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Diagnosis and treatment ofMovement dysfunction
SyndromesPrepared byMohamed Abu Bakr PT OPD Annex
Sabeer Kanhirathodi PT OPD Annex
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Introduction
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Most of chronic musculoskeletalpain/chronic injuries in the spine
lower extremity and upper
extremity are caused or
perpetuated by muscle
imbalances/weaknesses in thecore musculature
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Individuals with a weak core
substitute/compensate during
dynamic functional movementsleading to overuse/chronic
injuries both upper and lowerextremity
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Definitions:
Function: Integrated proprioceptively
enriched mulidirectional movement
vs unidimentional, low proprioception, all three
planes
All functional exercises are triplanar (even
walking) appears unidirectional but need other
planes to stabilize (frontal & transverse).All functional movements required
acceleration, deceleration & dynamic
stabilization (typically concentrate in concentric
and acceleration in rehab)
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Cont.
Functional Strength - ability neuromuscular
system to produce dynamic eccentric
concentric and dynamic isometricstabilization contraction during all
functional movement patterns
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Cont.
Neuromuscular efficiency: the ability of
your entire kinetic chain to work as an
integrated functional movementThis will provide optimal dynamic stabilization
at right joint, right time, right plane of
movement
most athletes can produce the force but cannot
stabilize or control eccentrically thus increasing
stresses in different plane of movement and in
different joints (compensation)
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Biomechanics
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ActiveSubsystem( muscles )
PassiveSubsystem
ControlSubsystem
neural
The Stabilizing Subsystems
Self Locking Mechanism
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Kinetic Chain
When it works efficiently:
optimal control
distribute force appropriately
optimal efficiency during all movements
impact absorption/ground reaction forces
no excessive compressive transitory shear forcein kinetic chain
dynamic joint stabilization
neuromuscular control
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Patho-Kinesiological Model
Any change of the delicate balance of the 3
Stabilizing Subsystems will cause a Patho-
kinesiological Model or injuryExample: articular dysfunction with change
length tension ratio etc..
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Example: Pelvo-Occular reflex
(Janda) Cervical spine weak: during running fatigue
head will go into extension, thus to see
straight in front of you the pelvis tipsanteriorly
This changes length tension ratios of the
lower extremity, become less efficient, mayend up with hamstring injury
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Basic Concept of Stabilization -
Performance Paradigm
Stretch/shortening cycle (natural visco-
elastic properties of muscles)
The more efficient every single movement
through Dynamic Functional Pattern the
more efficient force can be created and/or
absorbed .
efficiency: less wasted movements
Example walking
Every single movement we do is the
performance paradigm
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Basic Concepts of Stabilization -
Continuum of Function
Must do movements and exercises in adynamic systematic program
Movements are not isolated unidirectional
Practically take the patient or athlete frommovement thinking to pattern thinking .the
challenging position they can control in afunctional pattern and progress them fromthere
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Paradigm Shift: NO longer
looking to improve strength in
one muscle but improvement inmultidirectional neuromuscular
efficiency (firing patterns inentire kinetic chain with complex
motor patterns). The body doesn't
just fire one muscle at a time for
movement
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Stabilization - Open and Closed
Chain
Functional movement is a succession ofopening and closing the chain
Functional activity is therefore a timing
issue within opening and closing the chain
Need core stability to stabilize transition
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Functional pattern: Three Phases
Pronation - deceleration/force reduction
phase (where most injuries occur due to
lack of eccentric control)For rehabilitation need to look at this phase
what muscles are decelerating and stabilizing to
create a rehabilitation program
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Three Phases Cont.
Supination - acceleration phase/force
production phase (most % time)
Coupling - stabilization, ability to change
from pronation to supination phase
(stronger the core more efficient
achievement thus less time spend in thisphase prevent overuse injuries)
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Patho-Kinesiological Diagnosis
Look Feel Analyze
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Anterior
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Foot
Compensation 1
Foot Turned Out
Possible Over Active Muscles
Tenser Fascia Laeta
Biceps Femoris
Lat.Gastronemius
Soleus
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Probable Underactive Muscles Med Gastrocnemius. Med.Hamstring
Gluteus Medius /Maxi. Gracilis. Popliteus
Flexibility Ex(SMR &Static.
