The “Z” angle

As we know how important it is, for runners, to maintain optimal running form to maximize efficiency and to prevent injury. One method to optimize running form for injury prevention is to maintain and appropriate Z angle.

The Z angle is formed by analyzing running from side and measuring joint angles at your hip and ankle. The z angle is the angle formed by your hips and ankles when your foot is on the ground, just prior to a terminal stance.

How to find ‘z’ angle?

• Obtain a still photo of you running, shot from the either side. Your back foot should be on the ground, but just about to leave the ground in terminal stance. Your front leg should be up in the air and flexed in front of you. ( You’ll need a friend or PT to take the video of you running on a treadmill.)
• Once you have the photo, draw a line through your hip joint that is parallel to the plane of the top of your pelvis.
• Draw a line along your stance leg extending down from your hip to your ankle.
• Draw a line from your ankle joint, through your foot, and to your toes.
The three lines you have drawn should form the shape of the letter “Z.” This is your Z angle.Runner Ahmedabad india
The optimal Z angle should show that your hip extension range of motion is equal to your ankle dorsiflexion range of motion. Your letter Z should look like a symmetrical letter. If your letter Z is altered in any way, it could mean that you have some running gait deviations that may need to be addressed to optimize efficiency and to possibly prevent injury.

Deviations and treatment :

If ankle of dorsiflexion is less, then athlet’s Z angle will show bigger angle at ankle than at hip. This means
• Gastro and soleus are tight, and
• Tebialis anterior is weak

The correction regime includes,
• Stretching of gastro and soleus, and
• Strengthening of tebialis anterior
If hip extension is less, this means
• Hip flexor and rectus femoris tightness and
• Hip extensors weakness
The correctional regime includes,
• Stretching of hip flexors and rectus femoris
• Glute strengthening.

 

free full text :

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424456/

Referance:

1. Ferber R, et al. Suspected Mechanisms in the Cause of Overuse Running Injuries: A Clinical Review. Athletic Training. 2009.

2. Kim S and Yu J. Changes of Gait Parameters and Lower Limb Dynamics in Recreational Runners with Achilles Tendinopathy. J Sport Sci Med. 2015. 284-89.

3. Schmitz A, et al. Do Novice Runners Have Weak Hips and Bad Running Form? Gait Posture. 40(1). 2014. 82-6.

image courtesy: capitalregionpt.com, flexible.com

 

Scapula stabilisation

Thoughts on Scapula exercise

Scapula exercises are very common and usually a needed to any shoulder rehabilitation or corrective exercise program.    No program is right for everyone!  Here are of scapular exercises that we thought would good to discuss.

 

1) Pinch Your Shoulder Blades Together :

Pinch your shoulder blades , Squeeze your scaps together.  Retract your shoulders back.  These are common coaching cues given during scapular exercises.  The goal of these concepts is to get into better posture and set your scapula  in correct postion ,ultimately resulting in  better movement patterns along with better posture  when performing exercises.

The classic example is Upper Body Cross Syndrome of forward head, rounded shoulders.

scapulohumeral rhythm requires a sequence of shoulder and scapular movement simultaneously.  Pinching your shoulder blades together is essentially contracting your middle trapezius to fully retract your scapula and then move your arm.  While this is not nearly as bad on shoulder mechanics as lifting your arm . it does not have good advantage to lift your arm in a fully retracted position. While fully retract the scapula  which is essentially performing and isometric trapezius contraction, you are likely to limit the normal protraction and upward rotation movement  that occurs  during arm elevation and movement.

If the milestone  of this to give cue for  improve posture and improve mechanics while exercising the arm, maybe a better cue would be to instruct thoracic extension.

Think about , you can still have a very kyphotic and rounded thoracic spine and retract your scapula, it’s. Very difficult to perform , but the goal is to really get your thoracic spine extended.

2) Mobility and Strength to Improve Scapular Symmetry.

S

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Introduction to core subsystem

Muscles don’t work alone to create movement. They work together in synergies to create coordinated movements. Here we’ll identify the four muscle subsystems, discover how these synergies work together, and how to select exercises for developing optimal performance.

