Flexor Hallucis Longus (FHL):

Origin: Posterior surface of the distal 2/3rds of the fibula, interosseous membrane, and adjacent intermuscular septa and fascia.

Insertion: Base of the distal phalanx of the great toe, plantar surface .

Nerve: Tibial nerve arising from the sciatic nerve via the sacral plexus, originating from nerve roots L5, S1, and S2.

Action:

Phalanges: flexion of the interphalangeal joint of the great toe and assists in flexion of the metatarsophalangeal joint

Ankle: Plantar flexion of the foot, as well as, aaccesory  invertor of the foot and ankle.

Relative Location:

The flexor hallucis longus (FHL) is located lateral to the tibialis posterior. The anterolateral border combined with the periosteum of the fibula and posterior intermuscular septum.

Integrated Function:

Stabilization:

Stabilizes the tibiotalor & subtalor joints,transverse tarsal, tarsometatasal, metatarsophalangeal, interphalengeal joints.

Eccentric action :

The FHL eccentrically decelerate extension of the metatarsophalangeal and interphalangeal joints, as well as dorsiflexion and eversion of the ankle.

Synergists:

The FHL work synergistically with the tibialis posterior to eccentrically decelerate eversion during the mid-stance of gait cycle. In addition, it also helps medial gastronemus and plantaris . It also assist in push off and landing mechanics during gait cycle.

A functional relationship may exist between the FHL, the tibialis posterior and tibialis anterior in control of the talus. Some evidence state that the FHL may control talar inversion via the groove in the talus and the sustentaculum tali of the calcaneus.

Arthrokinematics:

The FHL cross several joints, but likely have their largest impact on the interphalangeal joints – capable of producing plantar glide. In claw toe deformity the extensor hallucis longus and extensor digitorum longus may also contribute to dysfunction by producing excessive dorsal glide of the metatarsophalangeal joints.

Course of FHL:

The FHL has an interesting course, running through a groove on the posterior medial talus and continuing through a groove inferior to the sustentaculum tali.

During contraction of the FHL this creates an anterior and superior force on the medial side of the talus. This may have functional implications on talar and calcaneal mechanics, specifically an ability to contribute to inversion and a varus tilt of the talus and calcaneus . It potentially anterior glide of the talus on the tibia.

Fascial Integration of the FHL

The most obvious relationship exists between the posterior tibial fascia and the combined FHL and FDL. Which links the deep posterior compartment muscles by function and fascia.

Additionally, the  tendinous slips of the FHL may distribute the load in the forefoot, especially during toe-off phase of gait cycle. This increases the weight-bearing on the forefoot and eventually helps the FHL support the medial longitudinal arch of the foot .

Lower Leg Dysfunction (LLD):

These muscles are long due to excessive eversion at the subtalar joint and tilt of the talus, but rather than resulting in a decrease in tone, the inhibition of prime movers results in over-use and hyper-facilitation of these synergistic muscles.

When tibialis posterior is inhibited , the FHL become synergistically dominant. That is to state that the overactive fibularis muscles result in altered reciprocal inhibition of the tibialis posterior and a relative increase in FHL activity to compensate for a lack of force production in inversion. Furthermore , there is evidence suggest that the FHL and FDL may play a similar role at the metatarsalphalangeal joints, compensating for inhibited short toe flexors.

Excessive pronation:

The change in arthrokinematics and activity may limit extension of the toes  a compensation pattern that generally leads to excessive pronation (eversion) from heel-off to toe-off during the stance phase of gait cycle.

To sum up, the FHL is long and over-active, acting as overactive synergists. This clearly indicate that this muscles should be released, but do not stretched or activated. This trigger points in these muscles are often mistaken for gastrocnemius and soleus trigger points during self-administered release technique.

Anantomy

image coutsey : wikipedia.com

FHL Trigger Points :

Palpation results in tenderness (trigger points or tender points) and may result in radiating symptoms along the muscle and its tendons. Based on the theoretical model of trigger point development it would seem likely that “trigger points” are dysfunction at the “motor point” of a muscle, and release will decrease tonicity via reflexive inhibition or ischemic pressure .