Calf stretch
Hamstring stretch
Standing TFL stretch
Strengthening Exs;
Single Leg Balance
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Example Flexibility Ex(SMR
&Static
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Example Strengthening Ex
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Knee
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Moves Inward
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Probable Over Active Muscles
Adductor Complex
Bicep Femoris(Short Head)
TFL
Vas- Lateralis
Lat Gastrocnemius
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Probable Underactive Muscles
Gluteus Medius /Max
VMO
Med Hamstring
Med Gastrocnemius
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Flexibility Exs (SMR & Static ) Add &TFL
Add Stretch
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Example Strengthening Ex
Ball Bridge Lateral Tube Walking
Ball Squat W/Abduction
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Moves Outward
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Probable Over Active Muscles
Piriformis
Biceps Femoris
TFL
Gluteus Menimus/Medius
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Probable Underactive Muscles
Add Complex
Med Hamstring
Gluteus Max
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Example Flexibility Ex
(SMR &Static) Piriformis Stretch
Hamstring Stretch
TFL Stretch
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Example Strengthening Ex
Ball squat Ball Bridge
W/Add
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Posterior
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Foot
Foot flattens
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Probable Over Active Muscles
Peroneals
Lat.gastrocnemius
Bicep Femoris(Short head)
TFL
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Probable Underactive Muscles
Ante Tibialis
Post Tibialis
Med Gastrocnemius Gluteus Medius
Flexibility Exs (SMR & Static )
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Flexibility Ex s (SMR & Static )
Hamstring Stretch
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Example Strengthening Ex
Single Leg Balance Reach
Single Leg Medial
Calf raise
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Heel Rises
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Probable Over Active Muscles
Soleus
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Example Flexibility Ex
(SMR &Static) Soleus Stretch
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Example Strengthening Ex
Reach
Single Leg squat
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Check Point
L-P-H-C
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Asymmetrical Weight Shift
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Probable Over Active Muscles
Add Complex
TFL (Same Side)
Piriformis
Biceps Femoris
Glutius Medius(Same side)
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Probable Underactive Muscles
Gluteus Medius (Same side)
Add Complex (Opposite Side)
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Example Flexibility Ex
(SMR &Static) Adductor Stretch
TFL Stretch (Same Side)
&
Piriformis Stretch
Hamstring Stretch (Opposite Side)
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Example Strengthening Ex
Gluteus Medius(Same Side)
Add Complex (Opposite Side)
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Lateral View
Lateral ( L P H C )
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Lateral ( LP- HC )
Compensation 1
Excessive forward leanProbable overactive muscles : soleus
GastrocnemiusHip flexor complex
Abdominal complex ( Rectus
abdominus , External oblique ) .
Probable hypoactive muscles : Anterior
TibialisGluteus MaximusErector
Spinae .
Flexibility exs ( SMR & Static ) : Calf
StretchHip Flexor StretchBall
Abdominal stretch
Strengthening exs : Ball Squat
Stretching Exs ( SMR &Static) Calf Hip flex
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Stretching Ex s ( SMR &Static) Calf Hip flex
- Abdominal
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Strengthening Exs : Ball Squats
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Lateral ( LPHC ) Cont
Compensation 2
Low Back ArchesProbable overactive muscles : Hip Flexor
ComplexErector SpinaeLatissimus
Dorsi
Probable hypoactive muscles : Gluteus
MaximusHamstringsIntrinsic CoreStabilizers ( transversus abdominus
multifidusinternal oblique
transversospinalispelvic floor muscles )
Flexibility Exs ( SMR&Static ) : Hip Flexor
StretchLatissimus Dorsi StretchErectorSpinae Stretch
Strengthening Exs : Ball SquatFloor
BridgeBall Bridge
Stretching Exs (SMR & Static ) Latissimus &
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Stretching Ex s (SMR & Static ) Latissimus &
Erector Spinae
Strengthening Exs ( Ball Squat , Floor
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g g ( q ,
Bridge & Ball Bridge )
Lateral (L P H C ) Cont
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Lateral (LPHC ) Cont.
Compensation 3
Low Back Rounds
Probable Overactive Muscles :
HamstringsAdductor Magnus
Rectus AbdonimusExternal
Obliques .
