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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pic coutsey: Wikipedia.org

 

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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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?

 

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

 

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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Gluteal Amnesia and selecting the most effective interventions

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

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

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

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

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

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

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

kinetic chain, gluteus maximmus, eric dalton

Coutrsey : Ericdalton

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

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

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

 

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Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lumbar pain during flexion movement  is one of the commonest symptoms that we all face in our routine practice. There are a number of clinical reasoning processes, which need to be considered.

Much of the literature focuses on the changes in intra-discal pressure associated with spinal flexion. Which indicate that spinal flexion pain is associated with increased disc strain.  In order to strengthen the hypothesis of disc related flexion pain the clinician needs to establish other components of discogenic characteristics to support the hypothesis.

Here are some few things to remember when patient come with lower back pain.

  1. Observe everything, from entering into our examination room, starting with the client rising from a chair.
  2. History – link injury mechanisms, pain mechanisms with specific activities and past exercise regimens. Is there any “red flags” appear or not .
  3. Perform provocative tests – what loads, postures and motions exacerbate, what are relieving factors and what are aggravating factors? This needs to be address.
  4. Perform functional screens and tests – Are there perturbed postural, motion and motor patterns?
  5. If the clinical picture is complex and beyond your comfort zone, develop a referral relationship with a competent corrective exercise specialist.

It is not a matter of client performing an exercise – it is a matter of the client performing the exercise with perfection.

Observation Point:

  • Look for a dysfunctional movement pattern
  • Not able to hip hinge properly.
  • Allow the lower lumbar spine to flex forward.
  • Look for the patient get up from their seat
  • Do they difficulty to maintain neutral spine or bend forward into flexion as they arise?
  • Do they have pain while getting up from chair?
  • In the treatment room, watch them take off their shoes.
  • Ask patient to pick object from floor and observe behavior pattern of movement.
  • Look for fear or uncertainty at the prospect of bending forward.

Physical examination :

This is the main part one should find out what exact pathology it is.

  • Positive straight leg raise. Often you’ll see more subtle findings than in classic sciatica. They may experience more tightness in the back of the leg on one side or the other. They may experience buttock pain. I prefer the sitting straight leg raise. If needed, add foot dorsiflexion, have the patient bend forward, and/or add a Valsalva maneuver.
  • One of Comerford’s tests for flexion control is called the waiter’s bow. Briefly teach the patient to bend forward while maintaining the spine in neutral. Stand to the side and watch them do this. Do they do it well or do they lose neutral? For tactile feedback, place your index finger horizontally on the sacrum, and the other hand’s index finger just above, across the L5 spinous process. Now have the patient bend forward using the waiter’s bow. Do your fingers separate? Recheck between L5 and L4. If your fingers are separating, the patient’s lumbar spine in moving into flexion. It means that even when they are trying to, they cannot control flexion. See pictures below.

  • Palpate the interspace for tenderness. Place the patient prone with a pillow under their abdomen, so the lumbar spine is in slight flexion. Apply deep digital pressure to the interspinous spaces and the inferior spinous process, pushing simultaneously posterior to anterior and inferior to superior. I start with L5-S1 and work upward to at least L3-4. Is the interspace tender? Ask them to rate the tenderness on a 1-3 scale: 1-mild, 2-moderate or 3-severe. (I used to think this was the ideal test, but it is not always positive, even in those I know have flexion intolerance. Maybe it represents increased inflammation in those with flexion intolerance.)
  • Repeated end-range loading of extension This can be done prone or standing. Does this relieve or centralize their pain?
  • If they are not in acute pain, you can do repeated end-range loading of flexion, either from standing or in a long sit posture. Ask them to slump forward. Does this aggravate their pain; does this elicit increased buttock or leg pain, or sensory changes?
  • Palpate the lower lumbar paraspinal muscles. In disc-related pain, a discrete area will often feel atrophied, often unilaterally. There is often a divot, a hole, a small area of atrophy, at the level of the disc injury. As chiropractors, we are much more used to getting information on the restricted side, rather than the side that is moving too much.

 Unlock the mystery of pain

  • Treatment of flexion-intolerant pain is primarily self-care. Yes, your soft-tissue work and mobilizations can help, but self-care is primary and essential. There is no magic you can do that will override what the patient is doing 24/7. You have to teach them to move differently to solve flexion-intolerant pain. According toStuart McGill, “The first step in any exercise progression is to remove the cause of the pain, namely the perturbed motion and motor patterns.”9
  • There are two components of self-care. First, have them quit doing stupid stuff that is reinjuring them over and over. Totally stop the sit-ups and crunches. They cannot do yoga-style prolonged flexion. Pilates is not much effective as it often uses too much uncontrolled flexion. Don’t assume the patient knows this; they likely don’t. If they are sitting too much and for too long, help them figure out how to change that habit via frequent breaks and/or by utilizing a standing workstation.
  • Second, train them to move differently.
  • Yes, they need to strengthen their inhibited core muscles, but they need start with these simple movements, done precisely.

References

  1. Yin-gang Zhang, Tuan-mao Guo, Xiong Guo, Shi-xun Wu. Clinical diagnosis for discogenic low back pain.Int J Biol Sci, 2009;5(7):647-658.
  2. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain.Spine, 1996;21(23):2763-2769.
  3. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.Spine, 1993;19(2):165-172.
  4. O’Sullivan P, Twomey L, Allison G, et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain.Aust J Physio, 1997;43:91-98.
  5. MacDonald D, Moseley GL, Hodges PW. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms.Spine, 2010 Apr 1;35(7):818-24.
  6. Gibbons SGT, Comerford MJ. Strength versus stability. Part 1: Concept and terms.Orthopaedic Division Review. March / April: 2001:21-27.
  7. Liebenson C. “Flexion Intolerant Back” (10-minute video). Toronto, Ontario, 2011; filmed and edited by Phillip Snell.
  8. McGill S. “Designing Back Exercise: From Rehabilitation to Enhancing Performance.” (Guide to training the flexion-intolerant back.)

 

Courtsey : http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56837

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