Conservative Management of meniscus knee pain with an Olympic athlete using Motion Dynamics protocols

Recipient: Russell Aylsworth, 20 years old. Born in Hong Kong. World sailing ranking 62. Member of the Hong Kong Olympic Sailing team.

Medical report: Russell has several small radial tears in his right knee in the lateral meniscus. (refer radiologist’s report) His Sports Physiotherapist  at the Hong Kong Sports Institute has suggested no surgery. His sports GP has also suggested no surgery. He will be seeing his orthopaedic doctor on Monday 18th May 2021 for a consultation . Should he say no surgery then we at Motion Dynamics will go ahead with a full knee rehabilitation program, 6 to 10 weeks of focused rehabilitation.

What is the Meniscus?

The meniscus are two C-shaped pieces of rubbery cartilage in the knee that fit between the femur (thigh bone) and tibia (shine bone). The meniscus act as shock absorbers and bumpers inside the knee joint. They allow the knee joint to glide smoothly and distribute the forces within the knee during activities such as walking, running, and jumping.

Meniscus Tear Causes and Symptoms

Meniscus tears come in many different shapes and sizes, and they can occur for a variety of reasons. Often times they occur as a result of a specific trauma such as landing awkwardly from a jump or being tackled in football. Other tears occur over time as a result of degeneration (wearing out) of the cartilage. In general, there are five common types of tears –flap, radial, vertical, bucket-handle, and degenerative. Each type has its own set of causes and treatment options.

In cases of traumatic tears, the patient often experiences an acute popping sensation in the knee followed by pain and swelling. In cases of degenerative tears, patients will sometimes experience the slow onset of symptoms. When a meniscus tear is symptomatic, a patient may experience pain, swelling, and/or mechanical symptoms (clicking, catching, and/or locking of the knee).

It is important to understand that each patient is different and the symptoms listed above do not always mean you have a meniscus tear. A diagnosis should be made by an orthopedic surgeon to ensure the injury is treated appropriately.

Diagnosis and Examination

Diagnosis is based on the patient history, physical exam, and imaging (such as X-rays and/or MRI). A meniscus tear can often be diagnosed on physical exam. The McMurray test is used to detect a tear of the meniscus, and will often cause pain and clicking when performed. Additional exam findings include swelling, pain with range of motion, and joint line tenderness. In most cases, x-rays of the knee will appear normal. If there is a concern about a meniscus tear or other knee injury, an MRI is usually performed. An MRI can be used to determine the size and shape of a tear as well as, look for other knee injuries such as cartilage or ligament tears.

Types of Meniscus Tears

The meniscus is a C-shaped structure that sits inside the knee joint. There are different types of meniscus tears and the type of tear can usually be determined with a knee MRI. Described here are 5 common types of meniscus tears.

  • Radial Tear: Radial tears of the meniscus are the most common. These appear as small tears in the inner part of the meniscus. These tears occur in the avascular part of the meniscus (where there is no blood supply) and, as a result, have little ability to heal on their own..

Non-Surgical Treatment for Meniscus Tears

Surgery is not required in all patients with a meniscus tear. Your surgeon will take into consideration the tear type, as well as your specific lifestyle needs when determine the best treatment option. Non-operative treatment often includes a period of rest followed by a course of physical therapy. This allows the patient to build strength in the muscles surrounding the knee joint, allowing for normal knee function with activities. Nonsteroidal anti-inflammatory drugs (NSAIDs) may also be helpful in reducing pain and swelling. Lastly, some patients benefit from a corticosteroid injection into the knee. Corticosteroid is a strong anti-inflammatory and can often relive knee symptoms associated with a torn meniscus.


14th May 2021: Postural assessment with Chris Watts CEO Motion Dynamics Limited

Weight bearing assessment:

  • Right hip up-slipped by 1.5 inches.
  • Left side shoulder and hip torque (Twist) left to right by ¾ of an inch. Right shoulder elevated by 1 inch.
  • Both shoulders internally rotated and protracted with left being more prominent in protraction.
  • Right knee is externally rotated and laterally positioned. Tibial torsion on Right lower leg. Biceps femoris very restricted on the right side.
  • 3 Inches of forward head protraction..
  • Mild kyphosis in mid thoracic.
  • Both SI joints are frozen mean no rotation or out-flaring and squish test is negative for mobility.
  • Peroneal muscles on both ankles are weak.

Non-weight bearing postural assessment:

  • Left hip upslip not right as when Russell was standing. Poor S I Joint mobility and no gliding of the joints on both sides.
  • Right leg appears to be ½ inch shorter.
  • Testing the psoas muscle on right side showed that it was severely hypertonic with pain up to 8 out of 10 when palpating. Left Psoas pain level 2 out of 10.
  • Right quadricep is hypertonic and the right pelvis is anteriorly tilted by 10 degrees. Specifically the rectus femoris origin on the AIIS is also hypertonic with a 5 out of 10 pain scale on the trigger point of that origin.
  • Hip external rotation whilst non-weightbearing is very noticeable compared to the left side. Piriformis on right side had less that 10 degrees of rotational motion out of a potential of 45 degrees.
  • Both ankles are very inverted when non weight bearing. Weak evertors.