Probable Hypoactive Muscles :
Gluteus MaximusErector Spinae
Intrinsic Core Stabilizers .
Flexibility Exs (SMR & Static ) :
Hamstring StretchAdductor
Magnus StretchBall Abdominal
Stretch
Strengthening Exs : Floor Cobra
Ball CobraBall Back Extension
Stretching Exs (SMR &Static) HamstringsAdd
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g ( ) g
MagnusBall Abdominal Stretch
Strengthening Exs Floor CobraBall CobraBall Back
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Extension
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Lateral Upper Body
Lateral Upper Body
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Lateral Upper Body
Compensation 1
Arms Fall ForwardProbable Overactive Muscles :
Latissimus DorsiPectoralisMajor / Minor - Teres MajorCoracobrachialis .
Probable Hypoactive Muscles :Mid / Lower TrapeziusRhomboidsRotator CuffPosterior Deltoid .
Flexibility Exs ( SMR& Static) :Latissimus StretchPectoralisStretchSMR Thoracic Spine .
Strengthening Exs : Floor CobraBall CobraSquat To Row .
Stretching Exs (SMR & Static) Latissimus Pec SMR T Spine
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Stretching Ex s (SMR & Static) Latissimus Pec SMR T Spine
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Strengthening Exs Floor CobraBall Cobra
Squat To Row
Lateral Upper Body Cont.
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pp y
Compensation 2
Forward Head
Probable overactive Muscles: Levator
Scapula - Sternocleidomastoid
Scalenes .
Probable Hypoactive Muscles : Deep
Cervical Flexores .
Flexibility Exs ( SMR &Static ) :
Levator Scapula StretchSCM
StretchScalenes Stretch .Strengthening Exs : Tuck Chin ,
Keeping Head in Neutral Position
during All Exs
Stretching Exs ( SMR & Static) Levator ScapulaSCM - Scalenes
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Strengthening Exs Deep Cervical Flexores
Lateral Upper Body
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Lateral Upper Body
Compensation 3
Shoulder ElevationProbable overactive Muscles : Upper
TrapeziusSCMLevator Scapula
.
Probable Hypoactive Muscles : Mid /Lower TrapeziusRhomboids
Rotator Cuff
Flexibility Exs (SMR & Static ) :
Upper Trapezius StretchSCMStretchLevator Scapula Stretch .
Strengthening Exs : Floor Cobra
Ball Cobra
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LPH Complex
Stabilization system(Core System) if notfunctioning
optimally will endneuromuscularsubstituting to utilizethe strength power
and neuromuscularcontrol in the rest ofthe body
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LPH Complex Cont.
Otherwise will get neuromuscular inhibition and
CNS will shut down the prime movers if LPH not
stabilized, thus minimizing the kinetic chain.
Muscle strength is not enough to achieve the
normal efficient functional movements e.g most
athletes have functional strength and control in
prime movers but not stabilization in spine(C,T,L)
C S bili i F i
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Core Stabilization Function
Remember 29 muscles connected to each
side of your pelvis. These work
synergistically with entire kinetic chain
Primary Function: maintain center of
gravity over base of support during dynamic
movement (Example gait cycle - loss of
balance)
Stability & control offers more
biomechanically correct position for
function of entire core and lower extremity
muscles
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Muscle Fatigue
Ability to generate or maintain decreaseability to require correct muscle
Ability to maintain dynamic muscle force
decreases
Example: fatigue running unable to stabilize
core: get shear forces and compressive
forces in lumbar spine:- reason why see many LB comp0laints and
hamstring strains (actually attributed to weak
abdominals)
Transverse Abdominis and
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Internal Obliques during
functional activityOnly 2 abdominal muscles that attach to the L-spine
Attach thorocolumbar facia (L-spine) via lateral
rafia attach to transverse processes
Thus when they fire they create a tension affect
inherent STABILITY in L-Spine
These prevent rotational and transnational forces
If these muscles are not stabilized the Psoas is used
to create a compressive force and mimic stability
Transverse Abdominis and
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Transverse Abdominis and
Internal Obliques during
functional activity Actually creates anterior shear force and
extension force
Leading to reciprocal inhibition of lowerabdominals
The pelvis will tip forward
Leading to reciprocal inhibition of thegluteals (extensor mechanism)
This can cause hip internal rotation knee
overuse syndromes etc..
