Category Archives: Lower Extremity

Foot, Ankle, Knee, and Hip

The Effect of Stretching Alone

19 Sunday Feb 2017

Posted by in Ankle, Flexibility, Uncategorized

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Stretching is a common principle used to improve resistance during activity, when feeling a sensation of tightness, or to lengthen a short muscle.  But how much is enough?  We as practitioners prescribe 30 second holds, repeat 30 second holds, or to hold for up to 2 minutes.  Some studies show a benefit from holding for those lengths of time.  But that is in the short-term.

What is the effect in the long term?

A randomized controlled study by Youdas et al. assessed the effects of a closed-kinetic chain stretch of the ankle dorsiflexors over a 6 week period.  They compared a control group versus 3 experimental groups (30 second hold, 1 minute hold, and 2 minute holds).  This was conducted 1 time a day.  Sixty to seventy-two hours later after the final day of the 6 week period the ankle range of motion was taken again.  They found no significant change in the range of motion between the experimental and the control groups.

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So what does that mean?

As practitioners, we know that stretching will help with lengthening a muscle.  We prescribe the stretch for multiple times a day and hope that is followed.  But in reality, how many people are able to set time aside (three, four, or five times a day) to complete the prescribed home exercise program as well as remember to complete in their busy schedules.

Should we be prescribing stretching multiple times a day or should we prescribe the stretch 1 time a day but combine it with functional activities that make use of that range gained from the stretching?  Example, complete a calf stretch for 60 seconds and then teach them to walk with a longer step length and trying to keep the heel down a little longer during terminal stance to use that increased motion.

We can know and educate individuals the right thing to do for themselves with stretching or exercise but the carryover comes from incorporating it into everyday life.

 

Reference:

Youdas JW, Krause DA, Egan KS, Therneau TM, Laskowski ER. The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion. J Orthop Sports Phys Ther. 2003; 33(7):408-417.

Types of Muscle Tightness

06 Sunday Mar 2016

Posted by in Flexibility, Lower Extremity

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Rectus femoris length

When assessing the flexibility of a muscle, it is easy to just look at the muscle itself.  But it is important to look at the response of joint(s) that the muscle acts on.

First we must understand that there are different types of tightness.  There is a short muscle and there is a stiff muscle.

  • Short muscle – a muscle that has a reduction of sarcomeres limiting its length
  • Stiff muscle – a muscle that has appropriate length but maintains increased tension through that range

Now that this is addressed we can look further at assessing muscle flexibility.  There can be different presentations of a short/stiff muscle.  The 6 categories will be presented with assessment of the rectus femoris (RF) muscle.  This muscle is most easily assessed in the prone position and by flexing the knee; normal motion will be between 115-125 degrees knee flexion.

  • Normal – the knee is able to be flexed >115 degrees without compensatory pelvic motion
  • Short RF- knee flexion is <115 degrees without compensatory pelvic motion.  The anterior abdominal muscles have normal tension.
  • Stiff RF – the knee is flexed >115 degrees with sensation of tension in the muscle and compensatory anterior pelvic tilt and when the pelvis is stabilized to prevent tilting the knee continues to its initial range.
  • Stiff + Short RF – the knee is flexed >115 degrees with anterior pelvic tilt and when the pelvis is stabilized knee flexion <115 degrees.  This shows that the abdominal muscles have less stiffness than RF but there is also a component of shortening of the RF.
  • Stiff RF with automatic stabilization – passive knee flexion will cause compensatory anterior pelvic tilt.  Active knee flexion does not have an associated anterior pelvic tilt.  This is a sign that the body will maintain stability due to the stiffness of the RF.
  • Deficient counter stabilization – the initial motion of knee flexion will cause a posterior pelvic tilt (the opposite anticipated reaction).  Motor control issue.

Being able to differentiate between these 6 categories when assessing flexibility of a muscle will help appropriately guide treatment.  I encourage you to use this when assess muscle flexibility for other areas of the body; such as the latissimus dorsi, hamstrings, pecs, gastrocs, etc.

 

Resisted Upright Side Stepping or Resisted Squat Side Stepping. That is the Question.

21 Monday Sep 2015

Posted by in Hip, Lower Extremity, Patellofemoral Pain

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The Journal of Orthopedic and Sports Physical Therapy published an article in the September 2015 issue about the differences between completed a resisted upright side step verses a resisted squat side step.  I found this article to be very interesting because I use these two exercises in my practice when trying to help patients who have hip abduction weakness and present with a hip drop or a trunk lean while walking.  Here is the synopsis of the article and hopefully it helps you achieve your goals.

