In regards to the nerve supply, the "nerves" often proclaimed as supplying the VMO or VML have been shown to be partitions of the femoral nerve to supply distal motor units, sensory nerves of the saphenous nerve, or nerve supply for the knee capsule. Additionally, let's take a look at the claimed function of the VMO: medial patellar tracking. No one has ever been able to demonstrate isolated medial patellar tracking. Many of the studies cited in this article are outdated. We are not disagreeing with the fact that different parts of the muscle have different proportions of fiber types, but we cannot come to the same conclusion of the significance of these findings. What are your thoughts on this recent article?
As physical therapy students, much emphasis is placed on screening for Red Flags to help determine if a patient is appropriate for our services. Generally speaking, a Red Flag can be defined as a sign or symptom indicating the presence of a serious pathology. In a 2011 article, Davenport and Sebelski defined Red Flags as "abnormalities within the systems review...which may suggest the need for referral to another healthcare practitioner (Davenport 2011)." In this same article, these authors are quick to point out that Red Flags have a low predictive value for forms of pathology.
A list of Red Flags commonly seen in the clinic are as follows:
With the profession of physical therapy on the brink of direct access and autonomous care, our ability to correctly determine a patient's appropriateness for therapy is crucial. A recent post from the ForwardThinkingPT outlines a 2013 Cochrane Review regarding the effectiveness of using red flags to screen for malignancy in the low-back pain population. The review assessed 8 cohort studies that specifically addressed 11 Red Flags in the patient's subjective interviews and physical examinations.* Of these 8 studies, which looked at >6000 patients, the symptom of low back pain presented as a more serious pathology <1% of the time. The review found that Red Flags associated with low back pain have high false positive ratings and that the "indication of spinal malignancy should not be based on the results of one single red flag question (Henschke 2013)." Despite the overall low probability of Red Flags, a few studies did find a meaningful increase in probability if the patient had a previous history of cancer.
So where does this leave us as practitioners? It is important to consider that the Cochrane review only assessed the impact of 1 Red Flag in its relationship to increasing the chance of malignancy. In the clinic it is important to document Red Flags and use proper judgement if several of them are positive. Because of the high false positive occurrence, Davenport and Sebelski recommend utilizing a diagnostic process to help guide your clinical reasoning. This diagnostic process involves using a symptom based approach for diagnosis. With each patient you should ask yourself, "Among all possible health conditions, what is causing my patient's symptoms (Davenport 2011)?" Obviously this is a loaded question, but the question does stress the importance of having strong differential diagnosis skills. In conclusion, assessing for Red Flags can be a difficult process. Always remember to utilize good communication and practice forward-inductive reasoning to recognize patterns during your examinations.
*It should be noted that all 11 Red Flag questions were not indicated in every chart and a possible limitation to the study is inadequate therapist documentation.
Davenport & Sebelski. (2011). The Physical Therapist as a Diagnostician: How do we, Should we, and Could we use Information about Pathology in our Practice? Physical Therapy. 2011;91.11. Web. 3 April 2013.
Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L. Red ﬂags to screen for malig-
nancy in patients with low-back pain. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008686. DOI: 10.1002/14651858.CD008686.pub2. Web. 3 April 2013.
There are various types of stretching techniques: sustained, ballistic, proprioceptive neuromuscular facilitation (PNF), etc. They have the common goal of increasing musculotendinous length. Before considering which type is best, we must consider the properties of muscle. Muscles are composed of viscoelastic characteristics that can be influenced by stretch. The elastic component refers to the fact that a muscle has built in memory of it's original length. Just like the elastic part of your socks, given a temporary stretch, a muscle (or sock) will contract back into its resting length. That being said, with proper technique, a more permanent (or plastic) change in muscle length can be achieved. One of these techniques is a sustained stretch. But how long do we hold this stretch? In a classic study by Bandy & Irion, the researchers examined the difference in muscle length over time period of 6 weeks following sustained stretching programs based on time periods of 15, 30, and 60 seconds. A control group of no stretching was also followed. The study had several interesting findings. No significant differences in muscle length were found between the no stretching group and 15 second stretch group. This begs the question, what is the point of wasting time on a 15 second stretch, if there are no lasting effects. The results also found that significant gains were achieved with both the 30 second and 60 second groups, but minimal increase was found for the 60 second group. This means there isn't really a point of holding a stretch for 60 seconds either. The impact of this study displays the importance of reinforcing 30 second holds for stretches during a HEP. We often see our patients say they are holding a stretch for 30 seconds when in reality they are counting to 30 practically in one breath. It's no wonder they aren't seeing changes!