 

Referances:

  1. Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004
  2. Phillip Page, Clare Frank, Robert Lardner, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  3. Donald A. Neumann, “Kinesiology of the Musculoskeletal System: Foundations of Rehabilitation – 2nd Edition” © 2012 Mosby, Inc.
  4. Tom Myers, Anatomy Trains: Second Edition. © Elsevier Limited 2009
  5. David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’
  6. Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens
  7. Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion: A Guide to Goniometry – Third Edition. © 2003 by F.A. Davis Company
  8. Leon Chaitow, Muscle Energy Techniques: Third Edition, © Elsevier 2007
  9. Cynthia C. Norkin, Pamela K. Levangie, Joint Structure and Function: A Comprehensive Analysis: Fifth Edition © 2011 F.A. Davis Company
  10. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
  11. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
  12. Andrew Biel, Trail Guide to the Human Body: 4th Edition, © 2010
Proactivephysiotherapy, hamstring, assesment, lower limb

Hamstring muscles strain : Assessment & Risk factors

Hamstring muscle strain injuries  are common in sports  which required acceleration, deceleration, rapid change in direction.

According to Schache et al 2009 & Heiderscheit et al 2005 Hamstring injuries are proposed to occur during the terminal swing phase of running as a consequence of an eccentric contraction. Sometimes hamstring late firing also contribute to strain.

There are two mechanisms of hamstring injuries. .

  1. Type 1: high intensity running with the injury occurring during late swing phase involving the proximal musculotendinous junction of the long head of biceps femoris.
  2. Type 2: stretching of the hamstring complex due to an extreme joint position involving mostly semimembranosus and the proximal tendon.

The majority of hamstring injuries occur at the biceps femoris (BF) long head.

What are the RISK FACTORS?

Many research papers have considered a potential risk factor for hamstring muscles strain injury however other authors inconsistently identified as contributing to the injury.

In addition to that, A systematic review and meta-analysis research said   risk factors for hamstring injury

  • Older age
  • Increase quadriceps peak torque
  • Past history of hamstring injury

There are Other strength measures such as hamstring: quadriceps ratio, which is the best commonly perceived to be predictive of injury, were not associated with a hamstring injury (Freckleton & Pizzari, 2013).

 

CLINICAL ASSESSMENT AND DIFFERENTIAL DIAGNOSIS

Here you can predict the differential diagnosis for hamstring strain injury

  1. lumbar spine (disc/ facet joint),
  2. SIJ dysfunction, gluteal/piriformis/Gemelli trigger points,
  3. Hamstring tendinopathy, avulsion injuries,
  4. vascular claudication and compartment syndrome (Brukner & Khan, 2006).

The subjective assessment is a key point to correctly diagnose an injury. Players with a hamstring injury will report sudden onset of pain localized to the hamstring region with a clear mechanism or incident.  (Pizzari, et al., 2010).  A particularly previous hamstring injury is also important of the major risk factors for future hamstring injuries (Freckleton, et al., 2012).

There are some  positive clinical signs, and symptoms for hamstring injury (Bennell, et al., 1999):

  • Immediate onset of posterior thigh pain,
  • Tenderness on palpation,
  • Reproduction of pain on a stretch of hamstring,
  • Reduced straight leg raise ROM,
  • Reduced strength on a resisted active contraction of hamstrings

 

What should you include in your  physical examination ?

  1.  lumbar spine AROM,
  2. Slump test
  3. SLR, active knee extension test (AKE),
  4. passive hamstring muscle stretch and palpation of pelvic musculature for trigger points and reproduction of posterior thigh pain.
  5. Resisted contraction of the hamstrings should be tested in multiple positions of knee flexion (Brukner & Khan, 2006).

Palpation is the most important aspect of the physical examination to help identify location and severity of the injury (Pizzari, et al., 2010).

 

A  study investigated the use of the single leg hamstring bridge(SLHB) as a clinical test in predicting hamstring injuries in football players. The hamstring muscles in a functional position similar to terminal swing and assesses endurance parameters rather than peak torque.

SLHB test could be used to screen and identify athletes who are potentially at risk of sustaining a hamstring injury. It may be used to evaluate an athlete to return to sport.

 

REFERENCES :

 

