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.


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:


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.


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.


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.


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 .



  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).



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.




  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.

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

To Read More Register Now

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


Register to access full text……………..

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.


Register to gain full access of this article…………….

What is Resisted isometric movements?

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

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

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

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

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

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

Steps to perform Resisted Isometric Movements:

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

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

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

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

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


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

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


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


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

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



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


Hunh back, Rounded shoulder

How to fix Poor Posture?

We hear it all the time…”Keep your shoulders back! Stand straight!  Posture has become an ever present issue within healthcare circles but why exactly is posture so important? As renowned Doctor of Science Vladimir Janda explains,

“Human movement and function requires a balance of muscle length and strength between opposing muscles surrounding a joint.”


Poor posture results in  muscle imbalance at a joint, in which opposing muscles (the agonist and the antagonist) on opposite sides of a joint provide differing amounts of tension, due to muscle weakness or tightness. Muscle imbalances can then result in abnormal stresses applied to the joint.


While a muscle imbalance might not directly be a source of pain, many musculoskeletal pain syndromes are a result of chronic muscle imbalances. One musculoskeletal pain syndrome often diagnosed within the medical community is called upper cross syndrome.

Upper cross syndrome is characterized by forward head posture, increased thoracic kyphosis (rounded back), excessive mid-upper cervical spine extension, and scapular protraction (forward shoulders).

This results in tight upper cervical extensors and anterior thoracic muscles, as well as weakened (elongated) deep neck flexors and scapular muscles.
Tight muscles can impact joint movements in a variety of ways. Moreover, tight muscles tend to adapt  a consistently shortened position. Conversely, elongated muscles become weak when they are lengthened  their optimal length. Every muscle has an optimal length in which it can produce the most tension (force). The amount of crossbridging between the myosin (thick) and actin (thin) filaments is directly correlated with the amount of tension the muscle can produce. Therefore, an elongated muscle does not have as much overlap between myosin and actin filaments so it cannot produce as much active muscle force. Overtime period of time, these muscle imbalances of tight and weak muscles can lead to abnormal movement patterns, movement dysfunctions, and ultimately predispose your body to a host of other potential issues.

We found that when patient came with neck pain or shoulder you should check out the below muscles box which can help you in your assessment.

Via Dr. Dan Kirages

References :

  • Biondi, David M. “Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies.” Current Science Inc Current Pain and Headache Reports 5.4 (2001): 361-68.
  • Bullock, Michael P., Nadine E. Foster, and Chris C. Wright. “Shoulder Impingement: The Effect of Sitting Posture on Shoulder Pain and Range of Motion.” Manual Therapy 10.1 (2005): 28-37.
  • Chiu, Tai-Wing. “The Efficacy of Exercise for Patients with Chronic Neck Pain.” Spine 30.1 (2005): 1-7.
  • “What Is Muscle Imbalance.” Muscle Imbalance Syndromes RSS. N.p., n.d. Web. 19 Aug. 2015.

Cervicogenic Headache : What’s the Evidencebase treatment?

How many of your patients with neck pain suffer from headaches as well, or vice-versa? Cervicogenic headaches are characterized by unilateral headache radiating from the posterior to anterior head, unilateral upper cervical pain and facet “locking,” which is often aggravated by sustained neck positions. 

For cervicogenic headache patients, modalities such as TENS, cryotherapy, or low-level laser therapy can be helpful. Spinal manipulative therapy has been shown effective for cervicogenic headache patients in several studies. Other manual therapies such as instrument-assisted soft tissue mobilization and kinesiological taping can be helpful adjuncts.

Therapeutic exercise including muscle stretching and specific strengthening exercises can help address muscle imbalances seen in cervicogenic headaches. Several studies have shown that cervical strengthening exercises with  elastic resistance can help reduce headache and neck pain symptom.

In summary, management of cervicogenic headaches begins with an accurate diagnosis.  A multi-modal approach including Thera-Band exercises, modalities and manual therapies can help to reduce  symptoms of cervicogenic  headache.

Cervicogenic headaches: An evidence-led approach to clinical management.  

  2011 Int J Sports Phys Ther. 6(3):254-266.