Posterior tibialis tendonopathy can be tricky to treat sometimes. There are many different theories to the causes of PTT. However, what we do know is some of the signs of posterior tibial tendon dysfunction which can include: increased heal valgus, PF of the talus, flattening of the medial longitudinal arch, and abduction of the forefoot. While we won't go into the examination of the posterior tibial tendon dysfunction or tendinopathy in this post, we will go over the functions of the posterior tibialis.
The tendon is posterior to ankle axis and medial to the STJ axis which makes it a plantarflexor and invertor. Additionally, it directly opposes the action of the peroneus brevis muscle by acting as an adductor of the forefoot. It is the primary dynamic stabilizer of the medial longitudinal arch.
The closed chain foot adduction exercise is one of the more effective ways of strengthening the posterior tibialis. In 2004, Kulig, et al. conducted a study using magnetic resonance transaxial imaging to find the signal intensity of the posterior tibialis muscle during 3 exercises (closed chain foot adduction, unilat. heel raise, and open chain foot supination). What they discovered was that in individuals with a normal arch index, the posterior tibialis was most activated during closed chain foot adduction when compared to the other two exercises mentioned above.
To perform this exercise, place a theraband around the leg of a table/therapy plinth and the patient's foot. Instruct them to keep their foot on the ground throughout the exercise. Teach them to perform foot adduction. Be sure to look for substitutions as they are often common when prescribing this exercise.
This is an easy, simple, and effective way to help your patients "feel" their low trap working. By cueing them to rotate their head away from the arm pushing down, the upper trap will relax a little. Give it a try if you can't get your patients to stop substituting at the upper traps.
With the theme of rhythmic stabilization the past few weeks, this week's exercise focuses on the GH joint and scapula stabilizers of the shoulder. This exercise challenges the patient to recruit the scapula stabilizers which is important to keep normal kinematics. By instructing the patient to keep the palm open instead of tightly closed over the ball, more activation of the shoulder stabilizers must come into play.
Instruct the patient to be seated on a stability ball with their palm on the ball against the wall. Keeping their feet close together, begin applying rhythmic stabilization in all directions, increasing speed as needed. To progress this exercise, have the patient extend their opposite knee to create more imbalance to the exercise. A final progression would be to have the patient abduct their opposite shoulder with a light weight for a sustained hold.
This week's exercise focus is on core stability in a functional position. In sports and everyday life we constantly have to work on balance and stability in unstable positions. Whether you are a basketball player getting hit while running or just bumped into while walking to work, core stability must kick in to keep you on your feet. Using an exercise like split stance lunge w/ rhythmic stabilization can help progress a good core program.
Have the patient/athlete assume a lunge position with their back leg on the bosu ball. After they assume the proper upright position instruct them to extend their arms straight out with hands together. Begin slowly applying rhythmic stabilization in all directions. Increase speed as needed.
To progress this exercise, simply have the patient/athlete move their back leg forward so that only their back toe is on the bosu ball, further creating an unstable surface to challenge their core.
Dynamic shoulder stability is extremely important in both rehabilitation and prevention. Unfortunately, all too often we get comfortable prescribing low level rotator cuff exercises that the patient gets bored with. For those patients that are ready to advance or need more dynamic stability of the shoulder, this exercise will most definitely challenge them. There are multiple ways to progress this difficult exercise which is why it is so valuable to have in your toolbox. It is especially useful for your high level athletes, such as baseball players, who often are in need of dynamic stability of the shoulder.
Have the patient seated on a stability ball with their feet close together to challenge the core immediately. Using a cable or theraband, have the patient assume the starting position for shoulder external rotation with a towel roll in between their arm and body. Next, have them perform external rotation to adjust to the stability ball. When ready, begin each repetition with manual resistance throughout the concentric portion of ER. It is important to begin the resistance at the beginning of the exercise where often the theraband is more slack or the cable is providing less resistance.
There are multiple ways you can challenge and progress this exercise:
- Have the patient perform external rotation and hold at a certain degree (45, 60, 90) against manual resistance (good for when a certain range of the motion is weaker)
- Have the patient extend their opposite knee to increase core activation and further challenge the shoulder stabilizers
- Have the patient hold a dumbbell with their opposite arm in an abducted position while performing the exercise to increase co-contraction of the shoulder musculature, increase endurance of the shoulder stabilizers, and promote physiologic overflow.