The researchers studied the muscle activation of the gluteus maximus, gluteus medius, and tensor fascia lata (TFL).  The subjects were given a theraband and wrapped it around their ankles with about 110% tension in the band.  Pt participant was then instructed to start with their feet 12 inches apart and side step to about 24 inches apart  and back to 12 inches apart for 8 steps in each direction.  The two posture used were upright standing without flexion in the hips and knees and the subject’s preferred squatting position.

The researchers found that the greatest muscle activations of the gluteus maximus, gluteus medius, and TFL were found in the stance limb compared to the moving limb, the muscle activation of the TFL was less and the gluteus muslces was greater in the squatting position compared to the upright position, and their was more hip abduction excursion in the stance limb compared to the moving limb.

So when completing these exercise, it is important to consider which muscles you want to focus on and the functional goal that you would like to improve upon.

Berry JW, Lee TS, Foley HD, Lewis CL. Resisted side stepping: the effect of posture on hip abductor muscle activation. Phys Ther. September 2015; 45(9):675-682.

Nerve Mobilizations to Treat Anterior Knee Pain?

25 Saturday Jul 2015

Posted by in Nerves, Patellofemoral Pain

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PatellofemoralPain_SM

People suffering from anterior knee pain/patellofemoral pain usually will benefit from proper strengthening, stretching, and alignment during functional activities.  But some people tend to continue to have discomfort at their knee even when those deficits are corrected.  There has been recent research showing that people suffering from anterior knee pain can also be from mechanosensitivity/hypersensitivity.

Continued irritation and swelling tends to promote blood vessel and nerve proliferation.  Also, nerves can eventually adhere to structures at the knee such as the bone, ligament, fascia, etc. from injury.  Treatment for improving neurodynamics at the femoral nerve, and associated medial and lateral patellar branches, around the knee can prove beneficial.

Two studies by Lin et al. and Huang et al. examined the use of the Femoral Slump Test to assess neurotension at the knee and other predictors that an individual might benefit from nerve tensioning/gliding.

Individuals that may benefit from this type of treatment are people with symptoms at the anterior knee at the knee cap during stair climbing, squatting, kneeling, or sitting for a long time.  They will also be positive for more than 2 of these clinical tests:

Clarke’s sign – The individual is supine with their knee extended and pressure is applied to the knee cap as they contract their quadriceps.  The test is positive if there is a reproduction of their symptoms.

Waldron Test – The individual is supine with their knee slightly flexed and pressure is applied to the knee cap the knee is progressively flexed more.  The test is positive if there is a reproduction of their pain or crepitus.

Active Patellar Grind Test – The individual sits with their knee at 90 degrees and the examiner palpates the knee cap as the individual straightens their knee.  The test is positive if crepitus is felt during the motion.

Patellar Compression Test – The individual is supine with their knee extended.  Their knee cap is compressed and shifted superiorly.  The test is positive is there is a reproduction of their symptoms.

Assessment and completion of nerve tensioning/gliding is not appropriate if the individual’s anterior knee pain is due to other pathologies such as meniscus, ligaments, etc.

The Femoral Slump Test should be completed with measurement of hip flexion bilaterally when symptoms come on.

The test is positive if the individual’s anterior knee pain is reproduced and then reduced or eliminated with extension of the head.  If the individual has a history of lower back pain and there is a difference of hip flexion during the slump (>3 degrees on the affected side) then the prediction that nerve tensioning/gliding is greatly improved.

The authors of the article completed tensioning of the nerve by taking the hip into extension in the Femoral Slump Test position until the individual’s anterior knee pain is  first felt  then held for 2 seconds.  This was completed 10 times for 3 sets.  Improvement of knee pain was seen on the first session in 50% of subjects and in all subjects by the sixth session.

References:

  1. Lin PL, Shih YF, Chen WY, Ma HL. Neurodynamic response to the femoral slump test in patients with anterior knee pain syndrome. J Ortho Phys Ther. May 2014; 44(5):350-357.
  2. Huang BY, Shih YF, Chen WY, Ma HL. Predictors for identifying patients with patellofemoral pain syndrome responding to femoral nerve mobilization. Arch Phys Med Rehabil. 2015; 96:920-927.