  1. Bennell K, Tully E, Harvey N. Does the toe-touch test predict hamstring injury in Australian Rules footballers? Aust J Physiother 1999;45:103–9.
  2. Brukner, P., & Khan, K. (2006). Clinical sports medicine. McGraw Hill.
  3. Askling, C., Saartok, T., & Thorstensson, A. (2006). Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. British Journal of Sports Medicine40(1), 40-44.
  4. Croisier, J. L. (2004). Factors associated with recurrent hamstring injuries. Sports Medicine34(10), 681-695.
  5. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis. Br J Sports Med 2013;47:351–8.
  6. Freckleton, G., Cook, J., & Pizzari, T. (2013). The predictive validity of a single leg bridge test for hamstring injuries in Australian Rules Football Players. British journal of sports medicine.
  7. De Smet, A. A., & Best, T. M. (2000). MR imaging of the distribution and location of acute hamstring injuries in athletes. American Journal of Roentgenology174(2), 393-399.
  8. Devlin L. Recurrent posterior thigh symptoms detrimental to performance in rugby union: predisposing factors. Sports Med 2000;29:273–87.
  9. Drezner JA. Practical management: hamstring muscle injuries. Clin J Sport Med 2003;13:48–52.
  10. Heiderscheit BC, Hoerth DM, Chumanov ES, et al. Identifying the time of occurrence of a hamstring strain injury during treadmill running: a case study. Clin Biomech 2005;20:1072–8.
  11. Koulouris, G., & Connell, D. (2005). Hamstring Muscle Complex: An Imaging Review1. Radiographics25(3), 571-586.
  12. Orchard J, Marsden J, Lord S, et al. Preseason hamstring muscle weakness associated with hamstring muscle injury in Australian footballers. Am J Sports Med 1997;25:81–5
  13. Pizzari, T., Taylor, R., &amp; Coburn, P. (2012). The who, where and how.. Understanding hamstring injuries in the AFL. <em>Journal of Science and Medicine in Sport, S143.
  14. Schache AG, Wrigley TV, Baker R, et al. Biomechanical response to hamstring muscle strain injury. Gait Posture 2009;29:332–8.12
  15. Schneider-Kolsky M, Hoving J, Warren P, et al. A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med 2006;34:1008
  16. The predictive validity of a single leg bridge test for hamstring injuries in Australian Rules Football Players   2014 Apr;48(8):713-7. doi: 10.1136/bjsports-2013-092356. Epub 2013 Aug 5.

Clinical reasoning & treatment for lateral epicondylitis

Tendons are the tissue that attaches the muscles to the bones. Overuse in the upper extremities can result in the diagnosis of the tendonitis or the tendonitis of the wrist, elbow or shoulder. The most common wrist or forearm problems include tendinopathy of the muscles that extend the wrist, otherwise known as tennis elbow.

The major muscles that move the wrist have their origin at the elbow. If the wrist is improperly used, pain may arise in the forearm and/or outside of the elbow. Tennis players and athletes who use backhand and does repetitive motions that extend and fled the wrist is, particularly at risk. Lateral elbow pain may not affect only such players or athletes but also affect who use a screwdriver or hammer on the daily bases or those who great amount of time in gardening taking, painting. The patient who works with a pronated forearm and flexed wrist like computer workers also feel lateral elbow pain and burning sensation which is called as (supinator syndrome).

Clinical reasoning in determining the nature of elbow pain:

Tennis elbow is the common nomenclature for lateral elbow pain.

It is caused due to one or more following consequence,

maligned bones in the elbow and/or carpals, tendonopathy, capsular pain, radial nerve pain, neck and thorax dysfunction.

 

Clinical reasoning of tennis elbow, proactive physiotherapy 

 

Treatment strategies :

Frequently tennis elbow is treated with local ultrasound, stretching and wrist strengthening, however, there are several reasons need to be addressed and treatment should be planned accordingly.

Depending on the examination findings, treatment could include

  • joint mobilizations to the elbow, cervical and thoracic spines
  • soft tissue massage of the scalenes, levator scapula, upper trapezius, latissimus dorsi, wrist flexors
  • dry needling of supinator, pronator teres, common extensors, posterior rotator cuff, upper trapezius, thoracic erector spinae
  • Exercises for scapulothoracic-cervical mobility & stability (rhythm)
  • exercises for thoracic (vertebrae & ribs) mobility and cervical mobility & stability
  • mobilization with movement (MWM’s – Mulligan’s technique) for upper ribs, wrist, and elbow
  • Mulligan’s and/or McConnell’s taping
  • Kinesiotaping
  • prescription of elbow or wrist brace
  • strengthening exercises for the shoulder, elbow and wrist muscles.
Shoulder joint

Shoulder impingement syndrome : Contribution of scapula

 

 

The shoulder is a ball and socket synovial joint . The shoulder is such a fascinating joint with 180 degrees of freedom, which relies on excellent dynamic movement.

How should we use it in the diagnosis of shoulder pain?

In early 1980, Neer et all describes Shoulder impingement and researched for many years and some of the original work . As our understanding of impingement has expanded we have come to realise that there are types of shoulder impingement i.e internal and external, and primary and secondary (Ludewig & Braman, 2011).

What is Internal versus external impingement?

It depends on the site of the impingement. If it is located in the subacromial space it is known as external impingement. If it is located within the glenohumeral joint it is known as internal impingement (Cools, Cambier & Witvrouw, 2008).