This week's exercise is a unique stretch for the hip adductors. This stretch comes from Eric Cressey and works on tissue extensibility of the hip adductors in both a hip flexed position as well as a hips extended position. I have found this exercise to be very beneficial and what is important about this particular stretch is it hits all fibers of the adductors. As we know from anatomy, the anterior fibers of the adductor magnus may assist in flexion of the hip while the posterior fibers may assist in extension. By performing this stretch in both the hip flexed and hips extended position we are covering all fibers of the hip adductor musculature.
Forearm strength is an underestimated variable in sports and everyday life. A strong grip is important for performance in sports, improvements in weight lifting, and can even help stabilize the shoulder. Sports like judo and wrestling have research behind them showing that grip strength is a strong determinant for performance. Furthermore, studies have shown that isometric hand strength and isometric shoulder stabilizers have a positive correlation.
Weight lifting exercises are a prime example of the importance of forearm strength. Any weight lifter knows that the stronger you grip the bar or dumbbell, the easier the exercise becomes. Have you ever tried to perform a heavy press or row with an open palm?
Towel Pullups can challenge an individual to activate more muscle to complete the pullup. A person who can perform body weight pullups will often find themselves struggling to complete reps with towel pullups. Grip strength is commonly the culprit.
Wrap two towels around each of the inside bars of the pullup station. Grip the towels toward the top to make the exercise easier to begin. If you find you cannot pull yourself up to complete a full rep, one way to begin building strength is placing a bench or chair underneath so you can perform negatives. If that is still too difficult, start by simply holding yourself up to work the forearms, back, and shoulders isometrically. Remember that the thicker the towels or the further away you grip the towels, the harder the exercise becomes.
Muscular imbalances are often very common among both athletes and patients. While many are non-symptomatic, the majority of imbalances put athletes at risk for potential injuries. Single Leg squats on an elevated surface, such as a standard bench, can be an effective exercise to train or rehab muscular imbalances in the lower extremity. Simply by watching an athlete perform a single leg squat on a bench you will be able to spot weak points, which often occur at the hips in this exercise (like mine do in the video). Furthermore, this exercise can be used as a eccentric exercise which can be very effective in patients with patellar tendinopathy if dosed appropriately(such as Alfredson protocol 3x15...) and performed with concentric assistance.
Make sure the patient has appropriate balance & strength before attempting this exercise. Instruct the patient to place one foot on the bench while the other foot is off of the bench with the toe pointed in the air. Have the patient cross their arms and keeping their back straight, squat down to the degree of knee flexion indicated.
Hamstring strains are among some of the most common injuries in sports. What we know from research is that quite a few hamstring strains result during the terminal phase of gait while running at high speeds. When we test of isometric hamstring strength during evaluations, testing the patient prone at 15 and 90 degrees(hip stabilized at 0 degrees) helps us to differentiate where the most weakness is occurring in knee flexion. Furthermore, because the hamstrings assist in hip extension, isometric strength testing of hip extension with the knee in 0 and 90 degrees of flexion is beneficial when creating treatment plans.
Hamstring walkouts is an exercise that can be very effective in the rehabilitation of hamstring strains. This exercise works the hamstring musculature in multiple ranges of knee flexion while simultaneously holding hip extension. Because the hamstrings assist in hip extension this exercise ensures strength throughout the hamstring.
Instruct the patient to lie hookline. Have them perform a bridge to begin. Cue them to hold that bridge and begin to walk out with their heels slowly. Once they reach near full knee extension instruct them to return, still maintaining the bridge and using their heels to slowly flex their knees.
Face Pulls is an exercise used to work the rhomboids, posterior deltoid and external rotators of the shoulder. This is an excellent exercise for athletes to do because it helps balance out all the pressing they typically do. Make sure that when coaching this exercise you place your fingers on the thoracic spine between the scapulae to cue the athlete and prevent substitution.
Have the athlete assume a wide base of support. Attach a rope to the cable and place it at where approximately 90 degrees of shoulder flexion occurs. Have the athlete grasp the end of the rope with a pronated grip and elbows extended. Next, cue the athlete to pull the rope toward their face while simultaneously externally rotating the shoulders. The end position should show the “V” part of the rope close to the face with the elbows flexed and shoulders externally rotated. Make sure to look for substitutions at the low back region.