First Treatment: May 14th 2021

Objective report by Chris Watts-Motion Dynamics

Using Positional release therapy a technique designed to reduce tone in the muscles and joints on the Psoas and Iliacus as well as the upper quadriceps on the right side. Used a manual release technique to mobilise the Sacro-Illiac joints on both Illia. Did some sacral  rocking and muscle energy work on the gliding action of the SI Joints.

We assessed Range of Motion on the hip joints. Both hip flexion and hip extension were limited. Right side single leg pelvic tilt was only 140 degrees out of a 160 degree potential and left was 150. Hip extension was zero degrees on both hips. Both psoas major and minor were hypertonic. To improve, Chris used the Active Isolated Stretching techniques with 3 sets on each side to loosen both hips.

Worked on distal hamstrings especially right side and insertions of the biceps femoris into the fibula. We had less than 45 degrees of full knee extension before experiencing sharp irritation to those insertion points on the fibula. Did 3 sets of active assisted stretching to open up the fascial sheaths that were over-shortened and thickened.

His hip/lumbo pelvic imbalances can and do create knee torsion and pressure on the meniscae. Russell was keen to see the link between the structural mechanics and functional bio-mechanics that causes excessive pressure on the tendons and joints.

Objective findings post treatment:

Russell has a straight shoulder, neck and hip alignment. His head is still 2 inches protracted, but his gait is softer and gliding with more fluidity. He was very happy with the session and we look forward to continuing with his spinal mobility and alignment next Thursday.


Session 1: May 14th 2021

Subjective findings from Russell Aylsworth

As an elite sailing athlete, strength and conditioning is a vital part of success. An often overlooked area in our training is recovery and mobility. Being in the gym five times a week is very stressful and demanding on the body.

In training, I tore my lateral meniscus in my right knee and decided to see Chris Watts at Motion Dynamics to help my recovery and fix my many other aches and pains through alignment training and postural and mechanical correction exercises.

When first seeing Chris, he did his examination on me with his laser eye vision seeing the errors in my posture, which surprised me to see how very accurate he was in spite of using an eyeball approach and no digital instruments and measurements. He did a very specific Range of Motion testing and joint restriction testing on the sacro-Illiac joints. We found out that I had a very tight hips, in extension and flexion and limited internal rotation on both hips.

To be honest, I didn’t think that my hips bothered me. But after doing his AIS stretching techniques and some manual soft tissue manipulations, I was surprised by how smooth and effortless it was to just walk around the room; I never knew I had this much potential to feel so loose and move so freely with my hips. After this first very enlightening session, I noticed a huge mobility gain for my sport enabling me to be even more fluid in my agility.

The day after the session with Chris, I was surprised how sore I was even though I was lying down for most of the session. The re-alignment of the fascial collagen fibres meant that I experienced some postural shifting and the utilisation of certain muscles that had become deficient from underuse.

I’m excited about next week’s session with Chris to see more improvements in my mobility and fluidity.


Session 2: May 20th 2021

Objective assessment from Chris Watts

Postural Re-assessment:

  • Right shoulder protracted.
  • Pec minor hypertonic and winging of right scapula.
  • Serratus anterior right side weak and rhomboids under developed.
  • Left hip upslip only 1/8 inch but causing mild functional lateral spinal flexion with head tilted mildly to right side.
  • Anterior pelvic tilt more noticeable on right iIlium by 10 degrees.
  • Both tibia’s are torqued outwards. Both Biceps femoris hamstrings are tight.

Treatment Plan and techniques

Strengthen the semi-tendinosis and inner thighs.

We spent the first part of the session on aligning the shoulders and removing the tension in the pec minor muscles.

Then used a special technique to stabilise the Rhomboid minor and major with 2 different angles of motion. Worked on stabilising the latissimus dorsi bi-laterally. This really helped with the shoulder and neck alignment.

Spent time on stretching the insertions of the bicep femoris on the lateral epicondyle of the fibula. Very restricted. Hips are more open today than last week. Finished with some upper back extensor stability work. Overall better awareness this week and better control of his mechanics.