An Ambiguous Dorsal-Lateral Foot Pain Case Study

07 Saturday Feb 2015

Posted by in Ankle

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Image-4-2

I found this case study interesting and beneficial when considering treatment for painful ankles.  The article presents with very vague symptoms with limited objective measures eliciting abnormal findings.  I thought this article showed the importance of assessing joint end feels during standard range of motion assessments.

This article examined a 54 year old male software engineer with chief complaint of right dorsal lateral foot pain described as an ache at the dorsal joint line of the cuboid and fourth metatarsal.  Symptoms were of insidious onset about 3 years ago when hiking.  He noticed the symptoms about 1 hour into the hiking and quickly resolved when he stopped hiking.  The subject continued to hike about 1x/week.  He then noticed an increase in symptoms about 1 year ago due to unknown cause with the symptoms occurring about 10 minutes into walking and took about 30 minutes to resolve.  The subject presented with negative x-rays and MRI’s and did not respond to orthotics or electrical stimulation; all provided by a podiatrist.

Physical therapy examination revealed:

1. Tenderness to the dorsal base of the fourth metatarsal

2. Manual Muscle tests of foot, ankle, knee, and hip to be 5/5

3. Negative ligament stress tests for anterior and posterior talo-fibular ligaments, calcaneal-fibular ligament, deltoid ligaments, anterior interosseus, and medial and lateral subtalar ligaments

4. Gait assessment did not show any obvious deviations or pain

5. Posture did not present with any asymmetries or faults

6. All range of motions were normal at the hip, knee,, ankle, and midfoot but the subject had pain at the end range of nonweight bearing plantar flexion and mid-range weight bearing dorsiflexion.  He also presented with a more firm capsular end feel at end range of nonweight bearing dorsiflexion.

7. Joint mobility of talocrural, tarsal, and metatarsal articulations showed decreased posterior and lateral glides with restricted firm capsular end feel of the talus on the tibia.  All others were normal.

Treatment consisted of a high-velocity low amplitude traction joint mobilization of the talocrural joint causing an audible cavitation and a palpable distraction of the joint.  This improved accessory motion of the talocrural joint, the end feel of joint mobility, and the elimination of pain during range of motion assessment.

The subject was given a home exercise program that consisted of wearing shoes as much as possible during the first week to allow the fourth metatarsal to heal and two exercises: completing squats with proper alignment and then a lunge with the affected leg forward and slight internal rotation of the tibia to promote external rotation of the talus both for 10 repetitions 4-5 times a day.

The subject’s symptoms improved and he was able to return to his activities.

Callan B. Clinical reasoning and multi-modal treatment for dorsal-lateral foot pain: a case study. Ortho Pract. 2015; 27(1): 26-31.

The Importance of Ankle Range of Motion for Knee Pain

25 Thursday Dec 2014

Posted by in Ankle, Patellofemoral Pain, Uncategorized

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Knee Mechanics

It is important to assess multiple areas of the body when treating knee pain and more specifically patellofemoral pain (PFP).  One major contributor to knee pain is hip strength.  Good hip strength is important to aid in appropriate knee alignment and mechanics.  Another important contributor is foot alignment.  Many individuals with PFP exhibit over pronation of the midfoot/flatfoot.  This will cause the lower leg to turn in and place more stress of the patella on the femur.

But one aspect that I believe needs more consideration is ankle range of motion; specifically ankle dorsiflexion range of motion.

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A study by Rabin et al. found that individuals with PFP had less than optimal movement during a lateral step down test and exhibited significantly less ankle dorsiflexion range of motion (4.7° in weight bearing and 5.3° in non-weight bearing) than individuals with optimal movement and without pain.  More specifically, they found that men had a significant difference of 8.5° with non-weight bearing measurements.

Could this limitation in ankle dorsiflexion range of motion be a precursor for maladaptive behavior found at the foot, knee, and hip?  The researchers proposed that the limitation in ankle dorsiflexion will cause less forward movement of the tibia when walking, running, and going up and down stairs.  This may cause excessive compensatory movement of the midfoot, such as over pronation, in order to get the needed range to complete those tasks.  This will also cause the knee to turn and place more force of the patella on the femur.

A recommendation to improve ankle dorsiflexion for people with PFP is to complete a stretch against the wall or counter holding for 30 seconds and completing 2 times.  Use this stretch (presented in the video below) until knee discomfort subsides and a lunge position with the knee on the floor can be tolerated.

