faulty biomechanics of the lower extremities, how a simple biomechanics dysfunction accelerates the...
TRANSCRIPT
Faulty Biomechanics of the Lower Extremities: A presentation of how a simple biomechanical dysfunction accelerates the aging
process. The most effective diagnosis, treatment and prevention.
James Stoxen, D.C. President, Team Doctors Treatment Centers
Discussion of anti- aging issues with lack of care and how the body ages more rapidly with the cascading domino effect of this syndrome. We will discuss the risks and complications of the development of more life threatening diseases, which can manifest from the lack of treatment of inappropriate care to this simple biomechanical dysfunction. The dysfunction is easily treated with the care cycle outlined if caught early, given effective treatment and prevented, the biomarkers affect the aging process.
Faulty Biomechanics of the Lower Extremities Related to Simple Foot
Pronation and its Effects on the Aging Process
By Dr James Stoxen DCPresident
Team Doctors PCChicago
(773) 735-5200Teamdoctors.org
[email protected]@teamdoctors.org
How Common
10,000 -15,000 average steps per day 640 metric tons of stress on the joints
Even subtle faulty biomechanics can easily yield a chronic condition or predispose a patient to serious injury
How common are conditions related to faulty biomechanics of the lower extremities related
to simple foot pronation?
What are the long term effects to the aging process?
The abnormal strain effects the entire kinematic chain effecting all muscles, tendons, ligaments and joints.
Tonic/chronic protective spasm, pain and arthritis
Inactivity due to pain Chronic fatigue Depression “I’m just getting old”
Long term effects of faulty biomechanics of the lower extremities
Chronic Arthritis The most common cause of disability in the
elderly 43 million cases in 1997
Heart Disease Genetic Factors Diet Lack of proper exercise
Simple Foot Pronation
One of the most common examples of faulty biomechanics of the lower extremities is simple foot pronation
Simple Foot pronation causescollapse of the kinematic chain
Pronation of the foot causes a collapse of the kinematic chain causing pain, arthritic changes in multiple joints in the kinematic chain leading to inactivity, fatigue and possible depression. When the foot pronation becomes chronic this condition can lead to chronic fatigue and subsequent heart conditions due to inactivity.
The leading cause ofsimple foot pronation is...
Shoes with weak counters
Improper lacing of shoes
Not lacing shoes at all!
Foot & Ankle Symptoms
Foot and or ankle pain Plantar Fascitis History of a heel spur Shin splints
Knee and Calf
Pain (especially after sitting for long periods)
Crepitus (especially when walking upstairs) Peripatellar pain Calf cramps Poor circulation in calves Cold feet
Hip and Thigh
The legs ache Leg cramps Illiotibial band pain Crepitus in the hip History of hip arthritis pain Tired legs
Lower Back Pain
Insidious lower back pain Lower back pain from a lifting
injury
Chronic Fatigue
Patient is fatigued all the time Negative laboratory work-up All other tests for pathology are
negative
Objective Findings
Orthopedic Tests and Radiographic Findings
Orthopedic FindingsFoot & Calf
Tenderness on deep palpation of Plantar Media Aspect of the Foot
Tenderness on deep palpation of the (lateral aspect) of the Calf
Heel Spur
Knee
(+) Clarks - crepitus on extension of the knee
(+) Waldron’s Chondromalacia
patella radiographic findings
Hip and Thigh
Weak and painful biceps femoris (on deep palpation)
Weak and painful tensor fascia latae (on deep palpation)
(+) Modified Obers Test (TFL)
(+) Nobles Test (TFL)
Hip Muscle testing
Weak & painful gluteus maximus (upon deep palpation)
Hip muscle testing
Weak & painful gluteus minimus and medius
Weak & painful piriformis