As we mentioned before, there are several different methods of stretching with the most common being ballistic, sustained, and PNF. Ballistic stretching is not usually performed or recommended by health care practitioners due to its link to injury. The theory of ballistic stretching is to exceed the normal constraints of the muscle in order to achieve length increases, which suggests damaging the muscle. In regards to deciding between PNF and sustained stretch, there is still ongoing debate as to which obtains better results. O'Hora et al performed a study that looked at the immediate effects of 1 bout of PNF versus sustained stretch versus no stretch. The PNF stretch was a contract-relax maneuver of the hamstrings for 6 seconds. They found both PNF and sustained stretch to have significant changes in length following 1 bout. PNF changes were found to be greater than sustained. In the discussion, the authors reviewed the discrepancy in the literature regarding differences between PNF and sustained stretches, reminding the readers that there are many studies that have found each to be more effective than the other. An obvious issue with this study was the fact that the authors only looked at immediate effects of stretch and did not examine long-term effects. What can be taken from these findings and the discussion is that both 30-second sustained stretch and contract-relax can result in increases in muscle length. The debate goes on in regards to which is more successful. A combination we like to use is 3 sessions of contract-relax at end range, followed by a 30 second sustained stretch.
Bandy & Irion. (1994). The Effect of Time on Static Stretch on the Flexibility of the Hamstring Muscles. Phys Ther. 1994 Sep;74(9):845-50. Web. 6 April 2013.
O'Hora J, Cartwright A, Wade CD, Hough AD, Shum GL. (2011). Efficacy of Static Stretching and Peripheral Neuromuscular Facilitation Stretch on Hamstrings Length after a Single Session. J Strength Cond Res. 2011 Jun;25(6):1586-91. Web. 6 April 2013.
Tissue Adaptation to Physical Stress: a proposed "Physical Stress Theory" to guide Physical Therapy Practice, Education and Research, an article by Mueller and Maluf, is a must read for any physical therapy student. At SLU, I was required to read it during my first semester in the program. At the time, I did not fully understand the full extent or importance of the article. Mueller and Maluf touch on several key concepts that directly relate to our patient care.
The premise behind the Physical Stress Theory (PST) is "that changes in the relative level of physical stress cause a predictable adaptive response in all biological tissues." When stresses are placed on a particular structure due to movement or posture for example, our bodies tissues must adapt to these stresses. Stress can be defined by Magnitude x Time x Direction, and it is a combination of these 3 factors that will determine our bodies response. Our goal as physical therapists is to identify patterns that lead to excessive stresses and teach the patient proper movement strategies to prevent further tissue injuries. After identifying the problem, we need to decrease pain and perceived level of disability, and then focus on increasing activity tolerance in the new pain-free movement pattern. During any initial evaluation, think about a) What factors are causing excessive stress (environmental, behavioral, etc.) and b) How can these factors be modified?
A few crucial take-home points from the PST:
-Movement is a significant source of physical stress. Depending on how we move can have either detrimental or beneficial effects on tissue injury.
-4 Fundamental tissues that undergo stress regularly are Epithelial, Connective, Muscular, and Nervous tissue.
-5 Qualities of physical stress include: Decreased stress tolerance, Maintenance (homeostasis), Increased stress tolerance (tissue overload), Injury, and Death. The article goes into great detail on each of these points.
-Stress will have different effects on tissues whether it is tensile, compressive, shearing, or torsional stress. Regardless which type of stress is present, inflammation will occur immediately following tissue injury.
-Postural deviations are one of the most common causes of musculoskeletal pain.
-Tissues atrophy at a much faster rate than they hypertrophy. Muscle force production losses can be between 6-40% in 4-6 weeks time.
-Similar to muscles, nerves can become overused due to malalignment and postural deficits. This is commonly seen in carpal tunnel sydrome and lumbar spinal stenosis.
Bottom Line: Good Alignment + Good Movement = Good Musculoskeletal Health. Factors such as posture, age, movement patterns, psychological factors and environmental factors all influence this equation. It is our goal to identifty these factors to allow for normal movemen
Mueller and Maluf. Tissue Adaptation to Physical Stress: a proposed "Physical Stress Theory" to guide Physical Therapy Practice, Education and Research. Physical Therapy. 2002. 84.4: 383-403. Web. 2010.
