SFMA Insights -- Multi-Segmental Extension
We've all seen it in the clinic. The patient who bends backward, experiences a familiar pinch, and points right to their low back. It’s a classic, but what are we really looking at?
This multi-segmental extension pattern from the SFMA is one of the most common dysfunctional painful movements we see. But simply labeling it "painful" isn't enough. We have to understand the nuances of the pattern to truly get to the root of the problem.
When I'm assessing this, I’m looking for two key things: a smooth anterior weight shift and, more importantly, smooth, proportional spinal curves. We should see that extension happen throughout the thoracic and lumbar spine.
The Hinge We All See
More often, we see the "hinge." The person does a quick anterior weight shift and then gets all their motion from one fulcrum, typically L5-S1. They don't extend through their thoracic spine, and they don't get proportional motion from the rest of their lumbar spine. They just hinge at that one painful segment.
So, what does this all mean?
This is where our clinical reasoning comes in. You can break out this dysfunctional, painful pattern. What happens when you put them in a lower-level posture? A lot of times, the pain will actually go away, and the pattern becomes functional.
When you see that—pain and dysfunction in the top-tier pattern but functional and non-painful in a lower-level test—you need to put that patient in the stability problem bucket.
The Hidden Culprit: The Flexion Connection
Here's where it gets interesting. This hinging in extension is almost always linked to a unique (and dysfunctional) finding in their multi-segmental flexion pattern.
This is the person who, when you ask them to touch their toes, can easily palm the floor. If you're not paying attention to all the criteria, you might clear their flexion pattern. But look closer. They aren't reversing their lordosis. They aren't flexing their spine. They are getting 100% of that motion from their hips.
If that person can palm the floor and they have other bilateral signs (think Beighton criteria, like hyperextended elbows or knees), this confirms it. This person is getting all their stability from a lumbar extended position. They fundamentally don't know how to be stable when they're trying to do a flexion activity.
No wonder their back gets pissed off. It's the only tool they have.
A Shift in Treatment Philosophy
This discovery has to change our treatment philosophy. The body will always take the path of least resistance, and for this person, that path is the L5-S1 hinge. Our job is to take that path away.
Our reset, reinforcement, and retraining techniques must be built around "locking out" that lumbar spine.
Here are two examples:
- Mobility Work: Let's say we want to work on an anterior superficial chain mobility problem, like the rectus femoris. If we just put them in a standard stretch, they're going to extend at L5-S1 and get no real hip extension. Instead, put them in a prone hip mobility position and bring the opposite knee up to their chest. This posteriorly tilts the pelvis, gets them into lumbar flexion, and locks them there. Now, when you work on that rectus femoris, you're actually working on the hip.
- Retraining: When we get to multi-segmental rolling, these patients will try to extend to create their flexion pattern. One way to combat this is with a "hard rolling" pattern (I now call this connected rolling). Have them bring their knee to their elbow and engage their core first. This posteriorly tilts the pelvis, locks them in flexion, and allows us to retrain an authentic, stabilized flexion pattern.
We have to be smarter than the body's compensation strategy. By identifying the stability problem and locking out the hinge, we can build the authentic patterns they're missing.
For more discussion on this, you can check out the full video here:
SFMA Insights With Dr. Phil Plisky: Multi-Segmental Extension