Difficulty with internal rotation of the hips
HipOrthopedic Tests
(+) Trendellenburg Test (poor balance)
Difficulty getting up from seated position
(+) Patrick Fabres test
Treatment training tip for weak gluteus medius
Hip Abductor training Restrict Spinal motion Short arch No Hip External
Rotation
10 x 3 (reps x sets)
Lower Back
(+) Hibs (+) Elys Chronic idiopathic
paraspinal muscle spasms
Bilateral or unilateral (SI) flexion fixation subluxation
Herniated disc or discs
Lower Back (Continued)
Anterior Tilted Pelvis Unilateral or Bilateral
Lower Extremity Anatomy Review
Foot – 28 bones– 55 articulations
Joints Ankle Joint
– Bones Tibia Fibula Talus
Mid Tarsal Joint– Bones
Talus Navicular Calcaneus Cuboid
Subtalar Joint– Bones
Talus Calcaneus
– Subtalar Joint Primary Motions
Eversion/Inversion Abduction/Adduction
Lower Extremity Anatomy Review
Mid Tarsal Joint Axis
The mid tarsal joint has 2 axis which function as a unit to allow for triplanar motion around these 2 axis
Mid Tarsal Joint Axis
Oblique Mid Tarsal Joint Axis– Primary Motions– Dorsiflexion Plantarflexion– Abduction Adduction
Longitudinal Midtarsal Joint Axis– Primary Motions– Pure inversion and eversion
Foot pronation occurs at the mid tarsal joint axis
Midtarsal pronation is limited when the cuboid comes in contact with the calcaneus
As long as the calcaneus is not in a valgus position
If the calcaneus is in a valgus position then the entire complex will collapse
The Leading Cause of Simple Foot Pronation
Shoes with weak counters (sides)
Shoes which are tied weak
not tied at all
The Leading Cause of Simple Foot Pronation
The Leading Cause of Simple Foot Pronation
The Leading Cause of Simple Foot Pronation
The Leading Cause of Simple Foot Pronation
The Leading Cause of Simple Foot Pronation
The Leading Cause of Simple Foot Pronation
Key to our Treatment Program
Maintaining the calcaneous in the neutral position is one of the key points to our treatment program. This demands excellent footwear selection with motion control. Use shoes with strong counters both for treatment and prevention purposes
Ligaments that Restrict Foot Pronation
Mid tarsal pronation is restricted by various restraining ligaments of the foot– Ligaments (See Figure)
Long and short Plantar Ligaments
Calcaneonavicular Ligament Bifurcate Ligament
Key to our treatment program
If these ligaments are damaged or chronically stressed they will not assist in limiting pronation. We manipulate the bones of the foot and work on the intrinsic muscles of the foot to increase the natural strength of the arch.– Midtarsal pronation is further limited in excessive
pronation in various stages of the gait cycle by the pronation/supinator cuff muscles
Key to our treatment program
Similar to the premise of treatment of rotator cuff musculature, we find that treatment of tonic protective spastic activity in Phase I and active strengthening of these muscles in Phase II, III and IV is a key component of our treatment program
Calf Muscles
Primary Movers Tibialis anterior– Soleus– Gastrocnemius
Pronator/Supinator Cuff
These muscles can act to prevent excessive pronation and supination of the foot (analogous to the rotator cuff muscles of the shoulder)
Flexor Hallucis Longus (See Figure) Strong plantar flexor
of the ankle joint Weak Sub Talar Joint
supinator
Pronator/Supinator Cuff
Peroneus Longus – Strong Plantar
Flexor of the First ray
– Pronator of the forefoot arouond the Longitudinal Midtarsal Joint Axis
Pronator/Supinator Cuff
Flexor Digitorum Longus (See Figure)– Strong ankle joint
plantar Flexor– Moderate subtalar
joint supinator– Very strong
supinator of the forefoot around the midtarsal joint
Pronator/Supinator Cuff
Extensor Digitorum Longus (See Figure)– Strong plantar flexor
Of the ankle joint– Moderate pronator of
the forefoot
Pronator/Supinator Cuff
Tibialis Anterior (See Figures)– Does not effect the