 

External impingement : According to Neer et all, when there is compression between the rotator cuff tendons or long head of bicep tendons, between the humeral head and the undersurface of the acromion, coracoacromial ligament .

Internal impingement : compression of the supraspinatus tendon and/or infraspinatus tendon between the humeral head and posterosuperior glenoid rim. This usually occurs at 90 degrees abduction and external rotation.

Remember , when you simply saying “shoulder impingement” as a diagnosis. This label does not indicate you:
• Which structures are involved.
• Where is the exact site of impingement

 

What is Primary and secondary impingement?

When there is injury to shoulder joint, it gradually leads to structural narrowing of the subacromial space due to acromioclavicular athropathy, or pathology within the tissues in the subacromial space .

According to Lewis (2011) et all, many people directly jump to the assumption that if structures are impinged, surgery is required to ‘make more room’, but it’s not the case. The pathology lies within tendon itself.

Secondary impingement :

• Glenohumeral joint instability, which can lead to excessive humeral head translation and/or poor position of the humerus in relation to the scapula. In addition to that subscapularis inefficiency to maintaining huneral head in central position.

• Scapula dyskinesis

• GIRD (glenohumeral internal rotation deficit) There is a loss of glenohumeral internal rotation and increase in external rotation, often the posterior cuff & capsule become tight and there is excessive anterior translation of the humeral head resulting in secondary impingement also we can say it’s shoulder medial rotation uncontrol movement. ( Lewis2011 et all)

Many authors said that secondary impingement can affect the rotator cuff tendons or long head of biceps, and it can be both internal and external (Burkhart, Morgan & Kibler 2003; Cools, Cambier & Witvrouw, 2008; Ludewig & Braman, 2011).

ASSESSMENT OF THE SHOULDER COMPLEX:

The knee movement occurs in sagittal plane only which we consider 1) flexion and 2) extension. Shoulder is complex joint and it has many range of motion which are even more complex.

When we see shoulder patient walk into our clinic , First question comes in our mind where to start assesment. The key to improving your assessment of shoulders is to have a routine checklist in your assessment technique. For instance you should always assess the injured then the non-injured side. According to chief complaint make order of your test because if you prove ke pain initially then all test will be false positive . You should always assess movements in the same order.

Cools et al (2008) published a fantastic paper outlining an assessment algorithm to assist clinicians in their screening of shoulder patients with suspected impingement and clinical diagnosis. This algorithm is a great place to start when you’re developing skills in shoulder assessment.

The images below represent the Hawkin’s Kennedy, Neer, and Jobe test for shoulder impingement described in the algorithm above (Cleland, 2005).

 

 

 

after reading this algorithm the scapula assistance test & scapula retraction test will become your routine clinical test

(Cools, Cambier & Witvrouw 2008)

 

Scapula assistance test : assesses the impact of correcting scapula position on shoulder pain and impingement symptoms during active shoulder elevation. the clinician assists the scapula into upward rotation while the patient elevates their arm and observes if there is a change in pain.

 

Scapula retraction test assesses the impact of maintaining scapula position during loading and assessing the impact on pain. For the scapula resistance test the therapist resists the scapula into retraction while assessment pain in the resisted elevation in an abducted and internally rotated position.

Let’s gather all points :

When assessing a shoulder you should always try to focus on the following:

• Carefully observing the functional aggravating position.
• Reproducing shoulder symptoms and then trying to change them with scapula positioning, muscle activation exercises or manual therapy.

• If there is a reduction in pain it indicates a ‘green light’ to go ahead and treat with same rehabilitation.

• If there is Red light during your assessment – you will need to reconsider your diagnosis, consider a referral for medical imaging and/or referral to a specialist.

 

References:

 

1. Braman, J. P., Zhao, K. D., Lawrence, R. L., Harrison, A. K., & Ludewig, P. M. (2014). Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgery and physical therapy. Medical & biological engineering & computing, 52(3), 211-219.

2) Cools, A. M., Cambier, D., & Witvrouw, E. E. (2008). Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British journal of sports medicine, 42(8), 628-635.

3)Cools, A. M., Declercq, G., Cagnie, B., Cambier, D., & Witvrouw, E. (2008). Internal impingement in the tennis player: rehabilitation guidelines. British journal of sports medicine, 42(3), 165-171.

4) Kibler, W. B., & McMullen, J. (2003). Scapular dyskinesis and its relation to shoulder pain. Journal of the American Academy of Orthopaedic Surgeons,11(2), 142-151.