Session 2: May 20th 2021

Subjective assessment from Russell Aylsworth

Milestones are always great to see. I love the process that I have with Chris because the first thing we do is examine my posture, and it was pleasing to know that I was generally more posturally aligned than last week. Chris determined that I have relatively underdeveloped rhomboids. Rhomboids are the back muscles that help keep the shoulder blades retracted as I have shoulders that roll forwards. I’ve been having upper back pain for a few months and have seen other physiotherapists, and they have never really gotten rid of the knot in my back that’s been nagging at me. I didn’t explain to Chris that I wanted to focus on this because I have gotten to the stage of just not caring about my nagging upper back pain. We started the session by aligning my shoulders and trying to release my very tight pectoral muscles. After releasing my pectoral muscles, the pain in my upper back just disappeared. It amazes me the potential my body has to be so loose and pain-free that Chris can see, and I would never realize without Chris’s help. Something I’ve never enjoyed doing is stretching because of the tingling pain and just makes time unbearably long.

Nevertheless, stretching is still essential for injury prevention and pain-free movement. Chris then worked on my hamstrings, which I have been told by a few physiotherapists and my gym coach that my hamstrings are very tight, but I can’t wait to see the improvement that we will have on them. Something interesting that Chris taught me was reworking my squat mechanics. We used a yoga ball on a wall to practice how my balance and posture are supposed to be while squatting, it felt entirely new for me and something I look forward to progressing. Overall I had an awesome session with Chris. The days after the session with Chris always feels like I’ve just gone to the gym, and it catches me off guard.


Session 3: May 28th 2021 

Objective assessment by Chris Watts

Russell had a postural assessment that showed huge improvements to his head and neck alignment as well as hip alignment. No visible torque in the hips. Only right shoulder had a 1 inch right to left torque with shoulder internal rotation and protraction with some winging of the shoulder blade. Tibial torsion on both lower legs has somewhat improved especially on the left leg. The apex of the knee cap is finally straight. The Apex of the right knee is still turned out. Our objective is to work on the tibial rotators such as the biceps femoris and the popliteal muscles to balance out the pressure on the right knee. The ASIS the apex of the knee and the 2nd toe should all be in a straight alignment when standing and walking. There is some improvement on hip flexor mobility too. Right side still tighter than left.

Started to stabilise the upper back especially the rhomboids minor and major for better retraction of the shoulder blade.


Session 3, May 28th 2021 

Subjective report by Russell Aylsworth

Chris and I had an excellent start to our session to support my overall growth to better alignment and healing. I had significant improvements in my head and upper body alignment.  My hips still felt loose when I would walk, which was a satisfying feeling. My right shoulder was still slightly protracted forward, which I attribute to a challenging upper body gym session beforehand. We first worked on my shoulder mobility and just loosening up my shoulders. Chris mentioned that I still need to strengthen specific back muscles that have been hindering my posture. I was surprised that even though I think I’m training quite intensively, I’m still neglecting specific vital muscles for posture and feeling pain-free. It’s good to have someone like Chris aware of the muscle development expectations for your body personally.

Since the first session with Chris, my feet and my kneecaps are pointed outwards instead of straight on, which is how it should be. Helping fix my leg posture could potentially take the load off my right knee, which would help my meniscus tear recovery process. Chris went about this by stretching my very tight outer hamstrings and the other two parts of my hamstrings intensively. I think stretching is mentally more challenging to endure than actually lifting weights, so I always have to be relaxed every time Chris works on my legs. We finished off the session by strengthening my upper back muscles, specifically my rhomboids major and minor. Overall it was another solid session with Chris, and always so good to see such a significant improvement every week.


Session 4:  May 31st 2021

Objective report by Chris Watts

On the weigh-bearing postural assessment, the pelvis was level in the mid-sagittal plane. However, the pelvis was still tilted forward by 5-10 degrees when measuring the alignment of the ASIS and PSIS. The hip flexors were very hypertonic on both sides especially the right side. For the first time I am able to see that the left and right knees are pointing straight forward. Only the right knee has the tendency to track laterally when walking. We did more pectoralis major and minor stretching which is getting much easier now. Both shoulders have a 60 degree horizontal abduction range, which is target athletic range for that specific movement. Only the internal shoulder rotation is limited . We are at 40 to 50 degrees of rotation and will need to build it to 90 degrees. The infraspinatus on both sides are weak.

Alvin Mesa who has a Master’s Degree in Physiotherapy and works alongside Chris Watts at Motion Dynamics did a series of tests on the right knee ligaments and meniscus. All the results were very functional with no pain or limitation or hypermobility associated with the knee. I believe we can start to do some gentle but focused stability work with the hip/leg and knee internal rotators. We started with the adductor stability program today.


Session 4: May 31st 2021

Subjective report from Russell Aylsworth

After my fourth session with Chris, I can say my meniscus tear is almost unnoticeable for my day-to-day life, and if I weren’t diagnosed or have MRI scans, I wouldn’t know I have an injury. A great indicator I have to attest to this is after my 21-day quarantine, I went indoor bouldering, and within 10 minutes, I could feel my right knee seize up, which caused me to stop climbing. Of course, no one likes to feel limited and forced to stop doing things they love. But after four thoughtful sessions with Chris, I was able to indoor boulder for an hour and a half with no issue on my knee. This is very encouraging to me for the potential our bodies have to recover with the guidance of Chris, of course.