Introduction :

The purpose of this article is to provide a brief overview and definition of the four subsystems within the human body , how they contribute to human movement system .
Muscle does not work in isolation. This simplifies movement by allowing muscles and joints to operate as a cohesive unit. For instance, during the simple act of shoulder extension, the latissimus dorsi, teres major, and posterior deltoid all work together as a unit to perform the movement pattern.

Local vs. Global Musculature:

Looking at the muscular system more closely, systems that enable our bodies to distribute forces efficiently. These systems include the local muscular system, known as the stabilization system, and the global muscular system, which referred to as the movement system.

. The local muscular system muscles provide stability and support during joint motion. Where as they are usually located in close to the joint which makes them ideal for increasing joint stiffness and stability, such as the transverse abdominis, multifidus, and pelvic floor.

On the other hand, the global muscular system is responsible for movement of the trunk and extremities, and primarily consists of large superficial musculature, such as the rectus abdominis, latissimus dorsi, and external obliques.

Subsystems:

The human body consists of four common muscle synergies:

• Lateral subsystem,
• Deep longitudinal subsystem,
• Posterior oblique subsystem,
• Anterior oblique subsystem.

These subsystems allow for an easier description and review of functional anatomy. The human body simultaneously utilizes all four of these subsystems during activity of daily routine.

Figure 1

The lateral subsystem (Figure 1) is comprised of the gluteus medius, tensor fascia latae, adductor complex, and contralateral (opposite) quadratus lumborum. The lateral subsystem is implicated in frontal plane stability and is responsible for pelvo-femoral stability during single-leg movements such as in gait, lunges, or stair climbing. The ipsilateral (same side) gluteus medius, tensor fascia latae, and adductors combine with the contralateral quadratus lumborum to control the pelvis and femur in the frontal plane.

Proactive physiotherapy india

Figure 2

Deep Longitudinal Subsystem :

The deep longitudinal subsystem (Figure 2) is comprised of the erector spinae, thoracolumbar fascia, sacrotuberous ligament, and bicep femoris. The deep longitudinal subsystem helps to stabilize the body . More accurately , it provides force transmission longitudinally from the foot and ankle to the trunk and vice versa. The dominant role of the deep longitudinal subsystem is to control ground reaction forces during gait motions .

Core subsystem

Figure 3

Posterior Oblique Subsystem:

The posterior oblique subsystem (Figure 3) is comprised of the gluteus maximus, latissimus dorsi, and thoracolumbar fascia. The posterior oblique subsystem works synergistically with the deep longitudinal subsystem which distributing transverse plane forces . The gluteus maximus and latissimus dorsi attach to the thoracolumbar fascia, which connects to the sacrum. The fiber arrangements of these muscles run perpendicular to the sacroiliac joint (SIJ). Thus the contralateral gluteus maximus and latissimus dorsi contract they create a stabilizing force for the SIJ.

Core subsystem

Figure 4

 

Anterior Oblique Subsystem:

The anterior oblique subsystem (Figure 4) is comprised of the internal oblique, external oblique, adductor complex, and hip external rotators. Likewise, the posterior oblique subsystem this system also functions in a transverse plane orientation, only from the anterior portion of the body. When we walk our pelvis must rotate in the transverse plane in order to create a swinging motion for the legs. This rotation comes in part from the posterior oblique subsystem posteriorly and the anterior oblique subsystem anteriorly.

 

Stay tune with us for next part : integrated exercise for core subsystem.

 

References :

1) Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1-54.

2) Clark MA. Lucett SC. Sutton, BG. NASM Essentials of Corrective Exercise Training 1st Edition Revised. Burlington, MA: Jones and Bartlett Learning; 2014.

3) image courtesy: Brian Sutton MS, MA, NASM-CPT, PES, CES ,  drstaceynaito.file.wordpress.com

proactive , AHmedabad , INDIA

The Untold story of Mighty Psoas Part 1

There seems to be lot of “dysfunctional psoas causing back pain” articles. We like to offer another viewpoint.

