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Clinical Neurodynamics and Sports Medicine: Origins and Development

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SPORTS REHABILITATION

CLINICAL
NEURODYNAMICS IN
SPORTS INJURIES
ORIGINS AND NEW DEVELOPMENTS
– Written by Michael Shacklock, Australia

INTRODUCTION intra-radicular blood flow, the capacity of be harmful, nor did we fully appreciate the
Physical tests for involvement of neural the nerve root to slide in the intervertebral complex nature of the local effects on the
structures in musculoskeletal disorders foramen5 and nerve root conductions6. nerves and the musculoskeletal structures
have been in existence for quite some time Since these manoeuvres emerged, our which are closely interwoven.
now, the first known one being introduced understanding of the integrative actions A significant extrapolation of the
in 2800 BC by the Egyptian physician between the nervous and musculoskeletal above marked the advent of the straight
Imhotep as he described a ‘leg straightening systems has continued to grow rapidly and leg raise test of the upper limb, originally
manoeuvre’ in physical examination of provide new and complex insights into the documented by Von Lanz and Wachsmuth3
people with back pain. Since then, much management of musculoskeletal and sports and developed into a much more useable
discussion about the test has occurred, injuries. clinical test by Elvey8. In the interim, the test
following various prominent authors such Even so, we physiotherapists initially has had different names such as ‘brachial
as Lasègue in 1864 and Forst in 18811, examined simplistically with respect to the plexus tension test’, ‘upper limb tension
Charnley2, von Lanz and Wachsmuth3 and idea that such physical tests were a reflection test’ and ‘upper limb neurodynamic test’.
Breig4. of solely the ‘length’ or ‘flexibility’ of nerves Subsequently there became cause to re-
From data obtained at surgery in which were often interpreted to be ‘tight’. examine these tests which took us from
patients with sciatica, Charnley2 described Clinically, we therefore sought to increase the initial idea of ‘nerve tension’ toward a
the abnormal straight leg raise test their length and mobility through ‘nerve new understanding of more factors that
as a reflection of intervertebral disc stretching’ or ‘mobilising’ techniques7. At contribute to the health of the nerve and its
protruding onto the local nerve root. More that time, it was not realised that such related surrounding structures, as well as
contemporary studies support this concept marked increases in tension produced by those it innervates9-11.21. Such aspects consist
that such compression also compromises the stretches or mobilisations were likely to of how the nervous system moves and

50
 1 2

3a 3b

Figure 1: Standard median neurodynamic test to end range with structural differentiation (Reproduced with permission from Elsevier,
Oxford21).
Figure 2: Standard slump testing for low back pain and sciatica (Reproduced with permission from Elsevier, Oxford21).
Figure 3: a) Neurodynamic test of the radial sensory nerve. b) Neurodynamic test for the peroneal nerve (Reproduced with permission from
Elsevier, Oxford21).

interacts with the musculoskeletal system conditions and describes current thoughts developed considerably and is now reflected
and the relevant physiological changes that regarding the diagnostic and therapeutic in a more expansive and multi-mechanism
can interact between the two10,11. implications of research in this area. approach9,11.
Finally, optimum human performance During the development of the neural
and movement are essential for sporting Origins and basis of the ‘neurodynamics approaches there arose a set of standard
success, such that these aspects are concept’ physical tests. These were directed at the
deeply involved in sports medicine and Mechanical treatment of neural tissues upper limb, spine and lower limb and consist
physiotherapy and movement science. in physiotherapy have been in existence of the median (upper limb) neurodynamic
However, one of the impediments to such for quite some time now7,8,12-14. In the early test (Figure 1), slump test (Figure 2) and
success to emerge in this area is the potential stages of the neural approaches, many straight leg raise tests respectively. A further
for a neural component to sports injuries of the techniques were based on only a development was that these tests were
(e.g. sciatic nerve component to hamstring small number of mechanisms and many given variations in which they could be
injury). A key aspect of management and aspects of a potentially new approach were sensitised with more extensive or specific
treatment of the athlete and sportsperson missing. Those early approaches had other movements. In addition, even specific joint
is detailed diagnosis and treatment. This names, for instance adverse neural tension movements are now used to test and treat
brief review aims to outline the status of and neural mobilisation, in which a key specific peripheral nerves, for instance
the science regarding the examination of part was stretching and moving nerves. the radial sensory, peroneal, tibial, sural,
the nervous system in musculoskeletal However, since then the approach has obturator and femoral. Now there is a