A more dynamic lunge stretch (shown in the video below) can be completed to further improve ankle dorsiflexion range of motion.  Hold this position for 5 seconds and complete 20 times.  These motions should be completed on both sides even of you do not have discomfort at both legs.

 

Limitations of the study:

  1. It was not possible to determine whether limited ankle dorsiflexion range of motion is the cause of abnormal lower quality of movement or a consequence.
  2. The findings are limited to visual assessment of the quality of movement during the lateral step down test.
  3. The subgroup analysis was not preplanned and they completed the analysis only after observing abnormal tendencies in the subjects.
  4. The examiners were not completely blinded to the quality of movement assessment.
  5. The sample of subjects were younger than other populations of people with patellofemoral pain so results should not be generalized to all individuals.

Reference: Rabin A, Kozol Z, Moran U, Efergan A, Geffen Y, Finestone AS. Factors associated with visually assessed quality of movement during a lateral step-down test among individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2014; 44(12): 937-946.

Patellofemoral Joint Pain Rehabilitation: How to Strengthen the Quadriceps and Limiting Joint Stress

20 Thursday Nov 2014

Posted by in Patellofemoral Pain

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knee_patella

Patellofemoral Joint (PFJ) pain is the most common knee problem and accounts for 25% of all knee injuries and is more common in females than males.(1)  Conservative treatments may consist of stretching, strengthening, balance exercises, and working on biomechanics.  But the individual dealing with the injury or the person treating that individual should consider appropriate interventions while avoiding exacerbation of symptoms and injury.

In this article, I will focus on quadriceps muscle strengthening as one aspect of conservative treatment.  Usually during a pain flareup an individual will more likely avoid certain positions leading to weakness of the leg muscles and eventually poor mechanics.  To avoid the progressive weakening of the quadriceps muscles it is important to complete exercises.  What exercises would be okay to complete without overly stressing the patellofemoral joint?

An article I just reviewed assessed the force of the patella on the femur during common rehabilitation exercises for the knee; the squat and seated knee extension.  The study showed that completing a squat from 0-45 degrees of knee flexion and seated knee extension from 90-45 degrees of knee flexion would be optimal to avoid overly stressing the PFJ.  Complete 10 repetitions 2-3 times a day and increase 5 repetitions every two weeks until you are able to complete 25 repetitions of each exercise without pain.  These exercises should be incorporated into the initial stages of PFJ rehabilitation until an individual is able to go up and down stairs or transitioning from sitting to standing from a chair without pain.  Then these exercises may be progressed to the full ranges.

Squats from 0-45 Degrees of Knee Flexion

Seated Knee Extension from 90-45 Degrees of Knee Flexion

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1. Sueki D, Brechter J. Orthopedic Rehabilitation Clinical Advisor. Maryland Heights, MO: Mosby, Inc.; 2010.

(Click the link below for access to the article)

Patellofemoral Joint Stress During Weight-Bearing and Non-Weight-Bearing Quadriceps Exercises

Purpose: To compare patellofemoral joint stress among weight bearing and nonweight bearing quadriceps exercises.

Methods: They assessed the knee musculature of squatting exercise (weight bearing) and two nonweight bearing knee extension exercises (seated knee extensions with variable resistance and seated knee extensions with constant resistance).  They used 10 subjects (5 male and 5 female) who did not have knee pain.

Results: They found that the squat produced significantly higher PFJ stress from 90-60 degrees knee flexion.  They reported that the two nonweight bearing exercises had significantly higher stresses from 30-0 degrees knee flexion.  And more specifically that the variable resistance produced significantly less stress than the constant resistance.

Limitations: There were 5 limitations with this study.  First, they only studied healthy individuals so the results should not be generalized to other populations.  They did not compare the exercises to a gold standard.  The researchers did not control the trunk position during the squat exercise which could change the muscle activity of the quadriceps.  They considered the segmental accelerations during the nonweight bearing exercises negligible and were not factored into the calculations.  Finally, they only studied concentric muscle activation and recommended that future studies assess eccentric muscle contractions.

Which Gluteus Medius and Maximus Exercises are Most Beneficial?

13 Thursday Nov 2014

Posted by in Hip

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Weakness in the gluteus muscles tends to be a cornerstone of many injuries in the lower extremities and back.  It is important to strengthen those muscles to take pressure off of joints and correct an individual’s biomechanics.  But what exercises are the most efficient in accomplishing this?

