  • B Ankles Long Axis Extension
  • Proximal and Distal Tib-Fib A-P and P-A Glides – Speeder Board 3x Each
  • Hip A-P and P-A utilizing a drop piece 3x Each

4). Home Program: Same Exercises To Be Done 3-4x daily

L Final Modified Thomas - Big Improvement

L Final Modified Thomas – Big Improvement

R Final Modified Thomas - Big Improvement

R Final Modified Thomas – Big Improvement

Re-Eval – Visit #6

  • Decreased self reported knee pain from 7/10 with activity to at worst 2/10 with activity (sprinting, running, lateral agility, etc.)
  • Improved soft tissue extensibility/flexibility as noted in the Modified Thomas test (pictures above) and prone knee to butt test
  • Squat & Lunge Patterns: Improved depth of the squat and lunge patterns. Decreased pain from 7/10 to 1/10 noted with both patterns. Improved and more coordinated movement while returning from the bottom of the squat and lunge to the starting position. Loss of thoracic (mid back extension) and lumbar flexion still noted with the squat and lunge at re-eval on visit #6. Mild loss of dorsiflexion present in the squat pattern at depth with bilateral heel rise.
  • Orthopedic Testing: No pain with orthopedic testing (patellar grind & patellar compression).
  • Side Hip Abduction: Improved hip range of motion. No visible pelvic roll.
  • Prone Hip Extension: Improved hip extension range of motion. Increased use of hamstring with knee flexion still noted.


We started with a bold comment, “Don’t Ignore The Obvious!” The obvious in this situation was that no structural findings in the knee were present as evidenced by our orthopedic testing and normal MRI findings (no ligament damage, no bony abnormalities and no cartilage damage). The obvious was that something else was triggering his complaints. The obvious turned out to be moderate to severe thigh tension as noted in our functional exams. Specific treatment to the obvious (moderate to severe tension of the anterior thigh muscles) made a huge impact on this patient in rapid fashion. He was able to resume high level training in less than 2 weeks (6 total sessions). He was signed to a Canadian League Football (CFL) team following a tryout after his sixth treatment session and left for minicamp less than 1 week later.

This was a functional problem meaning bad function such as tight tissues and improper movements contributed to his symptoms. This was not a structural problem that could be seen on MRI. Past medical care stopped once the MRI findings came back normal; however, the problem was still there. Standard knee MRI’s test structure, not function.

Think of the body as a computer. Human movement requires an intricate relationship between hardware (monitor, keyboard, mouse, motherboard, etc.) and software (computer programs – Windows, Microsoft Office, etc.). You can’t have a functional computer without hardware and software working harmoniously together. You can’t have movement quality without structure and function. Examination of this athlete focused on structure to the detriment of missing out on function. Don’t ignore the obvious!  If structure is intact, then it’s time to go looking at function.

*** About The Author — Dr. Dino Pappas, DC, MS, ATC, CSCS, CKTP, cert MDT, FMS – Level 1 *** 

Dr. Dino Pappas

Dr. Dino Pappas

Dr. Pappas is a chiropractic physician, certified athletic trainer and certified strength and conditioning specialist. Dr. Pappas blends the best of physical medicine with the best of integrated medicine to help patients and athletes of all shapes and sizes. He utilizes tools such as chiropractic manipulation, soft tissue work (IASTM, Graston, Active Release, Myofascial Release and joint mobilization), biomedical acupuncture, functional movement based assessment, the McKenzie Method,  strength training and conditioning, customized nutrition and specialty laboratory testing (blood, saliva, urine, and stool) when needed. Dr. Pappas’ clinical focus is sports medicine, conservative orthopedics, rehabilitation and integrated medicine. His sports medicine interests are endurance athletes, overhead athletes (pitchers, throwers, volleyball players and tennis players), contact sports athletes (football, rugby, lacrosse, field hockey, soccer and basketball) and Crossfit athletes. He reads and interprets the medical literature daily to stay abreast of cutting edge advances in his field. The doctor is currently the team chiropractor for the Windy City Thunderbolts minor league baseball team and a sports medicine volunteer for Andrew High School in Tinley Park, IL. He is an avid runner and aspiring triathlete having completed 4 marathons, 3 half marathons and numerous 5 and 10k races. The doctor is also active in the local, suburban Chicago running scene. He has goals of qualifying and competing in the Boston and New York Marathons, the Ironman in Kona, Hawaii, and climbing Mt. Kiliminjaro in Kenya, Africa. One day he hopes to serve his country as a team chiropractor for the United States Olympic teams and serve as a team chiropractor for one of the professional teams in Chicago. His mantra is “Why Put Off Feeling Good?” He can be reached by email at or at 708-532-2346. ***

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