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SPORTS REHABILITATION

4 5 Neurodynamics

Mechanics Physiology

Pathomechanics Pathophysiology

Pathodynamics

neurodynamic test and treatment available 6 Tension

for virtually all the major nerves of the body
(Figure 3a and b).
Compression
KEY MECHANISMS AND CORNERSTONES
Interdependence of mechanics and
physiology of the nervous system
The concept of neurodynamics relies
Sliding
on several key proposals, one of which is
Neurodynamic
the fact that, in our patients, mechanics tests
and physiology of the nervous system Intraneural
are often dynamically interdependent. blood flow
Changes in pressure and tension in the
nervous system produce changes in blood
flow5,15,16, inflammation and mechano-
Inflammation
sensitivity in the neural tissues17-19 which
can have important clinical consequences.
For instance, if a sportsperson pronates
excessively at the ankle, this movement Mechanosensitivity
tightens and compresses the tibial nerve
at the tarsal tunnel20 and may produce Figure 4: Pronation of the hindfoot producing increased tension and pressure in the tibial
foot or heel pain from a local tibial nerve nerve as it passes through the tarsal tunnel.
component (Figure 4).
Figure 5: Concept of neurodynamics linking mechanics and physiology of the nervous system
Likewise, changes in physiology of (Reproduced with permission from Physiotherapy10).
the nervous system may also produce
Figure 6: Local mechanisms involved in neurodynamic test (Reproduced with permission
changes in mechanical function. Diabetic
from Elsevier, Oxford21).
neuropathy is a good example whereby
the axons in a peripheral nerve may
become swollen, endoneurial fluid can be treated with mechanical techniques reflects the exact relevant mechanisms:
pressure increases, scar tissue may develop which makes neurodynamics ideal for the mechanics (tension, sliding pressure)
and the nerve’s mechanical function physiotherapist to apply clinically (Figure 5). and physiology (intraneural blood flow,
is compromised. Given a normal or In the event that an abnormality in neural sensitivity and inflammation) in the patient.
optimal mechanical environment for the function exists, both pathomechanical This is why the term ‘neurodynamic test’ is
nervous system, the system has a good and pathophysiological aspects may be recommended10,21 (Figure 6).
opportunity to remain normal and be free involved. In any case, mechanical treatment
of symptoms. However, in the event that is performed as a means of improving both Integrative functions of the nervous and
pathomechanics develop, a cascade of aspects. musculoskeletal systems
pathophysiological events can occur in the Conceptually, one of the most important The musculoskeletal system is effectively
neural tissues, such as those mentioned aspects of mechanical testing of the nervous the container, and forms a mechanical
above. Each of those pathophysiological system is the idea that we should be calling interface for the nervous system. It is
facets are key issues for the patient and the tests and movements a name that paramount that the nervous system be

52
 Figure 7: Layout of the
neurodynamics system, interface,
neural and innervated tissues
(Reproduced with permission from
Elsevier, Oxford21).

placed in as healthy an environment as For instance, a sportsperson might have occurs (Figure 8). The tensioner emphasises
possible in order for it to function optimally. a repetitive movement to perform during the elongation of nerve tissue and is more
When the mechanical interface misbehaves training or sport. If this activity produces likely to provoke symptoms. Therefore it is
in the form of mechanical dysfunction, excessive compression of nerves by the often used in the higher function athlete
its relationship with the nervous system interface, then it may be necessary to offer with a smaller neural component to the
becomes compromised and function of the movement-based protective strategies in problem (Figure 9).
nervous system may become abnormal. relation to the affected neural structure. This
Hence, a key aspect of the neurodynamics could naturally apply to nerve root or local
approach is that diagnosis and treatment of peripheral nerve and would be categorised
the musculoskeletal and nervous systems
are integrated.
as an interface dysfunction. However, other
sportspeople may develop a specific neural
we should call
Another important aspect is that, from component to their problem and this is the tests and
structure and function perspective, the when treatment may be directed at the
system comprises three parts: neural structures specifically in the form of movements
a name that
1. mechanical interface, slider or tensioner techniques. It is known
2. neural and that the two different techniques produce
3. innervated tissues.
This layout provides the clinician with
a difference in emphasis of forces in neural
tissues22. Naturally, the slider produces less
reflects the
a number of important opportunities:
to understand how to move the nervous
force in the nerves and more sliding and is
therefore best suited to the athlete with an
exact relevant
system specifically and how to formulate
diagnostic categories in relation to
acute problem or one in which there is a need
for the nerve to maintain its sliding capacity
mechanisms
abnormal neurodynamics (Figure 7). through myofascial structures as healing

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SPORTS REHABILITATION

8a 8b

9
In stating that a key aspect of the neurodynamics approach is
integration of neural and musculoskeletal function, usually athletes
present with a need for multi-structural treatment. In this case,
manual technique can be combined with neural mobilisation. This
is particularly relevant to hamstring disorders (Figure 10).