5) Kibler, W. B., Ludewig, P. M., McClure, P. W., Michener, L. A., Bak, K., Sciascia, A. D., … & Cote, M. (2013). Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’. British journal of sports medicine, bjsports-2013.

6) Kibler, W. B., Sciascia, A. D., Bak, K., Ebaugh, D., Ludewig, P., Kuhn, J., … & Cote, M. (2013). Introduction to the second international conference on scapular dyskinesis in shoulder injury—the ‘Scapular summit’report of 2013.British journal of sports medicine, bjsports-2013.

7) Ludewig, P. M., & Braman, J. P. (2011). Shoulder impingement: biomechanical considerations in rehabilitation. Manual therapy, 16(1), 33-39.

Influence of Sacrum during gait cycle….

Walking is influenced by the ability of the sacrum to torsion left on the left axis and right on the right axis.

Sacral torsional movement is considered to occur around an oblique axis.  the left oblique axis runs from the upper extremity of the left sacroiliac joint to the lower end of the right sacroiliac joint, and the right oblique axis runs from the upper end of the right sacroiliac joint to the lower extremity of the left sacroiliac joint.

Clinical observation of the normal walking cycle demonstrates that sacral side-bending and rotation couple to opposite sides.  This is also known as ‘Type 1 motion’.

‘Type 2 motion’ is coupling to the same side.

left torsion on the left oblique axis, the sacrum rotates left and side-bends right, with the right sacral base moving into anterior nutation.

right torsion on the right oblique axis, the sacrum rotates right and side-bends left, with the left sacral base moving into anterior nutation.

Because the nutational component of this normal walking movement is anterior in direction, left torsion on the left oblique axis  and right torsion on the right oblique axis are described as anterior torsional movements.

The exact biomechanics of the torsional movements of the sacrum are still unknown,  The nutational movement in normal walking is anterior on one sidereturn to neutral, and vice versa.

How sacrum moves during gait cycle?

Right heel strike, the right innominate has rotated in a posterior direction and the left innominate has rotated in an anterior direction. The anterior surface of the sacrum is rotated to the

 

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Proactive physiotherpay

Understanding Sacroiliac dysfunction or iliosacral dysfunction????

Sacroiliac joint dysfunction (SIJD) is a common cause of LBP occurring in 16–30% of patients with LBP. The sacroiliac joint is a diarthrodial synovial joint comprising an anterior segment, which is a true synovial joint, and the posterior segment, a syndesmosis comprising the gluteus minimus and medius muscle, piriformis muscle, and sacroiliac ligament. As all these muscles are shared with the hip joint, the sacroiliac joint (SIJ) cannot function independently. Furthermore, the ligamentous structures and the muscles influence the stability of the SIJ. The nerve supply for SIJ is mainly by the sacral rami dorsal.

The sacroiliac (SI) joint is formed by the articulation of the pelvis and the sacrum.  Dysfunction of this joint can result from how the pelvis impacts on the sacrum or how the sacrum impacts on the pelvis.  If the pelvis (ilium) is responsible for a fixated (immobile/stuck) SI joint, then it is called ‘iliosacral dysfunction’.  If the sacrum is responsible, it is called ‘sacroiliac dysfunction’.

Recent interest in rehabilitation involving the SI joint may be attributed in large part to the fact that approximately 20-30% of low back pain and referred pain comes from the SI joint itself and/or the surrounding ligaments, muscles and other soft tissues involved in the functioning of the joint  (Maigne et al, 1996, Schwarzer et al, 1995).

The concern in sports medicine relates primarily to the problems caused by the biomechanical changes inherent to the malalignment: specific sports injuries, impaired recovery from injury, and a failure of athletes to realize their full potential (Schamberger, 2002).

Sacral Motion and Dysfunction

When you forward bend, your sacral base moves in a posterior and slightly superior direction.  When you bend backward, your sacral base moves in the opposite direction, anteriorly and inferiorly.  The anterior and posterior movement of the sacral base is called nutation and counternutation, but many practitioners use the terms anterior nutation and posterior nutation.  “Nutation” means “nodding.”

Sacrum are also capable of side-bending and rotating.  If there are no joint fixations, then this is what your sacrum does in walking (or running) as you shift your weight from one leg to the other.  Most experts agree that the sacrum only exhibits ‘Type 1’ motion, meaning that side-bending and rotation are coupled to opposite sides (right rotated and left sidebent is known as ‘right torsioned’, left rotated and right sidebent are known as ‘left torsioned’).