How psoas  effects  on posture?   

The answer is a general facilitation along the anterior kinetic chain. The body doesn’t like to be in a position to  stabilize. If it is weak in an action such as flexion, the body will move more into flexion, which gives the illusion of being in a safe position. Lots of questions, and each person has their unique answer. Looking deeper into causation instead of chasing symptoms is a good practice.

 

 

                               Don’t just treat what you see, Peel off layer step by step.

The psoas is involved in posture, stability, and breath. The psoas is a multisegment muscle, as it crosses multiple joints from the thoracic lumbar junction through each lumbar vertebrae. The psoas connects the axis of the spine to the appendicular function of the hip. The attachment on the thigh, the lessor trochanter, gives the psoas mechanical advantage in external rotation of the hip. The psoas is a lumbar stabilizer, a hip flexor, and is also a synergist in the breathing .

The psoas is central to movement stability.  However, muscles that cross multiple joints don’t have as much mechanical leverage. Moreover , they are good at  dynamic stability of hip joint.  In the case of hip flexion, the function of the psoas is stabilization of the lumbar while its synergist, the iliacus, generate power .

The psoas is a multi-planer stabilizer that works in a three-dimensional model. The psoas more like to associate with  the quadrates lumborum,(QL). The QL has a fascial compartment just posterior of the psoas(as you can see in fighure). The compartments need to have the capacity to glide across one another , therefore it discreet function can happen in the sagittal, coronal and transverse planes.

In sagittal plane movement the psoas and QL work in ipsilateral pairs on the same side. This is also true for the coronal plane. Though in the coronal plane, while one side is shortening, the opposite side is lengthening. This is called lateral flexion. The function of the psoas in the transverse plane is related to the walking gait. The transverse plane pairing is contralateral.

One side of the psoas is working with the opposite side QL to stabilize the lumbar as the pelvis is moving around the axis of the spine.

The psoas is a primary compartment of the greater lumbodorsal fascia. This fascial sheath connects the torso to the pelvis so that the action of the appendicular skeleton and axial skeleton wind-up and release elastic energy throughout the cycle of the walking gait.

Psoas has its relationship to the breathing pattern. Further, the psoas shares connective tissue with the thoracic diaphragm. This is significant because when the psoas doesn’t play well with the breathing apparatus.

 

Biomechanics : An overview

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Rehabilitation Guideline after meniscus repair surgery

Meniscus injuries within the knee are a common occurrence.  In spite of this high event, numerous irregularities keep on existing in the restoration of a patient after meniscus repair surgery, especially including the rate of weight bearing and range of movement.

Rehabilitation Follow Meniscus Repair

Restoration after surgical debridement of the meniscus is entirely clear. We restore the patient’s range  of movement, quality and function,  their manifestations and let pain and swelling guide the recovery procedure (an exceptionally broad guide yet one frequently utilized by numerous rehabilitation specialists).

In any case, when the meniscus is really repaired and not only debrided, there are different variables to consider. At the point when a meniscus is repaired, the tear is approximated utilizing stitches to enable the tear to heal.

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

So if we’re going to talk some  protocols, take a look at these studies from way back when from Shelbourne et al  and Barber et al   that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave et al  and Lind et al on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

Again, these studies show meniscal repair outcomes are no different while using restricted weight bearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

 Weightbearing After Meniscus Repair : 

Things being what they are, if immobilized in extension, for what reason do we restrict weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are believed to help the healing procedure in many tears by approximating the tissue.

Besides, the compressive loads connected while weightbearing in full expansion following a vertical, longitudinal repair or container handle repair have been appeared to lessen the meniscus and settle the tear, as noted by Rodeo et al.  and all the more as of late by McCulloch et al.

There are studies said “A repaired longitudinal medial meniscal tear undergo compression, not gapping, during simulated gait ”

What about early range of motion? 