Convergence
This is a generic mechanism in that it occurs in all areas of the
body when a joint moves. It is when the nerves slide toward the
joint at which tension is applied (Figure 10). When joints are moved,
this applies force to the adjacent nerves, which then produces
relative displacement of nerves relative to the interface. This is a
protective mechanism and actually gives clinicians opportunities in
relation to a phenomenon which has been researched and applied
10 clinically since the 1980s23. The clinical corollary is ‘neurodynamic
sequencing’ which provides new opportunities to move the nervous
system in ways that are more specific to the patients’ needs. This is
because the sequence of movement influences the movement and
strain behaviour of the nerves which, in treatment, can be used to
produce patients’ relieving or symptomatic movements.

Neurodynamic sequencing
Even though the nervous system is a lengthy continuum4, its
biomechanical function is not uniform. Instead, areas of high
and low pressure and tension occur with daily movements
and neurodynamic testing10,21. Shacklock23 showed that, in
asymptomatic subjects, the order or sequence of application of the
component movements of the same neurodynamic test affected
the distribution of symptoms. More symptoms tended to develop
in the local area where the joint was moved first and more strongly.
Figure 8: Lumbar neural slider technique, lower forces and more These results were derived by comparison of three studies in which
movement of the neural tissues (Reproduced with permission from the above variables occurred23-25. The effects of the sequence of
Elsevier, Oxford21). movement on the upper quarter have also been investigated with
Figure 9: Lumbar neural tensioner technique – greater elongation the result that fewer responses occur in the area that is moved last26.
force in the neural tissues (Reproduced with permission from This phenomenon has support in cadavers in which the ulnar nerve
Elsevier, Oxford21). was tested in three different sequences of movement27 (Figure 12):
Figure 10: Integration of myofascial technique with sciatic nerve 1. Proximal-to-distal sequence.
mobilisation in the case of neural aspect to hamstring pain 2. Distal-to-proximal sequence.
(Reproduced with permission from Elsevier, Oxford21). 3. Elbow first sequence.

54
 Figure 11: Convergence of nerve toward the
joint at which tension is applied as a generic
adaptive function of the nervous system
(Reproduced with permission from Elsevier,
Oxford21).

biomechanics and applied movements.

Neurodynamic sequencing has several key
benefits:
• Opportunity to test and treat in a
way that is specific to the patient’s
movement-related needs, as opposed
to simply relying on standard
neurodynamic tests.
• A progressional system that can be
applied to patient problems ranging
from the patient who is very restricted
and painful to the patient with a minor
problem whose needs are quite athletic.
In two more recent studies of the median
and sciatic nerves in cadavers, it was found
that a nerve is under tension for longer
during a neurodynamic test when the local
joint is moved first28,29.

SUMMARY
The clinical neurodynamics approach
came from advances in neural tension and
neural mobilisation and now includes many
more aspects than in the past. These include
sliding, pressure changes (mechanics),
intraneural blood flow, sensitivity
(physiology) of neural tissues. Furthermore,
diagnosis and treatment are integrated
with musculoskeletal function, particularly
diagnostic categories and progressions in
relation to technique selection. The benefits
of this approach are that, when combining
Figure 12: Measurement of strain in the ulnar nerve at the elbow during different sequences the cornerstones of neurodynamics, many
of movement in the cadaver. The sequence which produced most strain in the nerve was more techniques are now available, such
the one in which elbow movement was performed first (Reproduced with permission from that diagnostic and treatment techniques
Tsai 199527). are more flexible and can be customised for
each individual patient more than before.
The elbow first sequence produced sequencing is now an important variable The principles of clinical neurodynamics
significantly more strain (i.e. local effects) in in neurodynamic testing and treatment. can be applied to many clinical syndromes,
the ulnar nerve at the elbow than the other This is called ‘neurodynamic sequencing’21 particularly including sports injuries and
two sequences of movement. and relies on the principle that the nervous their management. Furthermore this
Since the sequence of movements has system does not behave uniformly and approach can be applied to exercises,
now been shown to influence the response instead responds to movement in a variable movement and performance-based
and local strain in neural tissues, movement way, depending on the local anatomy, strategies in the sportsperson and athlete.

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SPORTS REHABILITATION

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