The combination of side bending and rotation is also known as ‘torsion.’ When the sacral base is ‘right rotated’ the right sacral base is posterior in relation the left sacral base, and vice versa.  If during an evaluation, you find that the sacral base is rotated (on either side) when you are in the neutral position (standing on two feet), then it is probably dysfunctional.

For instance, if an SI joint evaluation reveals that (in a neutral position) the sacral base is fixated on the right side, then you must determine whether the right sacral base is fixated in anterior or posterior nutation.  Making the correct diagnosis is essential because you must treat the fix side to correct the dysfunction.  Treating the non-fix side will be meaningless.

Why is this important to know?

In cases of pelvic dysfunction, the side that hurts is often the side of the symptom (pain), but not the side that is fixed.  Most practitioners will try to treat the symptomatic side instead of the fixed side. There is a high probability that they will not be the same, and as stated previously, this work will be relatively meaningless.

Hip (Ilium) Motion and Malalignment

When we walk or run our hips rotate reciprocally in all three planes of motion.  These are the ‘sagittal plane’, the ‘coronal’ plane, and the ‘transverse’ plane.  In the sagittal plane, a type of hip rotation (malalignment) occurs as anterior or posterior rotation.  In the coronal plane, a type of hip rotation occurs as upslip or downslip (this is also known as superior or inferior shear, respectively).  In the transverse plane, a type of hip rotation occurs as inflare or outflare (this is also known as medial or lateral rotation, respectively).

If you discover an iliosacral fixation, at first you will only know the side of the fixation.  You must then determine the type of malignment involvement wheather it is anterior/posterior rotation, inflare/outflare, upslip/downslip.  Occasionally, an individual will present with a single malalignment.  Typically, an individual presents with a combination of two malalignments. A triple combination is possible, but relatively rare.

Remember again, you must treat the fixed side.even if the contralateral side is the symptomatic side.  In the case of a single-type of malalignment, just go ahead and treat according to the appropriate technique.  In the case of a combination of malalignment types, you must treat with the appropriate techniques(s), but also in the correct sequence.  The correct sequence is critical because if your sequence is wrong, your work will be ineffective.

After you release the fixed side, you can treat the symptomatic side (especially if they are not the same side) to speed up the healing process on that side.  This healing process will probably happen on its own but may happen faster with treatment.  Again, the sequence is the key.

EVALUATION AND CORRECTION :

The passive straight leg raising test is most helpful in the evaluation of pain in the low back. Pain down the leg on passive straight leg raising, which is exacerbated by dorsiflexion of the foot, is indicative of sciatic nerve pain. Despite a study to the contrary by Danforth and Wil~on,’~ several researchers have found a relationship between sciatic nerve pain and pain in the sacroiliac joint.When the leg is raised, the pull of the hamstrings on the innominate bone causes a posterior torsion strain on the same side.

If this does not increase the pain in the back or if it eases the pain in the back, anterior dysfunction should be suspected. If passive straight leg raising causes pain or increases the pain on the same side, suspect a posterior or vertical complication.

Rationale:

The use of ‘direct’ techniques in treatment, the more effective the results will be.  The use of indirect techniques, however, usually indicates less than a full grasp of the biomechanical descriptions and how to more precisely locate and treat the joint fixation.

Knowing what you are releasing in a client’s body adds to your clarity of purpose and makes you a more effective therapist. The techniques you apply will be more effective than if you don’t know precisely what you are releasing.

 Knowing and naming what you are working on is an essential part of effective therapy.

Reference :

  1. Maitland, J.  Spinal Manipulation… 2001.  North Atlantic Books, Berkley, California.
  2. Schamberger, W. The Malalignment Syndrome, Implications for Medicine and Sport.  2002.  Elsevier Science Limited.
  3. Maigne J-Y, Aivalikis A, Pfefer S.  Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain.  Spine 1996; 21: 1889-1892.
  4. Schwarzer AC, Aprill CN, Boduk N.  The sacroiliac in chronic low back pain.  Spine 1995; 20:31-37.
  5.  Bernard TN, Jr, Kirkaldy-Willis WH: Recognizing specific characteristics of nonspecific low back painClin Orthop Relat Res, 1987, (217): 266–280.
  6. Erhard R, Bowling R: The recognition and management of the pelvic component of low back and sciatic painJ Am Phys Ther Assoc, 1977, 2: 4–15.
  7. Image coutsey :wikipedia

Warning bells for gluteus inhibition

 

 

What does inhibited mean?

The neural input to a muscle is lowered .The muscle still works but it’s not as efficient to generate power.  To generate power during movement. Therefore it appears weak!! The body finds balance to complete movement task but unfortunately it finds another way for muscle in the movement pattern to do more. Therefore movers become stabilizer for the joint.