Basic Concepts of Core
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p
Stabilization - Planes of
MovementWith any movement all three planes areworking together concurrently
Even through you may be moving in one plane
the other 2 planes must stabilize and workeccentrically for stabilization
Example: Posterior Pelvic tilt laying on the
floor changes the relationship, thus whenstanding he relationship again changes the
exercises have not been functional and will not
work in the altered position. Again it
changes when you lift one leg etc.
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Muscle Function Cont.
Stabilization: Prone to develop weakness
and inhibition, less activated during most
movement patterns, fatigue easily, primarilyfunction during stabilization movement
Peroneals, anterior tibialis, posterior tibilalis,
VMO, gluteus medius/maximus, transverse
abdominis, int/ext obliques, serratus anterior,
rhomboids, middle, lower trap, deep neck
flexors, longus capitus
Sheringtons Law of Reciprocal
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Sherington s Law of Reciprocal
Inhibition: tight muscles will inhibit its
functional antagonist. Example:ThePsoas (most athletes) inhibit functional
antagonists - deep abdominal wall,
transverse abdomnis, internal oblique,multifidi, deep transverse spinalis,
gluteus maximus. Thus the stabilization
and coupling phase will be reducesincreasing the movement phase and
muscle forces and decreasing efficiency.
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Muscle Functions - Abdomen:
Internal Oblique -
Decelerate transverse
plane rotation, frontal
plane and transverse
plane stability
Rectus Abdominis:
Decelerate Extension,create pelvic stability
during dynamic
movement
External oblique -
Decelerate transverse
plane rotation some
extension
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Muscle Functions - Abdomen:
Transverse Abdominis - The most important
abdominal muscle (attach to lumbar spine)
contract in feed forward mechanismcontract 1st before any other muscle
(research following back pain the transervse
abdominis is inhibited, thus when you move
for example an arm, your transverse
abdomnis does not stabilize thus the psoas
fires - compensation
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Muscle Function: Lumbar Spine
Superficial Erector Spinae: Extends Spinecreates extension force and shear force at
L4-S1 works with the Psoas (when Psoas
tight it facilitates erector spinae furtherincreasing the shear forces and inhibit
posterior muscles)
Deep erector Spine: Posterior translationand L4-S1, if weak or inhibited cannot
counterinteract affect or superficial erector
and get shearing forces
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Muscle Function: Lumbar Spine
Transversal Spinalis Muscles (Rotatories,
Multifidi, interspinalis, interanversari)
Provide intrisic, intrasegmental stabilityproprioceptive feedback since constantly
under compression and torsinal forces. If
these muscles are inhibited, loose the ability
to create dynamic stabilization from lack of
proprioceptive feedback.
SPINE MUSCLES
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Heads
1.Iliocastalis
LumborumThoracis
Cervicis
2.Longissimus
ThoracisCervicis
Capitis
3.Spinalis
Thoracis
Cervicis
Capitis
ANATOMY
Macro anatomy. Multifidus
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ac o a ato y. u t dus
(MF) is the largest and most
medial of the lumbar paraspinal
muscles. Each muscle consistsof five separate, overlapping
bands that form a triangle as
these bands run caudo laterally
from the midline.
Insertion: spinous process at
caudal tip.
Origin: transverse process at
mamillary process, iliac crest,and sacrum (polysegmental: 2-4
segments below insertion at
spinous process).
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Joint Dysfunction Example
Joint dysfunction example: lock up SI joint
plant and twist, Multifitus is inhibited
complains for low back pain, the erectorswill fire and attempt to stabilize (therefore a
muscle is doing opposite of its muscle
function). This is why pain syndromes are
perpetuated
Muscle Function: Hip
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Muscle Function: Hip
Musculature: Gluteus Maximus: decelerate hip flexion,
decelerate hip internal rotation during heel
strike. Psoas tightness creates inhibition of gluteus
maximus (anterior tilt)
Muscle Function: HipM l t
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Musculature:
If the gluteus maximus is inhibited or weakwill loose ability to control femur, femur
will internally rotate:
Microtruma can be created on medial capsule
of knee
Patellar tendonitis non-contact ACL injuries
posterior tibial tendonitis, plantar facitis
Hamstrings become tight in an attempt to createposterior stability of the pelvis (instead of
focusing on hamstring flexibility, work on
pelvic stabilization and flexibility will return)
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Lack of flexibility is often a
phenomenon created by lack ofstability in an attempt to stabilize
the body for activity
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Gluteus Maximus and minimus
are inhibited in most athletes due
to tight psoas (Summer, 1988).
