Last week I was evaluating a patient with a left 5th metatarsal fracture. He was 12 weeks post injury, but still having considerable pain with weight bearing and walking. What do you see?
As you can see during the clip, this patient does not have a toe-off phase of his gait cycle. Additionally he does not use his plantarflexors for propulsion during the gait cycle. In terminal stance he raises his left foot and extends his toes for foot clearance. An interesting finding during his examination was a weak tibialis anterior. From the video, one might think the tib anterior is over-facilitated. However, this patient had a very week anterior tibialis and over dominant toe extensors. Treatment has focused on isolated strengthening of the tibialis anterior, stretching the toe extensors, manual therapy to the hindfoot, and strengthening the toe flexors, intrinics, and plantarflexors.
As some of my evaluations may have indicated, I typically use the Selective Functional Movement Assessment for my mobility assessments. The system is built on using landmarks for determining full mobility or a deficit in mobility. While that aspect is easy, the system also emphasizes observation of even spinal motion throughout, otherwise the motion is labeled as dysfunctional. Take a look at the Cervical Flexion Top Tier Test out of the SFMA shown below:
By simply assessing landmarks, this individual passes the Cervical Flexion Top Tier Test because his chin reaches his chest. However, if you look closely (or palpate the curve), you will notice the individual's natural cervical lordotic curve is never reversed with flexion. The majority of motion is coming from the lower cervical joints with excessive anterior shear. This sort of observation and analysis does not just apply to the SFMA. Any joint measurements or movement analysis should incorporate some aspect of assessing joint motion. We have reviewed other joints in the past such as anterior glide of the humerus, extension rotation syndrome of the lumbar spine, etc. Be sure to consider the quality of the joint movement and not just the quantity in your examinations.
I recently had a lecture on Temporomandibular Dysfunction (TMD) and the huge impact physical therapy can have on these patient's lives. Prior to the lecture, I had never thought about the high prevalence of TMD (painful or not), but it is everywhere! The Temporomandibular Joints are similar to many other joints in the body: once you begin looking for impairments, you will surely find them.
Currently, there are 4 Orthopedic Residents at Harris Health & each one of us had some degree of Temporomandibular Dysfunction. Of the 4 of us, there was 1 C-curve, 1 S-Curve, and 2 capsular mobility with neuromuscular control deficits. Below I will outline the C-curve and S-Curve.
For a more in depth analysis of the TMJ that reviews anatomy & kinesiology, examination, and treatment options for TMD, check out a recent post on the TSPT webiste written by author Chris Fox.
-Jim Heafner PT, DPT
This patient here is a nurse who injured her shoulder resuscitating a baby. She presented with a positive cluster for impingement. The question is what type of impingement. One of the more common ones is subacromial impingement. With a positive Painful Arc Sign, Infraspinatus Test, and Hawkins Kennedy Test, it might have made sense to jump towards that diagnosis. However, the patient had a positive anterior drawers test on the R shoulder and presented with pain with abduction in internal rotation. Check out the video below:
If you watch closely, the first attempt you actually see the humerus gliding anteriorly with abduction as she attempts to abduct (sorry for the poor camera work!). On the second attempt, she focuses on centralizing the humerus while abduction. It may look like she is retracting and depressing her scapula, but the important component is centralization. This is a prime example of why we need to not forget where we come from as movement analysis specialists. If we were to simply rely on special tests, odds are this patient may have been treated inappropriately for a couple weeks. The key is closely watching (and sometimes palpating) the joint during movement - especially the painful/limited movement. The treatment for this patient has been to do self-mobilizations to the posterior capsule in quadruped while rocking back. This also helps to retrain the neuromuscular system for proper scapulohumeral rhythm. Additionally, we have been strengthening the the external rotators from an internally rotated position to help build an anterior restraint. The HEP included IR and ER using a theraband and focusing on centralization of the humeral head.