I found an article that assessed 12 common gluteus maximus and medius muscle exercises.  They wanted to figure out which exercise(s) will be most beneficial for those muscles.  They found that the Side-lying Hip Abduction Exercise activated the gluteus medius muscle the most out of all the other exercises and the Single Limb Squat and Single Limb Deadlift activated the gluteus maximus more than all other exercises.

Side-lying Hip Abduction

(Keep the knee extended and the hip in a neutral position while lifting the leg up to about 30 degrees)

Side-lying hip abduction

 

Single Limb Squat

(Stand on one leg and slowly lower by bending the hip, knee, and ankle until the opposite hand touches the foot that is on the ground without rotating the trunk)

Single Limb Squat

Single Limb Deadlift

(Stand on one leg with the knee flexed to 30 degrees and slowly flex the hip and trunk until the opposite hand touches the foot on the ground without rotating the trunk)

Single Leg Deadlift

(Click the link below for access to the article)

Gluteal Muscle Activation During Common Therapeutic Exercises

Study Design: Experimental Laboratory Study

Purpose:  To quantify and compare gluteal muscle activation across 12 common strengthening exercises of varying difficulty.

Methods: The study consisted of examining 21 subjects who were physically active (exercising 60 minutes at least 3 times a week), no pain, no history of ACL injury, and no history of lower extremity surgery.  They used surface EMG electrodes to measure gluteus medius and gluteus maximus muscle activation.  The subjects completed 8 repetitions of each of the 12 exercises in random order.  The exercises consisted of 3 non-weight bearing (clams with hips at 30 degrees, clams with hips at 60 degrees, and side-lying hip abductions) and 9 weight bearing (single limb squats, single limb deadlifts, lateral band walks, forward lunges, side lunges, lunges with rotation, forward hops, side hops, and hops with rotation).

Results:  The Side-lying Hip Abduction Exercise produced significantly greater gluteus medius activation than the 2 clam exercises, lunges, and hip exercises.  The Single Limb Squats and Single Limb Deadlifts had significantly greater gluteus maximus activation (also, equal activation of gluteus medius and gluteus maximus muscles) than the lateral band walks, clams, and hop exercises.

Limitations: Some of the limitations consisted of the potential for cross-talk between muscles during the surface EMG assessment.  Also, the dynamic movement of the hop exercises could cause EMG activity variability.  Finally, there were no non-weight bearing hip extension exercises assessed.

The Importance of the Hamstring Muscle and the Quadriceps to Hamstring Ratio: What Does that Mean?

09 Tuesday Sep 2014

Posted by in Hamstrings to Quadriceps Ratio, Noncontact sports

≈ 2 Comments

knee_hamstring_symptom01

I came across a small research project I was working on a number of months ago and wanted to further tackle the topic.  I came to the conclusion that I have not been paying as much attention to hamstrings strength for patient athletes and patients who participate in sports recreationally.  The hamstrings are quite a dynamic muscle, having to control movements of the hip while simultaneously regulating the knee.  You can also consider the types of muscle contractions that the hamstrings must complete; isotonic, isometric, and isokinetic.  And if you want to look deeper into the issue, by creating stability of the hip it also will effect the stability up the chain to the pelvis and lower back.

In order to do this the hamstrings must fight and create harmony between itself and the strength of the hip flexors and the overly strong quadriceps muscles.  If you are an individual who routinely attends the gym or if not you are not and know someone who does ask them or yourself what leg exercises they complete.  Most likely you will get a lot of exercises that primarily focus on quadriceps strengthening; such as the knee extension machine, leg press, squats, box jumps, etc.  (The reason I say primarily is because even though some of those exercises work all the muscles of the leg, people do them improperly which tends to place excessive load on the quadriceps.)  Then consider the hamstrings exercises you will see people participate in at the gym; mostly the hamstring curl machine and the dead lift.  The scales will tip in the quadriceps exercise direction.  The major problem with the hamstring curl machine is that it only works the distal aspect of the hamstrings at the knee.  The dead lift allows you to work the proximal aspect of the hamstrings but the issue is that in doing so you overload the lower back.  Both exercises are also not functional in nature.  When I use the word functional I use it in reference the hamstrings needing to work at the hip and the knee at the same time while completing the different types of muscle contractions mentioned earlier.  Think of it as primarily a motor control problem.  Just because you do exercises to strengthen the hip flexors, then exercises for quadriceps, and so forth for hamstrings and glutes the timing of these muscles to fire and work together is not being worked on.  So how do we go about improving this and what is an appropriate strength ratio for the quadriceps to hamstrings to provide optimal performance and prevent future injury?