Muscle Function: Hip
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musculature
Gluteus medius: provides frontal planestabilization, decelerate femoral adduction, assistin deceleration femoral internal rotation (duringclosed chain activity)
VB/BB with patellar tendonitis originate from tightpsoas and lack of core strength
attempting to get triple extension during jumping, couldntextend through hip using gluteus maxiumus due to thigh psoas
Thus they hyperextend at the knee and drive the inferior pole
of the patella into the fat pad creating the inflammatoryresponse (Summer, 1988).
Muscle Function: Hip
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Muscle Function: Hip
Musculature Adductors: frontal plane stability
Hip External Rotator: Create Pelvo-femoral
rhythmGemeli, Obturators, Piriformis help to
decelerate femur, If inhibited they become
extremely tight because they are attempting to
stabilize
Often we attempt to stretch these muscle where
a core program would eliminate the origin of
the problem
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Force Couples
Saggital Plane: Psoas and superficial erector
spinae which create and extension force and
shear force int he lumbar spinecounteracted by transverse abdominis, internal
oblique multifidi, transversal spinalis groups,
gluteus maximums
Trend - most athletes the psoas and erector
overdeveloped inhibiting stabilizers
Frontal Plane: Gluteus Medius,
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ipsilateral adductor and
contralateral quadratus lumborum
Example: weak gluteaus medius will causecontralateral LBP, into knee pain on
opposite side
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Force Couples Cont.
Transverse Plane Left Rotation - left
internal oblique, left adductor, right external
oblique and right external rotators of the hipExample: synergistic dominance Weak
transverse abdominis and internal oblique the
same side adductor will become tight and
inhibit gluteus medius causing anterior kneepain, posteior tib tendonitis etc. Down the
kinetic chain.
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Principle of Core Training:
Postural Alignment: Primary Function -
misalignment will produce predictable
stresses, pain, chronic injuries, jointdysfunction
Common Postural Dysfunction
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Common Postural Dysfunction Lower Cross System: Anterior Tilt in most
athletes increase lumbar lordosis tight muscles movement groups muscles erector spinae
superifical psoas, upper rectus, rectus femoris,sartorius, tensor facia latae, adductors
Weaker muscle/inhibited - stabilizing group deepabdominal wall transverse abdominis, internal obliquemultifidus, deep erector spinae biceps femoris gluteausmedius/maximus
muscle that decelerate femur are inhibited
Joint dysfunction illiosacral rotations, S1, L-spine, Tib-fib joint, subtalar joint
Injury patterns: plantar faciiitis, patellar tendonis,posterior tib tendonitis
Common Postural Dysfunction
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Common Postural Dysfunction
Upper Cross System: Rounded Back/ForwardHead
Tight muscles pec major/minor, lat, upper trap,levator, subscap, teres major, sternocleidomastoid,erectus capitus, and scalenes
Weak muscle: rhomboids, middle.lwr trap, teresminor , infraspinatus, posterior deltoid, deep neckflexors
Joint dysfunction: Upper cervical, cervicalthroricis, SC joint problems (which can causerotator cuff problems)
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Common Postural Dysfunction
Pronation Distortion Syndrome: Flat feet
tight muscles: peroneals, lateral gastroc IT
band, PsoasWeak muscles: intrinsic foot muscles,
anterior/post tibialis, VMO, bicep femoris,
piriformis, glut medius
muscles that control pronation are inhibited andweak causing overuse injuries
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Pronation Distortion Syndrome
Joint dysfunction: 1st MTB joint (EX: cause
anterior shoulder pain: stub toe and then
lack normal passive extension, shortenstride, internal rotation of the femur,
causing pain up the core chain into
movements of the extremity). The same
can occur with sprain ankle and lock tibo-
talar joint
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Through the kinetic chain,muscle problems can lead to joint
problems and joint problems canlead to muscle problems.