Kelly Starrett from Mobility Wod brought this issue to the light with a post last year. His findings showed that, yes, cryotherapy can be effective in reducing pain following injury, but it was inconclusive as to whether or not it improved clinical outcomes. Again, this modality can be useful in preventing the body from healing its natural way, but do we really want to do that? You might ask then about other methods of limiting pain and swelling in the area. Starrett suggests utilization of compression to limit the swelling, along with elevation at times. Another method to decrease swelling is muscle activation. Mobility (when safe) is an incredibly useful method to a) maintain strength, b) evacuate swelling through muscle pumping, and c) help to restore collagen alignment. Now we're not suggesting ice should suddenly be abandoned in physical therapy altogether, but it should be given a more serious consideration as to its appropriateness. In fact, an interesting response by Nick Heudecker was brought up to this post, questioning the analysis of the literature cited and the method of the studies as well.
Perhaps it is time to consider a shift from the traditional RICE theory to a MEAT theory, as discussed by The Sports Physiotherapist. We have actually seen the MEAT protocol in practice with impressive effectiveness for returning injured athletes to play. M=movement, E=exercise, A=analgesics (non-NSAID), T=treatment. What are your thoughts on the RICE vs MEAT debate? Should we choose one or the other? Or is there a middle-ground that is more desirable?
Treating a shoulder patient can seem very complex and overbearing at times. This post from the Sports Physiotherapist helps breakdown different scapular dyskinesias to allow for easier diagnosis and treatment of shoulder pathologies.
Reviewing each dyskinesia:
Type 1: Shortening of the musculature that attaches to the coracoid process. In this dyskinesia, muscles are being shortened on the anterior side of the body (pec major and pec minor specifically). In the clinic, you will observe anterior scapular tilting and likely rounded forward shoulders. Treatment options include performing a pec minor release and pec minor stretching. Both of these techniques are demonstrated by Dr. E (the manual therapist), Mike Reinold, and Chris Johnson.
Type 2: Weakness or poor activation of the Lower Trap and Serratus Anterior muscles. In the clinic, if you suspect a type 2 dyskinesia, you will likely see excessive internal rotation, "winging" of the medial border, and anterior scapular tilting. The original post has 6 great videos demonstrating how to elicit these muscles. Exercises that have shown great serratus anterior MVIC include serratus punch and push-up plus. For the lower trapezius performing prone Y's and prone shoulder external rotation is very beneficial. According to McCabe et al, Prone Shoulder External Rotation with the arm positioned at 90 degrees abduction elicited a 79% MVIC.
Type 3: Excessive Superior Border Prominence. These patients often have hypertonicity of the upper trapezius muscle and likely have a poor Upper Trap: Lower Trap muscle firing ratio. From my personal experiences in the clinic, these individuals have excessively tight upper trap muscles, hypomobile first ribs, and complaints of cervical tightness as well. The Sports Physiotherapists recommends performing external rotation in neutral, upper trapezius/ levator scapulae stretching, and joint mobilization to the cervical, thoracic, and scapular regions. Additionally, Arlotta, Lovasco, and McLean found that the Modified Prone Cobra selectively recruited the lower trapezius muscle with relatively low upper trapezius muscle activation.
The original article has great video demonstrations of how to perform each exercise. Check it out!
Arlotta M, Lovasco G, and McLean L. Selective Recruitment of the lower fibers of the Trapezius Muscle. J Electromyogr Kinesiol. 2011. 21.3: 403.410. Web. 27 Feb 2013
McCabe R, et al. Surface Electromyographic Analysis of the Lower Trapezius Muscle during exercises performed below 90 degrees of Shoulder Elevation in Healthy Subjects. N Am J Sports Phys Ther. 2007. 2.1: 34-43. Web. 27 Feb 2013.
We were recently asked about treatment methods for genu varum of the knee, so we thought we would do a little literature review on the subject. We believe the request was directed towards an exercise-based approach. Unfortunately, we were unable to find much evidence regarding treating genu varum with exercise. With genu varum, the line of gravity runs farther medial to the knee than normal, putting increased stress on the medial compartment of the knee. This puts the individual at risk for developing OA. Due to the increased risk in developing unicompartmental osteoarthritis, it is desireable for the patient to restore normal alignment in order to delay the need of having a Total Knee Replacement. There are several methods of managing genu varum right now, which we will briefly review.
The traditional method of treating genu varum involved an osteotomy of the proximal tibia with the goal of restoring normal knee alignment. Goutallier et al found a desirable range for realignment: 3-6 degrees of valgus. At < 3 degrees of valgus, individuals developed recurrent genu varus, while at > 6 degrees of valgus, individuals developed deterioration of the lateral tibiofemoral joint. A newer method that is currently being developed is known as the llizarov method (Park et al, 2012). During the osteotomy, the surgeon also places an external fixator on the patient. This allows gradual adjustments to be made to the knee alignment during the 24 weeks it remained on. While the method was able to restore normal alignment to the knee, there was a high level of complications to the patients.