I will be working on answering the strength ratio question today and focus on concentric and eccentric muscle contractions.  I have reviewed two articles that helped to tackle this question.  The article by Kim and Hong studied 82 male and female Division III intercollegiate basketball and soccer players and concluded that a ratio of hamstrings to quadriceps should be greater than 60% (The maximum strength of the hamstrings should be about 60% of the maximum strength of the quadriceps).  They suggested to work more on landing techniques rather than jumping techniques to better improve the hamstrings as opposed to the quadriceps.

But I wanted to further delve into the correlations that two muscle groups have when compared with the different muscle contractions (eccentric vs. concentric).  So I reviewed another article by Hadzic et al. who studied 95 male professional volleyball players and found that the higher level volleyball players had significantly higher hamstrings strength (both eccentric and concentric) and hamstrings eccentric strength to quadriceps concentric strength ratios (A ratio of >70% hamstrings to quadriceps for the international level compared to 62-66% for the two lower level professional volleyball player groups).

(Click on the links below for access to the articles)

Hamstring to Quadriceps Strength Ratio and Noncontact Leg Injuries: A Prospective Study

The Isokinetic Strength Profile of Quadriceps and Hamstrings in Elite Volleyball Players

Kim D and Hong J. Hamstring to quadriceps strength ratio and noncontact leg injuries: a prospective study. Isokinect Exerc Sci. 2011; 19:1-6.

Purpose: To investigate the relationship of hamstrings and quadriceps strength imbalance with overall non-contact lower extremity injuries.

Methods: Subjects were 82 male and female intercollegiate Division III basketball and soccer players.  The subjects were followed over a full season.  Participants completed 3 maximal muscle contractions for knee flexion and extension at 60 degrees/second over a 90 degree range.  The researchers only counted injuries that were non-contact in nature.

Results: There were 35 right leg injuries and 32 left leg injuries during the season.  The researchers showed that participants with a hamstrings to quadriceps ratio of greater than 60% had significantly less of injury to their legs than subjects with less than 60%.

Limitations: The researchers believed that only using one testing parameter (60 degrees/second) could have limited the results. Also they thought that only assessing concentric strength could have limited their findings.

Hadzic V, Sattler T, Markovic G, Veselko M, Dervisevic E. The isokinetic strength profile of quadriceps and hamstrings in elite volleyball players. Isokinet Exerc Sci. 2010; 18: 31-37.

Purpose: To establish the concentric and eccentric strength of quadriceps and hamstrings in healthy male volleyball players varying in age, playing position, and playing level.  To evaluate the differences in concentric and eccentric peak torques, various strength ratios and bilateral leg strength asymmetries among different playing positions, age groups, and playing levels.  To assess bilateral concentric and eccentric strength asymmetry of quadriceps and hamstrings.

Methods: The researchers were able to examine 95 male national Division I and II professional volleyball players from Slovenia.  Quadriceps and hamstrings muscles were tested eccentrically and concentrically using an isokinetic dynamometer.  They measured subjects at 60 degrees per second at a range of 60 degrees for 30 degrees to 90 degrees knee flexion.  The subjects completed 5 consecutive maximal concentric quadriceps and hamstrings contractions and 5 maximal eccentric quadriceps and hamstrings contractions with 60 second breaks in between.  Participants had a short 5 minute warm-up on a bike and stretching.

Results: The higher level international volleyball players had significantly higher peak torque on the right for eccentric hamstrings strength when compared to the Division I and II players and significantly stronger right concentric hamstrings strength when compared to the Division II players.  They also found that international players (73%) had higher eccentric hamstrings strength to concentric quadriceps strength when compared to Division I professional players (66%) and significantly higher values when compared to Division II professional players (62%).

Limitations: The researchers did not determine any limitations with their study but conclusions can be drawn based on personal findings.