What’s the role of the glutes: They are the powerhouse of the lower limb.

The glutes action…

• Extend the hip
• Laterally rotate the hip
• Abduct the hip
• Adduct the hip
• Posterior tilt the pelvis
• Hips are designed for thrusting

1) Hip mobility :

When hip mobility is decrease think of glutes. . If the glutes are inhibited you aren’t stable. There will be difficulty in doing squat in many cases after surgery of lower limb if flutes are inhibited.

2) You find Low back pain without any     reason :

When you lose hip mobility your lumbar spine takes role of mobility,hence there may be more movement from the lower back. Lose movement in one place and you move more in another. To help your lower back from crying  activate your glutes.

3) Knee pain. :

The knee movement depend on what the foot say and the hip can control. To remember , traumatic knee injuries will inhibit the glutes. So always start Gluteus rehabilitation as part of knee injury

4) chronic ankle sprains. :

Poor hip control leads to vulnerability in proprioception and gait. When you find loss of ankle rocker during gait cycle , there is always restriction of hip extension. The main function of glutes  is hip extension. Unlock your ankle by improving ankle rocker .Problem solve and you wins.

5) Plantar fasciitis.:

oh it’s very common condition we face in our daily clinical practice. We have already discussed in our previous blog click on plantar fasciitis due proximal joint instability  Any problem in the feet check your glutes.

6) Shoulder decreased motion or pain. :

This is very tricky for you to think . You have question how it possible . See, The glutes connect to shoulder via the Posterior Oblique Sling. When glutes are inhibited the fascia becomes tight and shoulder range of motion is restricted. If you can’t generate force from the ground up . Many times and  lattismus dorsi is also inhibited. Hence forward when you see a patient of shoulder pain check his posterior oblique sling.

7) Tight psoas muscle :

The psoas is a functional opposite of the glutes. The psoas flexes the hip and glutes extend it. The psoas anterior tilts your pelvis and the glutes posterior tilt it. If the glutes are inhibited the lumbar spine becomes more unstable and the psoas turns into overactive to stabilize the lower back. When you find anterior pelvic tilt  think for the Gluteus.

8) Groin or hamstring pulls:

The hamstrings take over the primary work of the glutes to extend the hip. That extra work causes strain. The most common groin muscles to pull and get injured are (pectineus, adductor longus/brevis). They act as hip flexors, antagonist to the glutes. They are hip adductors, synergistic to the glutes.

 

Finally , activate them and wins the situation.

 

Thank you you for reading notes .any dought raise questions.

Selective exercise for cycling : What evidence say

It ’s ability of the trunk, lower back, pelvis, and hip region to generate effective and efficient generate power when external load act on it.

The ideal cycling position is one of a comfortable flexion with the pelvis supported by the saddle and arms supported by the handlebars. Moreover, cycling is non-weight bearing sports. Don’t think too much? how  “core stability” is important in cycling? Here we explain how it’s important.

During the pedal, stoke movement occurs in 3 planes; flexion-extension, lateral flexion, and rotation.

What does the evidence say?

Cyclists reporting lower back pain have been found to have an increase in lumbo-pelvic flexion and rotation (Burnett et al 2008). An inability to control the movement and position of the pelvis, especially excessive lumbar flexion, may cause undue strain on the lower back and pelvis which turns into pain and pathology (Burnett et al 2008).

It is very interesting that the cyclists with lower back pain had greater flexion in all cycling positions and their posture does not change from start to finish. Cyclist started in more a flexed position and stayed.Here the author gives a suggestion that the cause of back pain was due to positioning error rather than fatigue in the ‘core’ (Van Hoof et al (2012).

In 2007 study by Abt JP1Smoliga JM,  investigated the link between “core stability” and cycling. 15 highly trained cyclists were cycled to exhaustion before and after a core-fatiguing workout. The motion of both the knee and ankle increased following the core fatiguing workout. Unfortunately, Total frontal plane knee motion , sagittal plane knee motion , and sagittal plane ankle motion  increased after the core fatigue protocol. Only knee and ankle motion were measured so it difficult to know in the reduction of control movement in the lower limb. In addition to that whether it was due to reduced control and stability in the proximal joint. However, it does suggest that reduced control of lower limb movement was due to poor proximal stability and force transfer from the truck and pelvic region.

From the referances, we conclude the below exercise that is essential for cyclist.

Unlock Core”

The list of ‘core’ exercises is endless. We would recommend choosing few exercises that challenge trunk-pelvic-hip control and stability through different ranges.

