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