Hamstring strain due to Glute max late firing : Part 1

What is Synergistic dominance ?

 

It is a self-serving substitution system that allows us to carry on life even though parts of our structure . It may be slowly breaking down and decompensating.

A typical synergistic pattern often exists in runners with a unilaterally tight/hypertonic iliopsoas that is reciprocally inhibiting the ipsilateral gluteus maximus. The hamstrings and adductor magnus (synergists in hip extension) are over active to help the weakened gluteus maximus in hip extension efforts.

This pattern is one of the primary causes of hamstring pulls and is initiated by the late firing of the weakened gluteals during hip extension, especially during activities that include running.

Arthrokinetic Dysfunction :

Synergistic dominance eventually end up with Arthrokinetic Dysfunction .which is the result of prolonged alterations of

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What can be the different diagnosis?

Stay tune with us for next part…….

 

Guideline for Rotator cuff rehabilitation

There are many school of thoughts for RC rehabilitation, here we try to make you easy understanding how to approach . While assessing the rotator cuff in person .

when patient come to us after rotator cuff repair surgery we need to fully understand his daily activities affecting their ability to their normal life. Here there are few keys that need to be consider…….

Key consideration factors in Rotator Cuff Rehab :

• age of the patient,
• activity level,
• injury to affected shoulder,
• response to previous treatment,
• imaging and what were the findings,
• past medical history,
• joint status (hypermobile or hypomobile),
• what they think is going on in their shoulder,
• most importantly is the ultimate goal of the client.

 

Plan for treatment……..

what do we do for people presenting some form of shoulder pain? There are many different answers but for the purpose of this, we will keep it simple that will help restore
pain free ROM, strength, and slowly return them back to their functional level.

Control on the shoulder pain :

We want to get the shoulder joint moving through self-ROM activities. We prefered patient to go for foam roll their thoracic spine and Latismus dorsi muscles to achieve overhead shoulder mobility. We will work on external rotation ROM at 45 degrees and 90 degrees of abduction.

Following this exercise we prefer to work on shoulder flexion AAROM in supine position, once gradually ROM restore we’d prefer kinetic chain activation exercise.

For strengthening,we like to begin with isometric activities to help with pain control.

 

When to start  higher level strengthening programme:

Once you achieve all criteria for advanced training we would like to start strengthening activities, we add isotonic strength training with  theraband  : full can, sidelying external rotation, prone horizontal abduction, prone extension and prone full can. There are Many studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities.

There are  evidance, we like to add program in our routine protocol but will change the weights, sets and reps depending on Patient tolerance during exercise.

We rarely have patients perform 3 sets of 10 repetitions so the goal of the exercise needs to be fully understood in order to prescribe it correctly.

Advanced strengthening :

Once an adequate base of strength is achieved , we will add another level of strengthening programme depending upon patient’s requirement. We also focus on proprioceptive exercise once adequate strength achieved.

For athlete , Plyometric strength training is incorporated to allow the athlete to produce a force and power in his sports activities. which will hopefully help them in their return to their sport. This may include chest press, overhead throws, and rotational throws etc…

Pull ups, push-ups, bench pressing and overhead pressing are also added to make sure the athlete is strong in multiple planes to performing his sports.

Finally,The key is knowing the ultimate goal of the athlete .there are many factors that need to be considered when returning a patient back to their highest functional level when they have a  cuff injury.

This post was my attempt at outlining a very general guideline for an athlete or non athletic poplution with a rotator cuff issue and what my thought process may be.

Remember, listen to their issues…they may just tell you what program is best for them!

Any question!!!!!!!

 

image courtesy: I.pinimg.com

Supraspinatus tendonitis : Guide to treatment

The supraspinatus is usually injured because of heavy repeated demands placed on it ,such as carrying a briefcase, laptop computer, purse, or baby carrier. It is often impinged under the acromiom due to tight pectoralis and tight subscapularis muscles.

The supraspinatus has a small superior shear component, but its main function is compression because
of the horizontal orientation of the muscle fi bers, thus, it opposes the upward superior shear action of the deltoid.

The impingement cycle is a continuum that can begin anywhere in the sequence and can cause a vicious succession.

supraspinatus from proximal to distal with forward elevation. The primary point of contact on the bursal side is at  the supraspinatus insertion throughout forward elevation. The subacromialbursa facilitates this motion and contact. It is a unique anatomic arrangement that exposes the soft tissues to wear and degeneration as the arm is elevated and rotated during range of motion of the shoulder. Furthermore, the impingement may be accelerated by any anatomic architectural changes in the acromion or acromioclavicular joint that reduce the volume of the subacromial space.  

The long head of the biceps and tendons of the rotator cuff pass through the subacromial space; these include the supraspinatus, infraspinatus, and teres minor muscles, which insert onto the greater tuberosity of the humerus. The subscapularis muscle inserts onto the lesser tuberosity. The rotator interval is created between the subscapularis and
supraspinatus tendons. All four rotator cuff tendons interlace with each other over the humeral head before inserting. This continuity allows a functional interaction of the rotator cuff.

What should you do ?

The patient will complain of posterosuperior shoulder pain. You do asses the shoulder in the first 20-30˚ of abduction. Movement beyond that is the action of

the middle deltoid, which will be painful to a resisted test above 30˚ of abduction. Also, the fibers of the supraspinatus tendon can be impinged where it runs under the acromiom process, which can cause chronic pain .

 

Treatment:

Start with the basic shoulder protocol. Concentrate on scapula muscle balance exercise. You do release the pectoralis major and minor, subclavius, upper trapezius, middle deltoid, and subscapularis. Muscular balance is essential in shoulder rehabilitation.

It is necessary to balance and release all of the muscles perticularly the pectoralis minor and subscapularis, to properly treat this condition. The enhancement between upper trapezius and lower trapezius will help to relieve pain. Most of the time while doing retraction ,patient does elevation with retraction. We should observe the movemtn pattern and break it. Concentrate on serratus activity because it is responsible for upward rotation movement.

Next follow the specific protocol for the supraspinatus including myofascial release, trigger point work, and Eccentric exercise for tendon load is also helpful.

Reassess and repeat the protocol until the client is pain-free.

To find out more on supraspinatus ……..

 

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.

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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

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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

 

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