Proactive physiotherapyProactive physiotherapyProactive physiotheray,Ahmedabad

Improvements in ‘core stability’ could promote greater trunk stability leading to improved force transmission to the pedals which helps in the maintenance of core stability. Improved core stability and endurance could promote greater alignment of the lower extremity when riding for extended durations as the core is more resistant to fatigue.

 

Referances :

 

  1. Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls – field study using a wireless posture monitoring system . Wannes Van Hoof a,*, Koen Volkaerts a Manual Therapy 17 (2012)
  2. Lower lumbar spine axial rotation is reduced in end range sagittal posture as compare to neutral spine posture. Burnett A1, O’Sullivan P, Ankarberg L, Gooding M, Nelis R, Offermann F, Persson J.Man Ther. 2008 Aug;13(4):
  3. Relationship between cycling mechanics and core stability. J Strength Cond Res. 2007 Nov;21(4):
Posterio oblique subsytem, AHmedbad, Lattismus dorsi

Posterior Oblique Subsystem (POS)

Before reading this article click on introduction to core subsystem 

 

Structures are involved :

  • Latissimus dorsi,
  • Thoracolumbar fascia,
  • Gluteus maximus
  • Superior portion or gluteus medius.

 

Function (Brief):

IT stabilize the posterior kinetic chain Which including lumbar spine and sacroiliac joint. It transfers the force between us upper extremity and lower extremities eventually, integrated pulling movement of a body.

  • Eccentric deceleration of total body
  • Transference of force between lower and upper extremities
  • Maintaining alignment of the lumbosacral joints
  • Maintaining femoral alignment during legs with pull

 

Functional Arthrokinematics:

This subsystem is an important stabilizer of the posterior kinetic chain.  The fiber arrangement in such a way i.e subsystem indicate a special role in sacroiliac joint (SIJ) arthrokinematics, and lumbo-sacral function.

The fibers of each side run perpendicular which crossing from the gluteus maximus and associated it’s respective fascia which  traversing the SIJ, through the nearly continuous thoracolumbar fascia, across the lumbar spine, to the latissimus dorsi and associated fascia on the opposite side.

During the swing phase of gait cycle, the eccentric control of leg and contralateral arm pulls the thoracolumbar fascia tight.  Concurrently, the contralateral Posterior oblique subsystem concentrically contracts throughout the gait cycle , which in turn pulls the contralateral side of the thoracolumbar fascia.

Optimal function of POS is to stabilize posture.

 

Motor Behavior:

The POS could be underactive termed in upper body dysfunction, Lumbo Pelvic hip complex dysfunction, sacroiliac joint dysfunction , and lower leg dysfunction. Commonly, the under-activity of the POS is paired with a synergistic dominance of the deep longitudinal subsystem (DLS – publish soon).

 

How to find  POS underactive?

AOS may be dominance seen in upper body dysfunction and who present lower leg dysfunction that results in excessive forward lean during the overhead squat assessment. It indicates POS is

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Anterior Oblique subsystem (AOS)

The Anterior Oblique Subsystem (AOS) is comprised of:

External Obliques
Abdominal Fascia/Linea Alba
Contralateral Anterior Adductors
Internal Obliques
Rectus Abdominis

 

Function (Brief):

Stabilization of the anterior kinetic chain Which including the joints of the pubic symphysis, hip, and lumbar spine. It transfer force between lower and upper extremities.

 

Functional Arthrokinetic:

 

The Anterior Oblique Subsystem plays very important for stabilizing anterior kinetic chain. This subsystem has little effect on joint arthrokinematics .

The AOS is responsible for eccentric deceleration of rotation and extension of the lumbar and thoracic spine –  when there is asymmetrical movement pattern that may lead to facet joint and posterior disk compression and has been indicated in lumbar spine injury.

 

The AOS is also involved in eccentric deceleration of an anterior pelvic tilt, especially during standing and pushing motions. As an anterior pelvic tilt includes lumbar spine extension with little sacroiliac joint (SIJ) motion. If you find any change in pelvic rotation and SIJ dysfunction which may involve AOS involvement.

The AOS directly stabilizes the pubic symphysis. There is a most notable relationship in the AOS synergy relative to pubis symphysis joint is the fascial continuity.

 

It provides an optimal function to control of rotation with, superior/inferior glide, and other accessory motions at the pubic symphysis which associated with the normal pelvic torsion during gait.

 

What happen when AOS dysfunction occurs?

There is asymmetrical movement occur in the lumbar and thoracic spine, SI joint and pubic symphysis via rotation of the spine and/or innominate. This dysfunction may present as

 

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