midtarsal joint axis– Strong supinator
of the forefoot– Slightly weaker
supinator of the subtalar joint
Pronator/Supinator Cuff
Tibialis Posterior
Anatomy of the Leg and Knee
Knee Anatomy– Bones
Tibia Fibula Femur
Knee Joint Motions– Flexion– Extension– Rotation
Muscles which control the knee– Quads
Rectus Femoris Vastus Medialis Vastus Lateralis Intermedius
– Hamstrings Biceps Femoris Semimimbranosis Semitendinosis
– Tensor Fascia Larae - Illiotbial Band (Figures on next slide)
Gluteus Maximus, Medius and Minimus
Muscular Anatomy of the Hip and Lower Back
External Rotators (See Figure)
Adductors
Lower Back Muscles Illiopsoas Extensors Abdominal Muscles
MuscularAnatomy of the 1Hip and Lower Back
Correct the Foot Pronation with Deep Tissue Work to the Intinsic Muscles of
the Foot and Lateral Calf
Pronation Treatment and Prevention takes place when supination is aided by reduced weakness of and increased strength of the intrinsic muscles of the foot (See Figures)
Training Rehab Tip correct through training not through orthodics
Correct the Foot Pronation
Foot Pronation Correction
Treatment Tip Motion Control stabilizing foot wearPick you shoes like you pick your fruit
Foot Pronation Correction
Treatment Tip Alternative shoe
lacing for added counter stability (start under)
Pronator/Supinator Cuff Treatment
Phase I - Passive Treatment: Reduce weakness via deep
tissue work or EMS– Abductor Hallucis– Flexor Hallucis Brevis– Flexor Digitorum
Phase II, III, and IV - Active
Strength Training
– Abductor Hallucis– Flexor Hallucis– Flexor Digitorum Brevis
Pronation, treatment and prevention takes place when supination is aided by reduced weakness and increased strength of the extrinsic supinators of the foot (AKA supinator Cuff Muscles)
Pronator Supinator Chronic Weakness
With chronic pronator supinator cuff weakness the body shifts the weight to other muscles and serious injuries can occur
Calf Training
Training/Rehab demands joint motion in flexion extension be along the metatarsal joint axis
Phase I - Passive Treatment
Phase II, III and IV - Active
Strength Training Reduce weakness via deep
tissue work or EMS– Flexor Hallucis Longus– Flexor Digitorum Longus– Tibialis Posterior
Treatment of the Faulty Biomechanics of the Lower Extremity Related to Simple
Foot Pronation
Pronation Treatment/Training/Rehab Tip
Stretch these muscles– Extensor Hallucis Longus
– Extensor Longus & Brevis
– Tibialis Anterior
During the push off phase of gait, pronation is reduced when the peroneus longus is strengthened to insure that toe off will occur with a stable first, second and third digit. Joint motion is lost and must be regained through manipulation of the joints of the foot.
Improve toe off and Stride Length “Windlass Effect”
Excessive pronation is reduced with the “Windlass Effect”. When the toes dorsiflex, the heel lift draws the plantar fascia around the metatarsal heads which acts to pull the pillars of the longitudinal arch together thus decreasing the fore foot rear foot distance or strengthening the arch. This only happens when the patient steps off with reasonable toe off force.
Pronation CorrectionPhase I - Passive Treatment - Reduce weakness via deep tissue
work or EMS (See Figures)
Peroneus longus
Phase II, III and IV - Active Strength Training (See Figures)
Peroneus Training Tip
Reduce Tibial Torsion
Increase stride length to reduce tibial torsion
The sub talar joint acts as a directional torque transmitter converter frontal plane motion of the calcaneus into axial rotation torque or torsion of the tibia/fibula (shank). This can cause considerable internal rotational stresses on the tibia, femur and thus hip and lower back. When in the swing phase the opposite side, when swinging a reasonable distance or a longer stride which causes the effected side to reduce in torsion.
