Regional Interdependence: Evaluating the Areas Above and Below an Injury

By: Doug Bonnesen, DPT
Tuesday, December 10, 2013

I see a lot of runners and athletes in our clinic, and they come in with a myriad of issues: low back pain, plantar fasciitis and knee tendinitis just to name a few.

During the history, the patients report signs and symptoms of their issues and current troubles they are having. Sometimes there was a traumatic incident, but a lot of times “It just came on.” This can make it particularly difficult to find the reason why the current musculoskeletal dysfunction is present. There is usually one area that is the “squeaky wheel,” but often there are other contributing factors leading up to the actual injury, such as strength and flexibility issues or neuromuscular firing pattern problems due to biomechanical structural changes. This occurrence can be described by using the term “regional interdependence.” This term was first brought up by Rob Wainner in the Journal of Orthopaedic & Sports Physical Therapy in 2007.1 Within the context of musculoskeletal problems, regional interdependence refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patient’s primary complaint.

For example, in the clinic we sometimes see patients with low back pain who have no findings either radiologically or through special tests but have a lack of range of motion in the hip. The hip deficit is treated, and we see the low back pain resolve. When an athlete comes in with an ankle sprain and his or her hip strength is checked, we have seen a common denominator of lack of hip strength on the injured side. Did the lack of strength contribute to the ankle sprain? When an athlete presents with knee pain while running, we always need to be looking above (hip and low back) and below (foot and ankle) to see what factors may also be contributing to the knee pain. In the references below, you’ll find an excellent case report of this regarding a dancer and rehab of her patella femoral knee pain.2 Can you guess where they concentrated the treatment? The therapists focused on core and hip strengthening, and the patient was able to return to full activities.

When patients come into our offices with a chronic musculoskeletal issue or even something that “just came on,” we need to be looking not only at the problem area but the parts of the body above and below to see if there are deficits that may be contributing to the patients’ primary complaint. Sending a patient for a physical therapy evaluation could be a good first step to helping the patient recover from his or her injury.

Doug Bonnesen, DPTDoug Bonnesen, DPT, is an orthopedic physical therapist with Bodyworx Physical Therapy located at 7015 E. Central in Wichita. He specializes in the treatment of orthopedic and musculoskeletal injuries, with a special emphasis in lower body biomechanics, pediatric and adult sports injuries, and neck and back pain. He can be reached at 316-558-8808 or