Take a look around next time you're at the gym and observe the various ways people perform pull-ups. Odds are you'll see several different methods (some with good form, some with poor form). Do you know why people choose the method they do? We thought we'd look at some of the differences between wide-grip and close-grip pull-ups with Jim. As we've discussed before, Jim does have a history of some shoulder issues on his right side, which may be the cause of some differences in neuromuscular control on the right side compared to the left.
One of the things that stood out to us from the posterior view was the decrease in smoothness of scapulohumeral rhythm on the right side compared to the left. You can almost see the scapula "jump" at a couple different points where muscles are not being appropriately activated. Another interesting observation was the difference in trapezius activation during the close grip vs. wide grip pull-up. During wide grip, you can see much more trapezius activation along the vertebral column. Because wide grip is a more difficult motion, the latissimus dorsi is being forced to work harder and the trapezius is attempting to stabilize. Because of a history of pathology to the right shoulder, it was evident that he was incorporating his upper trapezius significantly more at the end-range of wide grip pull-ups, especially on the right side (this may be due to weakness of the latissimus dorsi). This can be observed by viewing slight scapular elevation on the right and noticing a decrease angle between his head and shoulder at end-range.
As you can see, Jim had become fatigued after doing 12 pull-ups. What's interesting is that you can see towards the end here, his lower body starts to shift forward with hip flexion, allowing his pecs and biceps to have a larger impact on the exercise (not to mention the fact that his chin is no longer making it to the top of the bar!). It's at this point that we would have our patients either take a break or move to another exercise as he is unable to maintain the proper form. The exercise is no longer achieving the desired purpose. Additionally, as mentioned above on the posterior view as, from the lateral view one can really see how much more latissimus dorsi activation is required with wide-grip. Jim was able to perform close-grip much more easily because he could use his arm musculature to assist with the last 30 degrees of motion. The arm muscles are put at a relative mechanical disadvantage in wide-grip. Combine that with fatigue and it is evident why he struggled with the last 2 wide grip pull-ups. What are your thoughts?
This individual came to us with complaints of being limited to running 1 mile secondary to pain. He described the pain located along the medial tibia as developing after about half a mile in and progressively worsening. Upon cessation of activity, the pain would gradually lessen. Take a look at his running form below:
One of the components that really stood out to us was the significant vertical displacement between each stride. That combined with an excessively prominent heel-strike led to our thoughts of poor foot intrinsic control. Check out the images below to see what we found upon visual inspection:
As you can see, he has some significant pes planus bilaterally. While we did not do a formal evaluation, we did find that he has limited dorsiflexion and strong tibialis posterior bilaterally. The individual was able to point to a specific spot of pain that was increased upon palpation after running. This led us to believe the possibility of stress fracture might be present. Testing with a tuning fork was negative. We believe this individual could be suffering from Medial Tibial Stress Syndrome.
We have long been interested in how shoe-type affects running mechanics. Below are videos of running in 4 different types of footwear: Asics, Nike Frees, New Balance Minimus, and Barefoot. There is a progression from restrictive footwear to barefoot. Asics are your traditional running shoe in that they provide extensive heel cushioning. Nike Free represent a movement towards the minimalist side. While Nike proclaims the shoes are a minimalist shoe, it still has significant heel cushioning. However, the flexibility of the forefoot allows for greater intrinsic foot muscle control. The New Balance Minimus is one of the shoes on the market that is closest to simulating barefoot running, while still providing protection to the tissue of the foot. Barefoot is pretty self-explanatory. Additionally, the runner was recorded at 2 speeds, jogging pace and a faster paced run, for each shoe type.
-Increased smoothness as footwear advanced towards barefoot
-Heel-strike most prominent in Asics. While heel-strike was notable with Nike Frees, it was not as exagerated.
-Interestingly, decreased based of support with the New Balance Minimus. The stance leg crosses into midline, while in the other shoe-types the stance leg stays ipsilaterally.
-At the time of this recording, Chris primarily ran in the Nike Frees, but running in the New Balance Minimus felt like it had the lowest energy expenditure.