Treatment of the Knee Disorders Related to Simple Pronation of the foot
Conditions– Knee Instability– Peri-patellar Pain Syndrome - Patellofemoral arthralgia– Infrapatellar Cartilage Damage - Chondromalicia Patella
Phase I - Passive TreatmentReduce weakness via deep tissue work or EMS
Tensor Fascia Latae Biceps Femoris
(See Figure) (See Figure)
Strength training tip to reduce tibial torsion
Tibial Torsion Treatment and Prevention takes place when Reduced Torsion is aided by reduced weakness and increased strength of the Tensor Fascia Latae and the Biceps Femoris of the thigh. (See Figure)
•Knee extensions - the quad group pull the patella in the correct alignment
•Knee Flexion Bicep femoris pulls the shank back into proper alignment
•Hamstring Curls
Strength training tip to reduce tibial torsion
Train your patient in hip abduction through the gluteus medius and indirectly TFL
Treatment of Hip and Thigh Disorders or Syndromes Related to Simple Pronation
of the foot
Conditions Tensor Facia Latae and/or
Illiotibial Band Syndrome (See Bottom Figure)
Piriformis Syndrome (Side Figure) Hip Arthritis
Phase I Reduced Weakness - Deep Tissue or EMS (See Figure)
– Tensor Fascia Latae– Gluteus Maximus– Gluteus Medius– Gluteus Minimus
Strength Training– Tensor Fascia Latae– Gluteus Maximus– Gluteus Medius– Gluteus Minimus
Treatment of Hip and Thigh Disorders or Syndromes Related to Simple Pronation
of the foot
Treatment of Lower Back Disorders or Syndromes
Non Traumatic Lower Back Pain Disorders or Syndromes Hyperlordosis Facet Syndrome
Traumatic Lower Back
Disorders and Syndromes Herniated Discs etc
We feel that a majority of these injuries are due to a prior predispositionfrom abnormal lower extremity biomechanics causing an anterior tilted pelvis and weight shift from the gluts and lateral thigh to the hamstrings and lower back causing overload and injury
Passive Phase I - Reduced Weakness of these muscles via deep tissue work or EMS
Hip External Rotators (See Figure)
Gluteus Medius Lumbar Extensors
Active Phase II - Active Strength Training in Phase II, III and IV
Midsection Training - This training must occur in flexion, extension, lateral flexion and rotation with the pelvis in a neutral position with reduced extensionof the lumbar spine.
The Spine must be trained in a neutral position.(See Figure)
Phase I - Goals - Reduced Inflamation and Tonic Protective Spasms, Pain Relief, Joint
Mobility Joint Swelling Reduced (Therapy) Joint Fixation Reduced via Manipulation of
Articular Structures Pronation Supported - Orthodics vs NMRE and
motion control shoe and active training Chronic Tonic Protective Reflex Reduction
(NMRE) Treatment Frequency and Duration Daily care
for 2 weeks or 3 days a week for 3 weeks
Phase II - Goals Flexibility, Joint Alignment, Joint Strengthening and Coordination
Joint fixation reduced via Manipulation of Articular Structures
Flexibility training technique (PNF) Light Strength Training Concentration on joint Alignment, Form and
Technique treatment frequency & duration 3 days a
week for 3 weeks
Phase III - Goals - Flexibility, Joint Alignment, Joint Strengthening and
Coordination
Manipulation of Articular Structures Flexibility training (PNF) Heavier and Faster Strength Training Concentration on Joint Alignment, Form
and Technique, Speed and Strength Treatment frequency and duration 3 days a
week for 3 - 4 weeks
Phase IV Goals - Heavier and Faster Strength Training
Concentration on Joint Alignment, Form and Technique, Speed and Strength
Sports Performance Training