 

 

 

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Questions and Answers

This section is made for good interaction. You can post your question under contact us form.
Our expert team will analyse and will give you answer in 24 hours. We don’t provide exact protocol for any pathology. We will publish relevant questions and its answers under this section.

netter anatomy , pectoralis minor , physiotherapy

PECTORALIS MINOR- THE NEGLECTED MUSCLE

Pectoralis minor ,proactive physiotherapy, kinetic chain

Coutsey : Wikipedia.com

Human body is designed in such an intricate manner that upper limbs are for manipulative activities and lower limbs are for mobility. When each of the body segments is aligned properly it gives a pleasant appearance as well as a disorder free body. While poor posture and muscular imbalance often results into pain and loss of function.

Physiotherapy musculoskeletal assessment format consists of many points in observation, palpation and examination which are extremely important for proper diagnosis, treatment planning and knowing the prognosis. However, many a times while assessing shoulder and cervical region; one of the important muscle- Pectoralis Minor is often neglected. A shortened pectoralis minor muscle commonly contributes to muscular imbalance and pain in shoulder and cervical region.

Poor upper body posture is many a times referred to as a ‘forward head posture’, ‘slouched posture’, ‘poking chin posture’, or ’rounded shoulder posture’ and is considered to be a potential etiological factor in the pathogenesis and perpetuation of many clinical syndromes like Thoracic outlet syndrome, Scapular downward rotation syndrome, Scapular winging & tilting syndrome, shoulder impingement syndrome and also upper cross syndrome involving the neck and shoulder.1, 2

origin insertion of pectoralis minor , neurokinetic

The pectoralis minor attaches at the coracoid process of the scapula and at the third, fourth, and fifth ribs near their sternocostal junctions. A short pectoralis minor muscle increases the muscles passive tension with arm elevation resulting in restriction of normal scapular movements such as external rotation, upward rotation and posterior tipping and this in turn will affect glenohumeral and cervical motion.1, 3

 

Few Clinical tests have been recommended to test for shortening of this muscle.

AT Distance: 1, 4, 5

Pectoralis length test

Courtsey:www.musculoskeletalkey.com

The patient in supine lying, arms by side or resting on abdomen and instructed to relax. With the help of rigid standard plastic transparent right angle, measure the linear distance in millimeters between the posterior border of the acromion and the table. Take care not to exert any downward pressure into the table and place the base on the treatment table and the vertical side adjacent to the lateral aspect of the acromion. A distance greater than 2.54 cm (1 inch) suggests short pectoralis minor.

Pectoralis Minor Length Index (PMI): 1, 4, 5, 6

The PMI is calculated by dividing the resting muscle length measurement by the subject height and multiplying by 100.The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a measuring tape or sliding caliper. PMI is suggested to reflect a shortened pectoralis minor when 7.65 or lower.

 

Referances :

  1. Jain S, Shukla Y. “To find the intra-rater reliability & concurrent validity of two methods of measuring Pectoralis Minor tightness in Periarthritic Shoulder patients.” Indian Journal Of Physical Therapy 2013;1(2):34-38
  2. Lewis J.S., Valentine R.E. “The Pectoralis minor length test: a study of the intra-rater reliability & diagnostic accuracy in subjects with & without shoulder symptoms.” BMC Musculoskeletal Disorders. 2007; 8:64.
  3. Borstad J.D. “Resting position variables at the shoulder: Evidence to support a posture-impairment association.” Journal of the American Physical Therapy Association. 2006; 86(4):549-557.
  4. Borstad J.D. “Measurement of Pectoralis Minor Muscle Length: Validation and Clinical Application.” Journal of Orthopaedic and Sports Physical Therapy. 2008; 38(4):169-174.
  5. Struyf F., Nijs J., Mottram S., Roussel N., Ann M J Cools, Meeusen R. “Clinical assessment of the scapula: a review of the literature.” Br J Sports Med 2012;0:1–8.
  6. Muraki T, Aoki M., Izu.mi T, Fujii M., Hidaka E., Miyamoto H. “Lengthening of the pectoralis minor muscle during passive shoulder motions & stretching techniques: a cadaveric biomechanical study.” Phys Ther. 2009; 89(4).
  7. Pic : Netter`s Anatomy

 

Gluteal Amnesia and selecting the most effective interventions

Most people spend a huge proportion of their time in a position of hip flexion (sitting down). An inactive lifestyle is a Janda approachsure-fire way to create glute dysfunction. Extended periods of time in this posture over the long term will lead to negative adaptations in the hip flexor muscles.