An alternative method of treating genu varum includes bracing and heel wedges. The brace under discussion is called a compartmental unloader. An individual with genu varum would want a valgus orthosis. It functions by either having a valgus stress built into it or the ability to develop the stress while donning the orthosis. With the valgus stress placed on the knee, the natural varus moment decreases, lowering the stress on the medial tibiofemoral joint. This hopefully delays the need for a Total Knee Replacement. Both a compartmental unloader and a lateral heel wedge have been shown to be effective as short-term pain relief methods (Brouwer et al, 2005). This can play a role in at least delaying the need for a Total Knee Replacement (Wilson et al, 2011).
Additionally, we must consider what mechanical issues may be predisposing a patient to genu varum alignment. It is well documented that abnormal strength of the hip muscles can alter knee mechanics. Strengthening the hip external rotators and hip extensors, for example, is a key component in the rehabilitation of patients with patellofemoral pain syndrome. Zeni and Synder-Mackler discuss the importance of strengthening the contralateral limb following a total knee replacement. They also report that decreasing body mass may have an impact on forces across the knee following replacement. Other authors discuss quadriceps strength as an important measurement to consider when viewing the success of a total knee replacement. There are examples across the literature that stress the importance of a lower limb strengthening and endurance program to decrease stresses at the knee to help prolong total joint replacements. While there may not be direct evidence linking hip strengthening programs to decreasing genu varum alignment, hip strength is definitely a measure to address when working with this population.
Again, unfortunately, we were unable to find much evidence on exercise as a treatment for genu varum. What about you, what has your research and experience shown in addressing the condition?
Brouwer RW, Jakma TS, Verhagen AP, Verhaar JA, Bierma-Zeinstra SM. (2005). Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. ;(1):CD004020. Web. 28 Jan 2013.
Goutallier D, Hernigou P, Medevielle D, Debeyre J. (1986). Outcome at more than 10 years of 93 tibial osteotomies for internal arthritis in genu varum (or the predominant influence of the frontal angular correction. Rev Chir Orthop Reparatrice Appar Mot.;72(2):101-13. Web. 28 Jan 2013.
Park YE, Song SH, Kwon HN, Refai MA, Park KW, Song HR. (2012). Gradual correction of idiopathic genu varum deformity using the Ilizarov technique. Knee Surg Sports Traumatol Arthrosc. Web. 28 Jan 2013.
Wilson B, Rankin H, Barnes CL. (2011). Long-term results of an unloader brace in patients with unicompartmental knee osteoarthritis. Orthopedics. ;34(8):e334-7. Web. 28 Jan 2013.
Zeni J, Synder-Mackler L. (2010). Early post-operative measures predict 1- and 2- year outcomes after unilateral total knee arthroplasty: importance of contralateral limb strength. Journal of the American Physical Therapy Association.; 90(1): 43-54. Web. 29 Jan 2013.
In the article Evaluation of an Injured Runner, Magrum and Wilder discuss several interesting points to consider when working with an injured runner. First, you must examine the entire kinetic chain. Running is truly a full body movement, which requires symmetry between the upper and lower extremities. Forces are transmitted from one area to the next, and excessive movement in one region can create dysfunction down the chain.
When working with this population, do not undermine the importance of a thorough history. Be sure to inquire about shoe type, weekly mileage, length of runs, running surface, and more. Because running is such a repetitive activity, the examiner needs to understand exactly when the pain occurs, where is occurs, and if symptoms persists or subside after exercise. Following a subjective history, they recommend beginning the evaluation in standing. Static posture is observed and any asymmetries are noted. Specifically look at patellar alignment, subtalar position, and sacroiliac joint motion.
As the evaluation moves from standing to sitting, ligament stress testing of the knee can be performed as well as reflexes, neural tensioning tests, and a vascular screening. Additionally, note how the patella tracks as the patient actively extends at the knee. Next, have the patient lie in supine. It is important to assess for a potential leg length discrepancy (clues from the standing and sitting evaluation can point toward a potential leg length issue). In supine, femoral torsion, tibial torsion, and the Q-angle can all be appropriately assessed.
The article continues on to discuss the sidelying evaluation and functional tests that should be performed when assessing a runner. Additionally, normal angles, pictures, and a review on how to perform different examination measures are outlined in the article. It is a great review for anyone, especially if you are expecting to evaluate a runner in the near future.
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