This week’s fourth session with Chris was slightly different because I had the opportunity to work with Alvin Cruz, who holds a master’s degree in physiotherapy. The session was split, so I worked with Chris for the first half and Alvin for the second half. Chris started by stretching my pectoral muscles, which showed more flexibility than last week. During the pectoral stretches, I told Chris I had a knot on my upper trap muscle, and Chris knew how to relieve the pressure and work on my upper trapezoid immediately. He eased the tension by simply pushing up my upper trap for only ninety seconds to alleviate the discomfort I was feeling. In addition, Chris identified some muscles apart of my rotator cuffs were underdeveloped, which we will be working on moving forward to minimize the potential for injuries. We then worked on my very tight hip flexors and worked on my stride while walking. It was interesting and funny to learn how to walk again by activating my hip flexors while walking. I then was handed over to Alvin, who assessed my meniscus tear and did a series of tests to ensure that I didn’t have any issues with my ligaments alongside my tear. It gave me confidence when I could do tests like a single-leg pistol squat with relative ease. Alvin then began working on my fascial trigger points on my body and releasing built-up tension I would have got from a heavy gym load. Finally, Alvin spoke to me about how we should start doing knee stability work to regain some of the muscle around my knee joint to support it and hopefully aid recovery. I am very grateful to work with Chris and Alvin to help my body be at its best.


5th session: June 9th 2021 

Objective report by Chris Watts

Alignment is significantly improved with all the mid-sagittal plane landmarks balanced. The only area that is still mildly imbalanced is the right shoulder girdle with a 1 inch shoulder protraction. Coronal plane shows a ½ inch forward head and a mild kyphotic T6-T9 curve. Also the right ilium is 10 degrees anteriorly tilted whilst the left ilium is 5 degrees anteriorly tilted.

We began the session with deep psoas and illiacus stretching using the AIS active dynamic stretch techniques which engages the Gluteus maximus medial fibres to extend the hip. We are now able to reach 10-15 degrees of hyperextension on both sides of the hip. This is very different to our first session where we were only able to reach zero degrees of hip extension.

We spent more time on centralising the right patella which is still mildly turned out. We performed 3 sets of outer hamstring (biceps femoris) stretches on both sides. We were able to reach 100 degrees of single leg lifts. This represents full functional ROM for the hamstrings with a locked out knee. Russell also had some DOMS from training the distal hamstrings at the Sports institute that made the stretching more challenging. We landed up doing 3 sets of 12 repetitions on both sides.

We spent 10 minutes releasing the right pectoralis major and minor using Neuromuscular and myofascial release techniques and finished the session with more stability training of the upper back and the shoulder external rotators using the “shoulder-cizer” device.

We have one more training session next week. So far the right meniscus and right knee pain is minimal and barely noticeable, not causing any significant slowing down of his general fitness training.


Session 5: June 9th 2021

Subjective report by Russell Aylsworth

Today was the first session with Chris, where my posture was almost entirely aligned except for my right shoulder, which rides forward a little. From an athlete’s perspective, working with Chris has made my body considerably loose. I anecdotally feel that I’ve been able to lift heavier weights in the gym and recover better. Chris and I started our session by working on leg extensions. Even though I did not realize it, Chris saw an improvement in the range I could get; it was motivating to see how much my body can adapt and become healthier with Chris’s help. My hamstrings have always been tight, and when I would see the sports massage people at Sports Institute, and they would always struggle to loosen my hamstrings. Chris is a very determined character and pushes my body to the potential he’s very aware of, and Chris and I work with my awfully tight hamstrings to lengthen them. It was extra tricky this session, especially to work on my hamstrings because I’ve had a gym session just before seeing Chris, yet Chris doesn’t lose confidence in what he does, and we push through together. By the end of the session, we worked on loosening my pectoral muscles from the strenuous effort I put through them from doing some bench presses earlier in that day. After every session with Chris, I always feel light under my feet and just more lively. Doctors have told me that with the type of meniscus tear I have, there is no blood flow going to the Injury, so my meniscus tear will never heal on its own. When I first told Chris about my meniscus tear before I started working with him. He had complete faith and confidence he could help me. It’s fantastic to know someone like Chris who’s invested in who you are and wants the best for you. Since working with Chris, I’ve been pain-free in my right knee and been able to go back and do the sports I love to do and improve and become a better, stronger athlete.


6thand final session: June 17th 2021

Objective report by Chris Watts

Assess, Address and Reassess is how we always go through our sessions here at Motion Dynamics.

The postural assessment on Russell showed a ¼ inch elevation to the left shoulder, a ¼ inch

depression of the right occiput and zygomatic arch. The right Illium was anteriorly tilted by 5 degrees only but caused some discomfort in the hips. Russell was unable to note exactly where that discomfort was but he did complain of some upper to mid back irritation.