Shortened hip flexors don’t allow for full hip extension, which is where your glutes are able to contract with the most force. Additionally, being an antagonistic pair, short and tight hip flexors will actually inhibit your glutes. The actual physical compression associated with sitting on your gluteus maximus will also impair blood flow and neuromuscular function.

Gluteal amnesia is a condition where your body can’t or forgets how to properly activate the gluteal muscles, whether it’s due to postural flaws or lack of use. As a result, you may lose the ability to move your hips through a full range of motion which adds stress to your knee, lower back, and even your shoulder joints! Common injuries associated with gluteal amnesia are patellofemoral pain syndrome, Iliotibial Band Syndrome, Disc Herniation, and Piriformis Syndrome. Fortunately, you can reverse this condition with the right corrective exercises.

A postural flaw that can lead to gluteal amnesia is known as anterior pelvic tilt. This occurs when the pelvis tilts forward and the stomach protrudes. The forward tilt of the pelvis stretches your gluteals into a relaxed state which decreases your ability to properly activate them. Other causes of gluteal amnesia are as follows:

• Too many quadriceps dominant exercises.
• Poor sitting or static posture.
• Improper abdominal training.
• Soft tissue contractures (i.e., tight hip flexors and low back extensors).
• Articular (joint) fixations.
• Not landing properly from jumps (i.e., landing from a rebound in basketball).
• Knee or back pain sufferer.

The gluteus maximus and lower back stability
Activating and strengthening the glutes needs to form an important part of your core routine.

Co-contraction of the gluteus maximus with the psoas major contributes to lumbo-sacral stabilisation The gluteus maximus provides stability to the sacroiliac joint (SI joint) by bracing and compression. Excess movement at the SI joint would compromise the L5-S1 intervertebral joints and disc and could lead to SI joint dysfunction and low back pain.

kinetic chain, gluteus maximmus, eric dalton

Coutrsey : Ericdalton

The gluteus maximus also provides lower back stability through its connection with the erector spinae and thoraco-lumbar fascia. Some of its fibres are continuous with the fibres of the erector spinae. A contraction of the gluteus maximus will generate tension in the erector spinae muscle on the same side, providing stiffness to the spinal column.

Gluteus maximus contraction also exerts a pull on the lower end of the thoraco-lumbar fascia, which is a thick layer of ligamentous connective tissue. Tightening of this fascia stabilises the vertebras. People with low back pain often have weak and deconditioned glutes.

Here are some simple but superbly effective exercises to tone up glutes muscles.

Gluteal Squeeze :

Purpose: Strengthen the hips (especially for the gluteus maximus).
Start in a standing position with your feet shoulder-width apart.
Squeeze the gluteal muscles for two seconds, then relax for two seconds. Count the two seconds out loud to avoid holding your breath.
Sets/Reps: 1-2 x 10, with 5-10-second holds and 5-10 seconds rest.

Bird Dog :Core stability, proactive physio

Purpose: Strengthen the hips (especially for the gluteus maximus).

Start on your hands and knees. Slowly raise your right arm and left leg so they are level to the floor. Turn your left foot slightly outward so you feel your gluteus maximus tightening. Hold this position for 10 seconds. Repeat with the opposite arm and leg.
Suggested Sets/Reps: 1-2 x 10 of 10-second holds.

Double-Leg Squat Series :

 

Purpose: Strengthen the hips and legs.

