Core stability : Local as well as Global musculature

What is core ?

It is a muscular box with the abdominals in the front, paraspinals and gluteals in the rear, the diaphragm at the top,  and the pelvic floor and hip girdle musculature at the bottom. Within the “box” multiple muscles help to stabilize the
spine and pelvis as well as transmit forces through the kinetic chain.

Defination of core stability ?

The core through three subsystems, the passive subsystem, active subsystem, and the neural control subsystem. It was proposed that these subsystems were highly integrated and optimization of all three were necessary for normal biomechanics of the spine. If any one of these subsystems became impaired it could lead to instability of the spinal column predisposing an individual to injury, dysfunction, and pain.

Generally, core stability comprises the lumbopelvic-hip complex and is the capacity to maintain equilibrium of the vertebral column within its physiologic limits by reducing displacement from perturbations and maintaining structural integrity.

Objective of core strengthening:

Strength is defined as the maximum force that a muscle or muscle group can generate at a specific velocity. Power refers to the amount of force that can be generated in a given time period 10 repeatation maximum squat is a measure of absolute strength, where the force of a racket on a ball a  given velocity determines the amount of power that is Imparted to the ball.

The crucial question is how core strength relates to each of these situations.


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Plantar fasciitis : proximal instability

Plantar fasciitis (PF) is the most common foot condition treated by health care providers.This painful condition can cause impairment of activity and disability.Patients usually report pain after palpation of the proximal insertion of the plantar fascia and plantar medial heel, and the pain is most noticeable when patients begin walking after a period of inactivity.Clinicians have used many approaches for treating pain and enhancing function.

Weakness in the gluteus region causes instability to your trunk that leads to excessive motion . The gluteus medius and gluteus minimus muscles control the sagittal plane motion of the body.

An anterior pelvic tilt : tight back extensors, weak glutes and hamstrings, weak abdominals, and tight hip flexors all commonly caused by prolonged sitting which activate reciprocal inhibition .  This anterior pelvic tilt leads to your body weight being shifted forward causing higher stress on Achilles’ tendon and plantar fascia.

A muscular imbalance cause a shift of weight but it also causes a misalignment the kinetic chain. Weak glutes and tight hip flexors lead to an internal rotation of the femur, causes a valgus position of the knee, tibial internal rotation, and ultimately excessive pronation which may loads the plantar fascia.

So include gluteus assessment in your plantar fascia patient . It’s not always plantar fasciitis is due to hip problem , but 70% cases it affect. Proper clinical reasoning give you better idea.


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A sophisticated approach for plantar fasciitis


Plantar Fascia is a broad, dense band originating from anterior aspect of calcaneal tuberosity in form of 3 bands namely medial, central and lateral and inserting after dividing into 5 digital bands at metatarsophalangeal joints. It plays vital role in supporting the arch of foot and act as a shock absorber.

Plantar Fasciitis is an inflammation of the plantar fascia specifically at the insertion on calcaneal tuberosity.
• This commonly occurs due to overuse injury among those who stand for prolonged period of time or whose activities require maximal plantar flexion of ankle and simultaneous dorsiflexion of MTP joints and long distance runners.
• It even happens among individuals who have pes planus, tight tendo-achilles, weak foot muscles- tibialis posterior, poor shoe support and obesity or sudden weight gain. This typically can happen in absence of windlass mechanism.


Symptoms & signs:

• Swelling at the insertion site
• Temperature rise and redness
• Tenderness at calcaneal tuberosity
• Heel pain that is worse in the morning with     the first few steps and exacerbate with climbing stairs. At times it becomes difficult to rest the foot on the floor in the morning. With progression, pain may start interfering with activities of daily living.

Biomechanical alterations due to plantar fasciitis :

• Individuals with flat feet or pronated feet are more prone to develop plantar fasciitis.

• Chronic long standing cases of plantar fasciitis disturbs the windlass mechanism and so individuals with normal arch also start losing flexibility and shock absorbing capacity of foot and it results into collapsing of medial longitudinal arch. This ultimately causes flattening of arch and thereby disturbance in metatarsal break.

• Body being a kinematic chain, any alteration at one joint result into alterations/ compensations at other joints.

• Flattening of medial longitudinal arch causes pronation of the foot, which is combination of talocrural dorsiflexion, calcaneal eversion & forefoot abduction. Following this, to have body in one alignment, there results into talar adduction & plantar flexion, compensatory internal rotation of tibia & femur.

• These internal rotatory forces cause positional mal-tracking of patella which causes lateral gliding of patella. The ilio-tibial band, tensor fascia lata & lateral retinaculum gets tight. This results gradual development of patellofemoral dysfunction & thereby knee pain.

• Tight ilio-tibial band, internal rotation of femur causes imbalance of pelvis and causes pelvic-femoral and sacroiliac dysfunction which results into back pain. This may progress to change biomechanics till cervical region and even atlanto occipital joint.

• Thus in a nutshell foot pain can alter entire biomechanical chain- foot pain can result pain in knee, back and even neck.

How to approach ?

• Rest- till pain subsides in acute cases. Avoid prolonged walking, running and jumping.
• Before initiating weight bearing in morning, patient can be asked to move toes in warm water to lessen the pain.
• Cryotherapy can help reduce pain- 5-10minutes massage or ice pack application for 15-20 minutes; 3-4times daily.
• Needling , myofascial release and deep friction massage over the plantar fascia.
• Plantar Fascia stretching- can be done in different positions- patient/ therapist’s hold the heel of the affected foot with one hand and other hand’s fingers pulling the toes of affected foot into extension at MTP joint.