We started the session with a series of deep AIS stretches of the right Psoas and illiacus. I then showed him how to release those muscles with a self-stretch technique. I noticed that after working on the psoas his right knee which has the radial tears in the meniscus had totally centred so that the apex of the knee cap was pointing directly forward even when he was walking. We did some Rhomboid minor and major stability work to draw back the shoulders 5 degrees. Now the distance between the vertebral border of the scapulae and the spinous processes is around 1.5 inches. For the right shoulder external rotators we were side-lying and used 4kgs for s set of 10 reps and then 5kgs for 10 reps followed by 6kgs at 10 reps. We were at maximum capacity for those shoulder external rotators on the right side.

The shoulder seems to be more naturally retracted and pinned back on the right. We took photographs of Russell’s posture at the end of the session and his knees when standing and walking to highlight the new centralised position. We also used a Swiss “Dipulse” EMS device to stimulate the Vastus Medialis Obliquus on the right thigh. It was very red and very pumped after using 50 hertz and intensity of 32 for 27 minutes.

I recommend that he supplements his training at the Sports Institute with an EMS device for the inner thigh muscles.


6th session:  June 17th 2021

Subjective report from Russell Aylsworth

Bittersweet to come to an end of my sessions with Chris and his team at Motion Dynamics. For the past six weeks, I have felt a considerable improvement in my overall posture and just the fluidity I have taken for granted. Being 20, I definitely underestimated how free and lose my body could actually be and never really knew thoroughly the potential my body has to adjust to the new postural alignment. Being very rigorous in the gym, I have neglected certain parts of my recovery. As an elite athlete, I would consider myself a healthy individual who is aware and attentive to my body’s needs. Chris has considerably widened my scope and awareness of the potential my body has to be optimal, and anecdotally I have found my strength and form to improve each session I have in the gym, which is huge and rewarding to see. Chris’s timing was quite good because we did not have anything serious to work on for our final session together.

Today was more of maintaining and providing me with exercise and stretches I could do at home before he sends me off. We did work on strengthening some of my weaker back muscles, such as the Rhomboid minor and major. I told Chris about this knee extension test which compares the strength of my quadriceps and hamstrings. The ratio of quadriceps strength to hamstring strength can help indicate future ACL tears. For myself, because I tore my right meniscus, my inner thigh muscles on my right leg were significantly weaker than my left leg, even though I am right-handed. A neat machine Chris wanted to try the Di-Pulse a Swiss EMS device that sends electric shocks specifically to the muscle to stimulate stress like in the gym. What I found was fascinating about the device was the accuracy it had on my specific muscle. Even though I was lying down in a relaxed position, this specific muscle in my leg was still working. Days after using this EMS Device, that specific muscle had the same soreness from a traditional gym workout.

After my final session with Chris, I was planning on going sailing for the first time in 2 months to see how my knee would fair. Even without surgery and just training my knee and the help I got from Chris has given me no trouble whatsoever, and I wouldn’t be able to tell I had an injury, to begin with. Chris’s warmth and genuine care for his clients are rare to see, and the adaptability matched with his understanding of the complexities of the body is honestly quite fantastic to see and further my knowledge. The type of care I received from Chris is exceptional even though I have exclusive access to the Hong Kong Sports Institution. Chris ‘ attention to the detail ensured that my Postural fitness will stay with me for a very long time. Thank you so much, Chris, for the opportunity to work with you, and helping me along my journey as an athlete is a great experience.

Case study written by Chris Watts- founder and CEO of Motion Dynamics

Tel: +852 28823397

Active Assisted Isolated Stretching Treatment of a race car driver patient with persistent back and neck pain


The purpose of this Case Study is to demonstrate and discuss the effectiveness of Active Assisted Isolated Stretching treatment as applied by caregivers at Motion Dynamics on a patient with persistent mild to severe back and neck pain.

Clinical history:

The patient is a 40-year-old male with a sedentary working lifestyle. He is also an amateur racing car driver. He suffered from chronic lower back pain, neck irritation, lack of shoulder flexion from adhesive shoulder capsules and poor finger grip strength.

This condition proved especially challenging for the patient given his specific activity. His limited range of motion in the neck can caused stiffness and irritation as well as discomfort. His driving was hampered, especially at high speeds.

This kind of persistent comfort can also be dangerous for more conventional driving. It is difficult to drive a car safely if an individual cannot turn their neck far enough to check their ‘blind spot’.

The patient had previously tried conventional physiotherapy for his back and neck pain, including massage, heat treatments and electro therapy, but these had proved ineffective.

As a first step, the patient did a full postural screening and a range of motion testing on all the major joints to see where his movement restrictions were, and to identify musculoskeletal compensation that could have been contributing to his lower back pain.