-The Asics fatigued Chris the most, likely due to the increased plantarflexion torque. Chris' dorsiflexors weren't used to having to compensate for plantarflexion torque caused by the increased heel cushion during heel strike.
-While barefoot running felt comfortable on Chris' calves, the stressed placed on his MTP joints prohibited him from running barefoot for prolonged periods.
With Cristina's squat, we noticed several things:
-Quite stance is in genu recurvatum and plantar flexion
-Stability deficits as noted by shaking of the knees during descent
-Stability deficits noted by involuntary head motion during descent
-Balance deficits due to the outstretched arms during the squat
-Either stability or mobility issues that inhibit Cristina from completing a full deep squat
-Poor lumbopelvic rhythm as noted by a loss of lumbar lordosis during descent
-"Snapping" of lateral hamstrings, as she passes 90 degrees of knee flexion (look closely and you can actually see the cord-like structure "snap" to a different position as if it's jumping over a structure)
-Pronounced Heel Strike
-Excessive thoracic/ upper torso motion
-Contralateral Pelvic Drop on the Right during Left stance phase
-Mild tibial whip during swing phase on the Left
-Greater pronation on L vs. R during stance phase (it appears as if she pronates too quickly as well. A shoe modification may be able to help with this).
These are the main abnormalities we found. What else do you see? Let us know!
There were several lessons that can be learned from our first movement analysis experiment that can be directly translated to the clinic:
1) Your outcomes will greatly depend on how compliant your patients are with their home exercise program. Unfortunately, Jim performed his HEP less than anticipated. Some changes were noted, but overall performance did change as anticipated. Being able to effectively teach an HEP will be important for your success as a therapist.
2) The ideal movement may not be attainable for all people. Since Jim has a pathological right shoulder, his end-range flexion and abduction will not be the same as his left shoulder. Due to some SC joint problems, the "perfect" movement was not possible for him based on the HEP we prescribed. We did not address the SC impairments specifically. Additionally, it must be considered that he is right handed. As Mike Reinold states, "we are unilateral creatures...and typically function in predominant movement patterns." We must work on proper alignment in addition to solely addressing muscular imbalances.
Some of the things we noted upon follow-up:
1. Increased scapular winging bilaterally (L >R)
2. Increased Upper Trapezius Muscle Activity (L> R)
3. R scapula relatively lower than L scapula
4. Asymmetrical Lateral Trunk Curvatures. It was noted that the asymmetry became worse during end-range flexion and abduction and improved upon return to starting position.
5. L Inferior Scapula border tilted anteriorly
One positive aspect we observed was smoother scapulohumeral eccentric control. Jim attributes this change to being most compliant with his seated theraband scapular retraction intervention & focusing on postural awareness.
What did we miss? Point out other asymmetries you observe & give us your thought process to why it might be occurring!
Finally, we want to apologize for delaying this follow-up post longer than expected. Our next movement analysis will be much more timely!
Summary: During the motions, we noted poor dynamic stabilization of the scapular stabilizers due to a lack of fluid rotation at the scapulothoracic and glenohumeral joints. Because of the lack of scapular stability, Jim's rotator cuff has been excessively working to maintain the humeral head in the glenoid fossa. Many impairments could be seen more significantly on the Right vs. Left due to a recent thoracic surgery. It is evident that the surgery has altered him mechanics and his axioscapular muscles are not functioning at the proper length/ tension relationship.
Over the next 3 weeks, we have prescribed Jim the following exercises to improve the timing, coordination, and neuromuscular endurance of the scapular stabilizers:
1) Seated theraband scapular retractions, emphasizing eccentric control.
3 sets x 15 repetitions, with a 5 second eccentric contraction.
2) Push-up Plus
3 sets x 12 repetitions
3) Plank Plus
2 sets x 12 repetitions
4) Standing wall "W's" w/ arms externally rotated and forearms pronated (little finger against the wall)
2 sets x 15 repetitions
Each exercise will be performed daily.
Check back in 3 weeks to see an update on Jim's Shoulder Mechanics!
|The Student Physical Therapist|