Stand with your feet shoulder-width apart. Looking straight ahead, slowly squat down until your thighs are parallel to the floor while simultaneously raising both arms out in front of you like you are guarding an opponent in basketball or skiing down a hill.
Try to keep your knees behind your toes, maintain a normal arch in your lower back and keep your core tight. Once you master perfect technique using your body weight with this simple exercise (feet side by side)

Single-Leg Squats :

Purpose: Strengthen the hips and legs.

Stand facing a step and hold on to a rail. Slowly step up and down on one side. Repeat with the opposite leg. Alternate version: perform the Step-Ups from the side, and progress by varying the step height from 4 or 6 inches to 8 inches.
Suggested Sets/Reps: 1-2 x 10-15

Side-Step Walking :

Purpose: Strengthen the hips and legs.

Start in a squatting position with your feet slightly wider than hip-width as if you were guarding an opponent in basketball.
Take five to 10 steps to the right. Your step lengths should be approximately 50 percent of the starting position distance between your feet.
Keep your knees aligned with the second toe. Repeat five to 10 steps to the left.
Once you master perfect technique using your own body weight.

Side-Lying Straight-Leg Abduction :

Hip abduction, core and posture st

Courtsey:Dr. Alex Jimenez D.C.,C.C.S.T

Purpose: Strengthen the hips and core.

Start by lying on your right side with your top leg straight and bottom leg bent. Place your top hand on the floor or mat in front of you for good support. Slowly raise your top leg up to approximately 40 degrees for the designated sets/reps.
Keep your hips level and don’t over-arch your back.
Repeat on the other side.
To increase the difficulty, place an elastic band around your thighs (just above the knees) or an ankle weight just above your ankle.
Sets/Reps: 2-3x 0-15

Side-Lying Bent-Leg Abductions: gluteus strengthning, gluteus activation

Purpose: Strengthen the hips and core

Start by lying on your right side with both knees bent 90 degrees and hips bent 45 degrees. Place your right arm under your head and your left arm on the floor in front of you for stability. Slowly raise your top leg up to 30 degrees of abduction, then lower slowly for the designated sets/reps. To increase the difficulty, hold the 30-degree hip-abducted position for five to 30 seconds as a single repetition.
Sets/Reps: 2-3×10-15

Supine Bridge:proactive physiotherapy

Purpose: Strengthen the hips and core

Start by lying on your back with your knees bent 90 degrees and feet hip-width apart. Place a small, soft ball between your knees and squeeze with no more than 50 percent effort.
Lift your hips off the floor approximately 4 inches, then slowly lower them while relaxing the squeeze between your knees.
To increase the difficulty, hold for five to 10 seconds as a single set.
Sets/Reps: 2-3×10-15

 

Referances :

  1. Distefano LJ, Blackburn JT, Marshall SW, Padua DA, Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. Jul;39(7):532-40, 2009.
  2. Vleeming A, Van Wingerden JP, Snijders CJ, Stoeckart R and Stijnen T (1989): Load application to the sacrotuberous ligament; influences on sacroiliac joint mechanics. Clinical Biomechanics, 4(4), 204-209.
  3. Snijders CJ, Vleeming A and Stoeckart R (1993): Transfer of lumbosacral load to iliac bones and legs. Clinical Biomechanics 8, 285-294.
  4. Sean GT Gibbons and Mark J Comerford (2001) Strength versus stability: Part 1: Concept and terms. Orthopaedic Division Review. March / April: 21-27
  5. Gibbons SGT 2005 Integrating the psoas major and deep sacral guteus maximus muscles into the lumbar cylinder model. Proceedings of: “The Spine”: World Congress on Manual Therapy. October 7th – 9th, 2005, Rome, Italy.
  6.  Kankaanpää M, Taimela S, Laaksonen D, Hanninen O and Airaksinen O (1998): Back and hip extensor fatigability in chronic low back pain patients and controls. Archives of 100 NZ Journal of Physiotherapy – November 2005. Vol. 33, 3 Physical Medical Rehabilitation 79, 412-417.

 

Shoulder joint

Clinical assessment of scapula

Upper limb is designed in such a way that there is ample amount of mobility which is required for manipulative activities that are a part of daily functional activities. In recent days there is increased interest on the role of scapula, its related pathologies and how entire upper extremity function is dependent on the controlled movement of scapula.