This postural assessment was performed standing (weight bearing) and lying down (non-weight bearing) to check for tilts, torque and rotation throughout the body structure.

[Photo: Chris Watts stretching and aligning Jonathon Hui]

The observational findings were as follows: Subject’s entire right hip was depressed by 1.5 inches and his left hip was up-slipped by 1 inch. His lower left lumbar quadrant was hypertonic, especially the quadratus lumborum muscle. It was also very sore to the touch.

His left hip was twisted and torqued to the right side creating irritation in his sacroiliac joint on his left side. The sacrum was also torsioned to the right with some muscular and ligamental strain on L4 and L5.

The head was tilted to the right side, compressing the right side neck flexors and shoulder elevators. There was some referred pain through the brachial plexus nerve bundle translating through into the tips of the fingers.

Treatment: Active Assisted Isolated Stretching and Strengthening (AIS) is a uniquely effective exercise system developed by Aaron Mattes. Motion Dynamics uses AIS and expands on the application of the method together with other physical therapy methods. AIS is a specific program of flexibility exercises, based on sound physiological principles. AIS, which is carried out actively or assisted by a practitioner/therapist or by the subject’s own efforts (often assisted by a rope or band), is designed to specifically increase range of movement of muscles, fascia and connective tissue. During AIS, movement is carefully monitored in order to prevent activation of the stretch reflex.

The patient underwent 5 months of treatment in an attempt to transform and rehabituate his alignment. This required deconstructing his existing poor postural patterns and then reconstructing the balance and alignment.

This consisted of 40 treatment sessions, with each session lasting about 90 mins. The patient underwent these sessions twice a week.

At the start of treatment, the patient’s shoulders had only 140 degrees of shoulder flexion with a very hard end feel, suggesting a very adhesive joint capsule on both sides.

His sideways elevation was restricted by a non-gliding acromio-clavicular joint that prevented the fluid motion when the arm was raised to only 120 degrees of range.

The shoulders were also protracted forwards by a very tight pectoralis minor and weak and tight serratus anterior muscle.

The head was also forwardly protracted by 2-3 inches creating strain on the posterior extensors of the neck.

The neck could only laterally tilt less than 25 degrees to the left side due to the right side constriction of scalene and upper trapezius shortening.

Cervical rotation was only 45 to 50 degrees on each side showing strong restrictions in range at C1 and C2

[Photo: Chris Watts chatting with Phil Whelan]


The application of the Active Assisted Isolated Stretching method used multiple sets of active and dynamic repetitive movements to slowly bring his soft tissue flexibility and joint mobility to a functional range.

These movements consisted of:

Cervical rotation with flexion at end of range In this movement, the patient tucked in the chin and rotated the neck to the right side 80 to 90 degrees, then flexed the neck by bringing the chin down towards the shoulder. He aimed to turn far enough that his chin was almost in line with your shoulder. The patient then repeats the exercise on the other side.

This specifically worked on the insertion of the upper trapezius muscle on the left side of the neck at the site of the acromium on the shoulder blade.

The patient reached a range of motion of the neck in rotation between 80 and 90 degrees. His lateral cervical flexion or side bending reached around 45 to 55 degrees.

Cervical flexion and extension This exercise has the patient touch his chin to his chest from a tucked chin position. Over the course of treatment, he reached an acceptable athletic range of motion for neck flexion of 40 to 60 degrees. Neck extension involved the patient tilting his head back. He attained a normal range of motion that allowed him to look straight up at the ceiling. The patient reached a range of motion from the neutral neck position of 45 to 70 degrees.

Cervical oblique hyperflexion and oblique hyperextension For the lateral cervical flexion exercise, the patient bent his neck to the side so that his ear was leaning towards his shoulder while looking straight ahead. He then brought his left ear toward his left shoulder, then rotated his neck 45 degrees to the right side and then drew the left ear towards the left chest. This exercise targeted the upper trapezius and levator scapular muscles. He would then perform the same exercise to the opposite side.

Having reached a normal range of motion in lateral cervical flexion, the patient was able to move halfway between straight ahead and his shoulder, which is a 45 degree angle. Shoulder forward elevation

For this exercise, the patient kept his shoulder blades set in a downward rotated position, raising his arm straight up with his thumb pointing upwards, lifting his arm through a full range of 180 degrees of forward elevation.

He then performed the same movement with the palm facing forward, followed by the arm fully internally rotated with the thumb pointing forward.

Sideways shoulder elevation For this exercise, the patient set the scapular in a downward depressed position and then abducted the shoulder with the thumb pointing upwards until the arm reached just behind the ear.

He then repeated this action with the fully internally rotated so that his thumb was pointing upwards and then abducted the shoulder until the arm touched the ear.

For these movements, the patient endeavoured not to elevate the shoulder, nor allow shoulder impingement at the acromioclavicular joint.