Plantar Fasciitis: Some Biomechanics While Walking

31 Sunday Aug 2014

Posted by in Plantar Fasciitis

≈ 1 Comment

Plantar_Fasciitis11Plantar Fasciitis is a difficult diagnosis to treat in some cases.  Individuals may have symptoms for a couple weeks to many many years.  One of the many reasons that this diagnosis is difficult to treat is due to a limited understanding of the root cause.  It is essential to differentiate between symptoms due to damage to the plantar fascia, harm to a muscle or tendon in the foot, bruising of the heel bone, or irritation of the nerve or nerves.

Once you make that discrimination and you are leaning heavily toward plantar fasciitis you may start to delve deeper into its cause.  Is it caused by a bone spur at the bottom of the heel or abnormal kinematics of the foot?  Usually an x-ray can help to find a bone spur in the heel that may be causing damage to the fascia.  After you rule out a spur you can focus on the mechanics of the foot.

There is some argument in the literature about the biomechanical effects the foot and ankle play into stressing the plantar fascia.  I reviewed an article that compared the kinematics of the foot and ankle in people with and without plantar fasciitis.  They showed that people with plantar fasciitis had greater total rearfoot eversion, greater forefoot plantar flexion at initial contact, greater total sagittal plane forefoot motion, greater maximum first toe dorsiflexion (this places increased strain on the plantar fascia due to the Windlass Mechanism), and decreased vertical Ground Reaction Force during propulsion.  The researchers stated that the decrease in Ground Reaction Force and the increase in forefoot plantar flexion are compensatory mechanisms due to pain. (An increase in arch angle of ~1 degree can cause an increase in plantar fascia tension from 0.4 to 0.7 of body weight during stance) They believe that the increased rearfoot eversion and first toe dorsiflexion are more of a factor in plantar fasciitis.  Focusing on these two factors may help people relieve their symptoms.  But what can be done to improve these abnormalities?  Towel Curls with the toes are great for strengthening to toes (mainly the first toe) but is that enough to strengthen the toes for walking or is there a more aggressive way to strengthen functionally?  Also, can you combine that with improving the strength of the muscles that invert the foot?  My thought would be to complete a toe raise on the edge of a step or leg press machine with the heel all the way down and only raising to neutral  while focusing on inverting the foot.  Make sure to not go past neutral as to not stress the plantar fascia and keep the knee slightly bent to avoid using the gastrocnemius muscle.  Complete barefoot to help engage the toes for stability.

The image below is an example of the exercise.  The only corrections I would suggest is standing closer to the edge of the step as to not have so much of the ball of the foot on the step and work on toe strengthening.  Also, make sure to keep the knee bent throughout the exercise.

plantar-fasciitis-achilles-stretch

(Click the link below for access to the article)

Multisegment Foot Kinematics and Ground Reaction Forces during Gait of Individuals with Plantar Fasciitis

Purpose: To determine whether healthy and plantar fasciitis feet are different with respect to multi-segment foot kinematics (rearfoot motion, medial forefoot motion, first metatarsal phalangeal joint motion) and Ground Reaction Force.

Methods: The researchers studied 44 subjects (22 healthy individuals and 22 with plantar fasciitis).  Inclusion criteria for the experimental group consisted of being 30-60 years old, heel pain with palpation at insertion point, persistent symptoms for at least 3 months, and 5 episodes of first-step pain in last month.  Exclusion criteria consisted of a history of local steroid injection within last 2 months, arthritis, local traumatic injury, a body mass index greater than 35, and a high foot arch.  The researchers placed markers on the foot and lower leg and assessed the movement of those points while the subjects walked at a predetermined speed.

Results: Both groups did not differ in age, height, body mass, standing arch ratio, foot posture index, and 6-meter preferred walking speed.

  • Rearfoot: There were significantly greater total rearfoot eversion with the plantar fasciitis group which means greater overall pronation motion.  They found that both groups had the same movement pattern during gait; inversion at initial contact, eversion at mid-stance, and inversion at push-off.
  • Medial Forefoot: Significantly greater total plantar-dorsiflexion motion with the medial forefoot being in a more plantar flexed position at initial contact.
  • First Metatarsal Phalangeal Joint (First Toe): Significantly greater maximum dorsiflexion/extension of this joint in late stance.
  • Ground Reaction Force: Significantly less peak vertical forces at propulsion with walking speed controlled.

Limitations: This was a case-controlled study and is retrospective by nature so it does not show that these deviations in the foot actually cause plantar fasciitis.  Also, the researchers mentioned that the skin markers may be able to move during walking due to gliding of tissues on bony prominences but was able to stay relatively stable overall.