For a full, efficient as well as atleast functional range of motion of entire upper limb, scapula plays many roles in facilitating optimal shoulder function by glenohumeral integration, motion on thoracic wall and as a part of scapula-humeral rhythm. With good proximal control there is good distal mobility. Any alterations in the activity of scapula hamper the control over all upper limb activities leading to pain, impingement and other clinical syndromes which gradually causes disability.

 

Observable alterations in the position of the scapula & the pattern of scapular motion in relation to thoracic cage are called scapular dyskinesis. It causes many clinical dysfunction of the shoulder leading to disabilities.

 

Causes of Scapular Dyskinesia:

 

  1. Bony injuries or abnormalities- Types of acromion process or postural alteration 
  2. .Alteration of muscle function- upper cross syndrome, inhibited muscle- serratus anterior, lower fibres of trapezius, rhomboids, deep neck flexors, force couples.

 

  1. Contracture & other flexibility problems- pectoralis minor & major, joint capsule, upper fibres of trapezius, levator scapula

 

  1. Nerve injury/ proprioceptive dysfunction- long thoracic nerve, spinal accessory nerve

 

 

Classification of Scapular Dyskinesia:

 

               (Slideshare.net)

  • Type I – Abnormal rotation around transverse axis: commonly found secondary after rotator cuff dysfunction- inferior angle becomes prominent
  • Type II – Abnormal rotation around vertical axis: commonly seen in patients with glenohumeral joint instability- medial border becomes prominent
  • Type III – Abnormal superior translation of entire scapula: commonly seen in rotator cuff dysfunction and deltoid-rotator cuff force imbalances- superior border becomes prominent
  • Type IV- both scapula are symmetrical at rest & during motion; they rotate symmetrically upward with inferior angles rotating laterally away from midline. This indicates scapular control muscles are not stabilizing the scapula.

 

 

Types of Winging:

  1. Static winging- winging happens at rest, usually caused by structural deformity of scapula, ribs, clavicle or spine.
  2. Dynamic winging- winging happens with shoulder motion. It can be cause of trapezius weakness or serratus anterior weakness. In case of trapezius weakness, scapula depresses and moves move laterally with inferior angle rotated laterally. In case of serratus anterior weakness, scapula elevates amd move medially with inferior angle rotated medially.

 

One more clinical syndrome exists which is coined as S.I.C.K scapula

S- Scapular mal-position

I- Inferior angle prominent

C- Coracoid pain

K- Dyskinesia

 

Clinical assessment of scapula includes evaluating posture, motion, muscular activation and control and corrective maneuvers. Steps for assessment

  1. History taking
  2. Thoracic and cervical posture – trigger points and flexibility
  3. Check for the shoulder posture- trigger points and flexibility
  4. Shoulder strength – especially supraspinatus, infraspinatus, and subscapularis, Serratus anterior, lower trapezius
  5. Shoulder ROM @ 0 and 90 degrees – GIRD
  6. Scapula position @ rest
  7. Scapula position during active abduction and flexion – especially watch descending phase
  8. Scapulothoracic bursitis

 

 

Few important tests include Lennie test, Lateral scapular slide test, Scapular assistance test, scapular isometric pinch test, wall push test, Labral tests, impingement tests, tendinitis tests, etc.

 

References

  • Kibler B, McMullen J. “Scapular dyskinesis and its relation to shoulder pain”. J Am Acad Orthop Surg. 2003;11:142-151.
  • Magee DJ. “Shoulder. Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012; 231-360.

 

What is Resisted isometric movements?

Working with the patients in the clinic and assessing their structural affection has always been a mind scratching job. Multiple tests are performed but there remains a doubt that which structure/ tissue is involved – contractile or non- contractile/ inert tissue. Contractile tissue refers to Muscle, Tendon, Musculo – Tendinous junction, Teno – Periosteal junction, Nerves, etc.  