Shoulder internal and external rotation in multiple positions of horizontal flexion and adduction The patient held his shoulder positioned with the arm abducted to 85 degrees, horizontally adducted 5 degrees and the elbow positioned at 95 degrees of flexion. Over the course of treatments, his internal rotation range of motion with a fixed glenohumeral joint reached 80 – 90 degrees.


The patient also changed the position of the humerus by horizontally adducting the humerus by 5 degrees to release the posterior shoulder capsule. For external or backward shoulder rotation, the patient worked towards developing a range of motion between 45 and 65 degrees.


Each set of the movements described above consisted of 10 to 15 repetitions to slowly and gradually unlock the patient’s shoulder joint capsule and fascial adhesions.

The patient was taught how to stabilize and eventually strengthen the neck and shoulders to maintain all the structural work undertaken to realign and reposition the shoulder and hip joints.

He accomplished this by a process of light stability training, using his own bodyweight as well as the natural weight of gravity. We worked in all planes of motion and through full functional ranges to build stability at the origins and insertions of the entire neck structure.

Over the course of this treatment, the patient became acutely aware of where his centre of mass was located and how to gauge a neutral pelvic base.

During the initial phase of treatment, the patient showed radical improvement, and there was a slow upward curve of benefits through the rest of the period.



As a result of the Active Assisted Isolated Stretching Treatment, the patient no longer experiences any pain or irritation in his back or neck.

Prior to beginning treatment, the patient neck movement was limited to 25 degrees of lateral neck flexion and less than 10 degrees of extension at C1 and C2. Neck flexion was less than 20 degrees. degree tilt in any direction. After treatment, he had a full range of neck movement in all directions.

Prior to his beginning treatment, the patient experienced persistent back and neck pain that he described as being between an 6 to 8 on a scale of 1 to 10. After treatment, his level of constant discomfort was reduced to Zero. He was experiencing a lower back compression that was referring pain into his mid gluteal region. His neck pain had also significantly reduced when driving and also post driving when dehydration can typically cause muscle spasms in the areas of common weakness. Most importantly, the patent was experiencing improved energy output during the day and also during the race event too. The physiological effects from improving posture and mobility were profound.


After receiving the treatment described above, he was able to participate in a 24 hour car race. For this event, the patient was driving over 10 hours during a 24 hour period. Throughout, he experienced no significant pain or discomfort in his lower back.



The conclusions obtained from the application of the relevant aspects of Motion Dynamics therapy are especially effective and successful in addressing the immediate symptomatic issues experienced by the patient, and also exponentially raised his level of mobility and comfort in his neck and back. The reduction of constant pain and discomfort has a direct effect in improving his sports performance.


[1] Chris Watts is the founder of Motion DynamicsTM in Hong Kong. He holds certifications from National Certification Board for Therapeutic Massage & Bodywork; Active Release Technique; Master Trainer of Active Isolated Stretching (AIS): The Mattes Method; Myofascial Release Therapy – John Barnes Technique; Neuromuscular Therapy – Paul St. John Method; and Positional Release – Kerry D’Ambrogio Method. He has studied with Aaron Mattes, who is the creator of AIS, and Paul St. John, founder of Neuromuscular Therapy. Watts has been in private practice for over 25 years and is the author of “The Beauty of Posture” (2014). Email:

Active Assisted Isolated Stretching Treatment of a patient with chronic back during pregnancy


The purpose of this Case Study is to demonstrate and discuss the effectiveness of Active Assisted Isolated stretching treatment on a patient with back pain caused by pregnancy.

Clinical history:

The client was a 38-year-old woman who experienced chronic back pain during and after her first pregnancy. The discomfort was most severe first thing in the morning. Initially, this pain was highly debilitating. The client described it as feeling as though it moved in multiple “arcs”, vertically and horizontally, across her lumbar spine. On rising, she would engage in movements that warmed the lumbar joints, and the pain would quickly diminish. The symptoms of her back pain started during the 2nd trimester of her first pregnancy. She would wake up with an inflamed and sore back at the L4 and L5 region of her lumbar spine.

The client had been diagnosed with disk herniation with a right-side bulge and disk narrowing in L4 and 5. This diagnosis was made by her orthopedic doctor after she underwent a physical examination and performed a range of motion tests. At the request of the patient, no x-rays or MRI scans were performed at that time, due to concerns regarding the potential damage to the fetus from radiation.

The pain was localized to the segments mentioned above but did on occasion refer down the right side of her body. The client is generally very fit, engaging in Pilates classes and stability resistance training 2 times a week. She otherwise led an active life, caring for and playing with her first child on a daily basis. She also has a very positive demeanor and is very determined to stay fit and pain-free.