Proactive , plantar fasciitis treatment , massage

Woodstown massage:

• Stretching of the tendoachilles- gastrocnemius and soleus with the help of towel or theraband- ankle dorsiflexion with knee in extension for gastrocnemius and ankle dorsiflexion with knee in flexion for soleus. It should be gentle, slow, static & can be done in long sitting or standing- hold time 30-60 secs, 5 reps, 3 times/day.

• Tight fascia can be released by rolling the fascia over a tennis ball or bottle filled with cold water.

Ahmedabad India , treatment

Podantics podiatry

• Once the flexibility is gained and its painfree, strengthening exercises of calf and intrinsic foot muscles should be started, as this can prevent reoccurrence and can provide muscular support for weakened plantar fascia.

✓ Toe curling/ towel scrunching exercises: strengthens the intrinsic muscles of foot. Patient in sitting position with foot flat on the floor with towel placed underneath. Patient is asked to curl the toes to try to lift & pull the towel off the floor with the heel in contact with the floor throughout the exercise- done for 1-2minutes.

✓ Calf raises –unilateral & bilateral- 3 times/day for 20 rep in each session.

✓ Short foot exercises/ arch lifts- strengthen the muscles that support the medial longitudinal arch. The patient is asked to draw the metatarsal heads towards the calcaneus without flexing the toes or lifting the ball of great toe & foot, heel off the floor. Hold for 5 secs and relax- 1 minute. Initially done by sitting on chair with foot flat on floor and the gradually progressed in standing. It will require good amount of practice to master.


✓ Toe band exercises for toe muscles strengthening- elastic band is wrapped around all 5 toes. It should be fit yet comfortable. Instruction is given to move the toes apart pulling against the band- 3-5secs hold & relax-10-2-times.

✓ Toe squeezes for toe muscles strengthening- small sponges are placed between each toe. Instruction is given to squeeze the sponge with the toes- 3-5secs hold & relax-10-2-times.

✓ Mobilization can be given- talocrural posterior glide, subtalar lateral glide, anterior & posterior glide of 1st tarsometatarsal joint.

✓ Calcaneal taping may help in temporary reducing pain & function by distributing force away from stressed plantar fascia.

✓ Proper foot wear during daily activities and sports provides good support and prevents plantar fasciitis.

✓ Orthotic devices like Insoles can be used which acts as a soft cushion for heel-12-15mm higher than sole or well molded Achilles pad or heel cuffs or medial longitudinal arch support.

With proper care & physiotherapy, plantar fasciitis patients can become painfree and return to normal activities.


Next Friday post will be on how proximal joint dysfunction can cause plantar fasciitis

Stay tune!!!!

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Proactivephysiotherapy, hamstring, assesment, lower limb

Hamstring strain due to Glute max late firing : Part 2


Read part 1 if you have missed…….

What can be the different diagnosis?

1 )Sciatic nerve entrapment
2)Gluteus trigger point
3) Trochetric bursitis
4) Piriformis syndrome

Here we have explained about trochentric bursitis between gluteal nerve affection relationships:

When a patient preset a complaint of pain while lying on one side , the therapist should suspect trochanteric bursitis. However , if the pain frequency is altered in the absence of hip movement, one should suspect superior gluteal nerve problems in SI joint dysfunction.

Inferior gluteal nerve pain is one of the most common incorrectly assessed in pain practices. When usually SI problems the inferior gluteal nerve refers pain into the gluteus maximus. The reason for this , gluteal nerve locates anterior side of sacrum . This irritation is commonly treated as piriformis syndrome. Beating on the piriformis, particularly the muscle belly, will cause even greater irritation of the inferior gluteal nerve.

Frequently, this type of arthrokinetic dysfunction is so intense that it excites alpha and gamma gain in surrounding muscles causing sympathetic spasm and involuntary tightness in all the hip extensors and abductors. The spasm deep into the SI and lumbar joint capsules . This is associate with hip and back muscles. Which become inflamed and are subjected to increased accumulations of waste products at the injured site.

Hence , The brain continues to cover the area with spasmodic tissue to protect sensitive nerve structures. This process only serves to further shorten the lumbopelvic connective tissues which often creating tissue micro-tearing and increased inflammation.

The brain attempts to prevent excessive movement by forming

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A new insight on back pain

In the early 20th century the SI joint was thought to be the main source of law back pain and was the focus of many scientific investigations. But recently two newest theories have been developed.

First, the theory of rotational malalignment known today as the Malalignment Syndrome which includes: SI joint upslip/downslip (superior/inferior shear), sacral torsion (hip anterior/posterior rotation), hip outflare/inflare (lateral/medial rotation), (Schamberger, 2002, 2006). Diagnosis of these syndromes is very straight forward, as is the treatment of each is

Second, the past 15 years, a well-known group of PTs, have been developing a newer theory that is known as the Joint-By-Joint Approach. This theory is based on understanding the primary role of the different major joints.

Of course all joints need a combination of mobility and stability, but interestingly, each joint displays a predominant need for either mobility or stability.

Lets start from the bottom which joint require mobility or stability…..

Ankles – mobility

Knees – stability

Hips – mobility

Lumbar Spine – stability

Thoracic Spine – mobility

Scapulae – stability

Shoulders – mobility

Cervical Spine (C7-C3) – stability

Cervical Spine (C2, C1) – mobility

Our CNS chooses mobility over stability depending on when we move. Another prospective , when a joint which predominantly requires mobility, reaches its mobility barrier ( it may be physiological or pathological), the surrounding joint will give up their stability to accomplish the mobility requirement. This is involuntary survival technique that is controlled by CNS.

How this above phenomenon will work with Hip and Spine lets understand.

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Proactivephysiotherapy, hamstring, assesment, lower limb

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?


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!!!!!!!


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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 .



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.

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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 :


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.

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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.


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