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Postural Considerations
Many individuals have well developed
muscle strength and power to perform
specific activities, however few havedeveloped stabilization systems optimally
Optimal alignment of each segment in the
kinetic chain is a cornerstone for allfunctional rehabilitation programs
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Postural Considerations
If one segment in the kinetic chains is out of
alignment, then predictable patterns of
dysfunction will develop in other parts ofthe kinetic chain
A weak core is a fundamental problem o
inefficient movement which leads to
injury
Low Back Pain & Rehabilitations
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Transerve abdominis, multifitus, internal oblique
are inhibited in someone with LBP Decrease in stabilization endurance can perform
the movement until fatigue. OK for 3x20 but oncestart functional movement revert back to previous
positions Increase interdisck pressure and compressive
forces with lack of pelvic stabilization
Think about athletes that lift and then have LBP
cause may not be stabilizing and can perpetuatemuscle imbalances creating hamstring dysfunctionetc.
Address through unstable ball training
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Hiltons Law: any muscle thatcrosses that joint will be
inhibited. With injuries theindividual will have a lot of joint
substitutions and muscle
imbalances
Muscle Imbalances
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An optimal functioning core helps to prevent
the development of muscle imbalancesOptimal core neuromuscular efficiency allows
for the maintenance of the normal:
Length-tension relationships
Force-couple relationships
The path of instantaneous center of rotation
A strong stable core can improve
neuromuscular efficiency throughout the kineticchain by improving dynamic postural control
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Assessment of the Core:
Core strength can be assessed using the
straight leg lowering test
Core power can be assessed using theoverhead medicine ball throw
Core muscle endurance can be assessed
using back extension
Core Stabilization to create
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Core Stabilization to create
program: Sport Demand Analysis
Demands of the individual sport
Demands of the athlete (player vs non-player)Demands of the position/specialty
G id li f C i i
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Guidelines for Core Training:
A comprehensive core stabilization training
program should:
progress from slow to fastsimple to complex
known to unknown
low force to high force
static to dynamic
G id li f T i i
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Guidelines for core Training
Exercises should be safe, challenging, stress
multiple planes, incorporate a multi-sensory
environment, and activity specific Put each athlete in the most challenging
environment they can control.
G id li f T i i
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Guidelines for core Training
Change program often
ROM
Loading (Cable, tubing etc.)Plane of motion
Body position, floor standing, one leg etc..)
speed of movementduration
frequency
Abd i l B i K
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Abdominal Bracing Key
Transverse Abdominis - draw belly-button
into spine Make self skinny)
Pelvis tilts work rectus abdominisavoid anchoring feet so as not to activate hip
flexors or psoas
Full ROM]Exercise profession
Stretch Antagonists between sets to prevent
inhibition (if working abdominal stretch hip
flexors between sets)
E i P i
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Exercise Progression
Stage I: Learning Abdominal Bracing
maintain stability
change duration and frequency Stage II
Educate on daily use
Increase ROM and instability mainly uniplanar,change body position
E i P i
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Exercise Progression
Stage III: instability
Maximize the use of functional activities with
abdominal bracing
Maximize multidirectional patterns and
unstable positions
Maximize frequency and duration changes
Stage IV:
Challenge the individual with high intensity
strength and power
H d
SPINE MUSCLES
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Heads
1.Iliocastalis
LumborumThoracis
Cervicis
2.Longissimus
ThoracisCervicis
Capitis
3.Spinalis
Thoracis
CervicisCapitis
ANATOMYMacro anatomy. Multifidus
(MF) is the largest and most
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(MF) is the largest and most
medial of the lumbar paraspinal
muscles. Each muscle consistsof five separate, overlapping
bands that form a triangle as
these bands run caudo laterally
from the midline.
Insertion: spinous process at
caudal tip.
Origin: transverse process at
mamillary process, iliac crest,and sacrum (polysegmental: 2-4
segments below insertion at
spinous process).
Functional Anatomy Lumbo-
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y
pelvic-hip Complex
The LPH complex musculature produces
force, reduces force, and stabilizes the
kinetic chain during functional movements The core functions primarily to maintain
dynamic postural control by keeping the
center of gravity over our base of support
during dynamic movements.
P l i Gi dl
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Pelvic Girdle
29 muscles
attach to the
core (LPHcomplex
unilaterally)
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