The back pain described above began during her first pregnancy and persisted right through to the end of that pregnancy. She still experienced back pain after giving birth to her first child, but it was much more tolerable than during the pregnancy. However, she continued to wake up with soreness and irritation in her back. Her first child is now two-and-a-half years old. It was when she became pregnant for the second time that her back pain returned with increased severity.

She came to Motion Dynamics for alignment training (postural re-balancing) on the 2nd month of her 2ndpregnancy.


On performing the initial postural assessment, it was noticeable that the misalignments were all around her hip/lumbo/pelvic structures where there was significant anterior pelvic tilting on both ilia with ensuing lower back lordosis.

The pelvis was tilted 25 degrees forward on the right side and 15 degrees on the left side, with a distinctive right dominant hip shift translating the extra weight to her right hip. The right gluteus medius and minimus were weak and hypertonic with poor range of motion in abduction (25 degrees).

The right-side rectus femoris at the AIIS origin was very sensitive to the touch as were the right-side hip flexors indicating weakness and hypertonicity to those important postural and phasic muscles groups. There was a distinctive shift or translation of her body weight to the right side with a very noticeable head tilt to the right side and shortening of her right sterno cleido mastoid muscles.


The entire spinal erectors were weak and unsupportive, and the client was incurring a lot of neck pain especially in the suboccipital region. The levator scapular on the right-side insertion point on the superior angle of the scapular had trigger points and was very sensitive to touch, as was the transverse process of C2 on the right side.


We mapped out a flexibility protocol plan for the coming weeks of her pregnancy to re-balance the client’s musculo-skeletal system. With optimal alignment and good functioning joint mechanics, we were able to have her move well and freely without restrictions and irritation. Then we addressed the muscle imbalances, especially in the lower back and gluteal muscles. These were all very weak and neurologically deficient.

We started the first trimester deconstructing some of her faulty structure and movement patterns, building a strong but balanced foundation using Active Isolated Stretching techniques to unwind the right-side muscle shortening.

I used the principle of 3 sets of AIS stretching on the right side to one on the left to help retrain the neuromuscular patterns of movement. The tightest tissues were in the Iliopsoas muscle group. She only had 5 degrees of hip extension on the right side.

Once we gained the full 20-25 degrees of extension and reactivated the gluteal and hamstrings on both sides, she was able to stand much more upright since her pelvis had shifted back to its neutral position.

Her postural muscles were very slack and weak, and much work was done to stabilize the spinal extensors using Active Assisted trunk hyperextension stability exercises and Assisted oblique trunk hyperextension for the latissimus dorsa, intervertebrales and quadratus lumborum muscles.

The client initially found these very challenging. At the start of treatment, she was only able to perform 4 repetitions of each exercise. Eventually, we were able to build these muscles so that she could perform up to 3 sets of 10 repetitions.

The client could only perform these exercises in the first trimester due to the fact they were performed in a prone position off the table. During the second trimester, all back-stability work was performed on a mat using the isometric tabletop exercises that target the deep multifidus muscles.

At the start of her 2nd trimester, she was only able to perform a 60-second hold on each side. When we finished the 2nd trimester she was doing 3 minutes holds on each side.

Most of the pain that she experienced when we first saw her had diminished by the end of the 2nd trimester.

The 3rd trimester saw the client grow rapidly around the trunk and at one point she was carrying 38 pounds more weight. Her calves were cramping at night and she was retaining fluids around her ankle.

We used Active Isolated Stretching for her lower body, having her lie in a side position with a wedged pillow under her abdomen to provide support whilst working on her calves, hamstrings hip flexors and quadriceps, as well as her gluteus maximus.


The client gained pain relief from the Active Assisted Stretching to the point where she rarely experienced calf cramping. Her lumbar spine was aching and uncomfortable, but she had no sharp pains from the excessive forward pelvic tilting.

We used an elastic belt to help support the extra-abdominal load and I used manual therapy soft tissue release more specifically Neuromuscular (NMT) techniques to relax the lower back and make sure the lumbar vertebrae were gliding well.

I kept up the AIS flexibility and stability training right up to the final session even using AIS for the adductors to open up the pelvic floor which was fully functional in terms of range and stability. The maximal range in abduction is 90 degrees with an internally rotated hip. She was at this end range by the final session.


We found that the client really enjoyed knowing the tiniest detail of each area of progress that we were able to make. She developed a strong kinesthetic and somatic sense along the journey. Her understanding of her own positioning and center of mass was key to the client being able to subconsciously make the necessary long-term changes to help de-pressurize the joint and soft tissue structures.

The mother had a natural birth and delivered on March 26th 2019. The baby was 7lbs and 6 ounces. The birth was comfortable and, after the month of confinement that is tradition for Chinese mothers, I was able to see her at the beginning of May. She is now having a period of abdominal bandaging to firm the abdominal muscles and I will start to see her again for post-natal stability training. The focus will be on the pelvic floor and the pelvic and lumbar extensors.