Contractile tissue assessment involves voluntary contraction of muscles. These contractions include strong isometric contraction, multiple angle isometrics or concentric/ eccentric contraction. During this testing, it is checked if there is any pain or not and if it is then what is the intensity and quality of pain. Along with the pain it is also assessed what is the strength of contraction and which type of contraction is painful as well as weak.

For solving the above queries, the testing is done by Resisted Isometric Movements. However these movements are always tested last in the examination of the joints. This type of movement consists of a strong, isometric voluntary contraction of muscles and primarily detects muscles as well as nerves supplying the tested muscles.

  • If the muscle, its tendon or the bone into which they insert is at fault, pain & weakness result; the severity of pain and weakness helps to judge the degree of injury and patient’s pain threshold.

Some of the important points to be taken care of while assessing:

  1. There should not be any movement while performing the test because if movement occurs then inert tissue will also move and it will be difficult to find out which is the offending structure- contractile or inert.
  2. The test joint should be put in neutral or resting position in order to minimize tension on inert tissue.
  3. The movements should be done in resting position of the joint as in this position muscle is in its optimal length so that maximum force can be elicited.
  4. Moreover this position can be modified if required when assessing for tight or lengthened structures as well performing multiple angle isometric testing.
  5. This test involves isometric hold so it is essential to have the muscle strength of grade 3 to 5 on the muscle test grading scale.
  6. If there is difficulty in differentiating between grades 4 and 5, eccentric break test can be used. The test starts as an isometric contraction, but then assessor applies sufficient force to cause eccentric contraction or break in the isometric contraction.
  7. Post testing isometrics, other types of contraction can also be checked for according to patient’s complain.

Steps to perform Resisted Isometric Movements:

  1. The joint is placed in neutral or resting position. Every joint has a specific resting position.
  2. The patient is asked to perform strong isometric contraction, not to move the part and the assessor will resist with almost equal amount of force to prevent any movement from occurring and also to ensure that patient exerts maximum effort.
  3. However movement cannot be completely eliminated, but this will minimize it.

After these movements are performed, the assessor determines the contractile tissue affected by judging the degree of pain & strength of contraction. Along with these movements, functional testing, myotomes assessment, manual muscle testing, palpation and special tests are also equally important.

Active movements as well as passive movements can also be performed. And it has been observed that if contractile tissue is injured, active movement is painful in one direction (contraction) and passive movement is painful in opposite direction (stretch). Resisted isometric movement is painful in the direction of active movement.

There are 4 classic Patterns of contractile tissue lesions, according to pain & strength. They are as follows:

  • Strong & Pain free: – There is no lesion of the contractile tissue (muscles as well as nerves supplying) which is being tested regardless of being tender on touch.

 

  • Strong & Painful – In this there is local lesion of muscle or tendon. 1st or 2nd degree muscle strain. 2nd degree strain produces more muscle weakness and pain than 1st degree strain.

There can be tendinitis, tendinosis, paratenonitis or paratenonitis with tendinosis or partial avulsion fracture, but in this contraction will be strong (not as good side) and painful, pain will be around the tendon and not the muscle.

 

  • Weak & Painful: – This is seen in cases of severe lesion around of joint such as fracture. Weakness is usually caused by reflex inhibition of muscles around the joint secondary to pain.

 

  • Weak & Pain free: – This indicates complete rupture of muscle or tendon (3rd degree) or involvement of peripheral nerve or nerve root supplying that muscle. With neurological involvement, assessor must differentiate between affection of (a) peripheral nerve by checking muscles & (b) nerve root by checking myotomes and dermatomes. Differentiate between UMN & LMN lesions.

3rd degree strains usually are painless, but many a times along with this there is 1st or 2nd degree strain of surrounding muscles resulting into pain. To find out 3rd degree strain, one must check for presence of hole or gap in muscle by palpation or check the muscle bulk when contraction is attempted and how it gives appearance of obvious deformity.

 

Reference

  • Magee DJ. “Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012.
  • Image : http://www.ptonthenet.com

 

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