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PrintRecurrent Hamsting injuries?
Footballers and sprinters- you must be wondering what your doing wrong? What is causing you to have recurrent problems with your hamstring?
Now as with any injury, you should always consult your GP and or physiotherapist before commencing any new exercise…
So a big mistake when rehabilitating the hamstring is the lack of eccentric work… people tend to stretch and concentrically strengthen muscles which does not protect the hamstring when it is under the most strain. Eccentric contraction involves contracting a muscle in a lengthened position- in the case of the hamstring this would be from knee flexion through to knee extension. This differs to concentric muscle activity where muscles are both contracted and shortened at the same time, this would be the equivalent of performing a hamstring curl
Nordic hamstring exercises are found to be quite useful in strengthening the hamstring muscle
Look out on MCR for a detailed hamstring rehabilitation programme in the coming weeks
Osteoarthiritis: Hip and Habits
The previous article touched upon hip Oa and muscles which may be weak and strong allowing for more specific rehabilitation.
In addition to muscle imbalance, are there particular postures that a person adopts that aggravates the disease process?
OA can affect all joints and where a lot has been said about arthiritic knees in this domain, there has not been much written regarding OA and the hip.
The purpose of this article aims to briefly discuss Hip Oa and associated postures that may progress the disease process.
The hip joint consists of the articulating surfaces between the symmetrical socket known as the acetabulum (of the pelvis) and the femur (thigh bone). The acetabulum is deepened by a cartilage-covered ring of fibrocartilage known as the labrum to aid in the congruency of the joint. The joint space between the acetabulum and femur are at equal points throughout, to allow adequate lubrication.
The hip joint relies heavily on surrounding capsule, ligaments (transverse, iliofemoral, pubofemoral, and ischiofemoral ligaments) and muscles to maintain it stability.
Hip osteoarthritis
Essentially the disease process affects the cartilage that surrounds the joint and thus exposes the bone reducing the joint space and allowing for bone and bone contact. Hip osteoarthritis is something that affects people more commonly over the age of 50 and is exacerbated by obesity, previous hip fractures, congenital conditions and genetic predispositions.
Symptoms
Arthritic hips can be very varied and transient depending on factors such as a weather. Main symptoms include:
Pain with weight bearing activities
Limited range of motion
Stiffness of the hip
Walking with a limp
Referred pain into the bottom and groin
Postural habits
In a clinical setting a patient will tend to stand in a way they deem is “good posture” for the benefit of the assessing therapist. This is all well and good and provides the therapist an idea of that patient’s perception and awareness of posture; However another important consideration is what posture that patient assumes during prolonged standing, or in relaxed postures in their normal environment.
When looking at the hip joint, one must consider negative postures like “hanging on the hips” where the weight is shifted to one side (e.g the right) and the opposing pelvis (i.e the left) is dropped down into relative adduction. If this hip (left) is in increased adduction (shortened adductors), by default of muscles working in pairs and as opposites, the abductors on the left will be stretched (lengthened).
Also in such stances, the ITB is in tension and muscle activity on the left is reduced. These are postures that are often observed by clinicians when assessing the single leg stance of patient with hip OA.
The problem with adopting such a pose is, it may lead to a phenomenon termed ‘stretch weakness’ occurring in these hip abductor muscles on the left resulting in inner range weakness.
What this suggests is ‘hanging on the hip’ in adduction, where hip abductors are lengthened, overtime may actually lead to physiological changes making the muscle weaker.
Clinically this proposes that testing and strengthening hip abductors ought to be done with the leg in adduction (10 degrees) as well as in neutral to gain the most therapeutic benefit for OA patients.
Interestingly there has been research suggesting that weight bearing with excessive hip adduction will also result in increased joint forces and this had been found in patients with early hip joint pathology during the stance phase of gait. Further highlighting the importance to reduce adduction and increase abduction strength.
In addition to increasing the load through the joint, excessive hip adduction also has the effect of increasing the compressive load of the ITB over the greater trochanter, into which the glut. medius tendon inserts. Therefore prolonged standing in the “hanging on the hips” posture produces a significant amount of compressive loading of the glut. medius tendon and therefore possible dysfunction.
Other negative postures that produce the above effects include sitting cross-legged in hip adduction, and sleeping in sidelying in hip and patients with occupations requiring prolonged standing must be correctly advised and rehabilitated.
Treatment for such clients should not only look at strengthening the abductor muscles at different ranges, as already discussed but also to educate the patient about these postures to avoid lengthening the abductors and compressive loading of the ITB and Glut. medius tendon.
References:
Grimaldi, A (2009)Assessing lateral stability of the hip and pelvis, Physiotec Physiotherapy, Manual Therapy:16 (2011) 26-32
Hip muscles to target in arthiritis
Hip osteoarthritis (OA) is very common amongst an elderly population. There is a lot of research looking at the causes, the process and even potential (conservative, pharmacological and operative) treatment of osteoarthritis, but what is not as clearly understood is how the muscles of the hip are affected.
Why is this important, as clinicians we are involved in the rehabilitation of patients pre- operatively and post- operatively and therefore it is vital for us to understand which muscles are weak, how best to strengthen them and which muscles are overactive and therefore do not require strengthening
When looking at the muscles synergy around the hip we can separate superficial muscles (Gluteal max (GM), tensor fascia lata (TFL) from those in the deep system which include the gluteus medius (G.MED), gluteal minimus (G.MIN), quadratus lumborum and piriformis.
There is research suggesting that increase adduction activity, increases compressive forces through the hip and therefore may make symptoms worse. What this suggests, is that in generic home exercise programmes, exercises to strengthen adduction ought to be avoided.
The notion of considering the gluteus max as acting like 2 separate muscles carrying out two different movements has also come about of late. This due to its attachment and insertion site, the upper portion of the GM muscle (UGM) arises from the posterior iliac crest, while the lower portion of the GM muscle (LGM) arises from the inferior sacrum and upper lateral coccyx. This therefore causes the UGM, to act primarily as a hip abductor, and not play a role in hip extension unlike the LGM which is predominately a hip extensor. Both portions are believed to externally rotate the femur.
When comparing muscle wastage of patients with unilateral hip osteoarthritis, the results showed muscle wastage in the LGM of the affected hip but not the UGM. On the unaffected side the UGM experienced hypertrophy. Hypertrophy can be explained by compensation with offloading the painful side leading to increase weight bearing on the unaffected side. Commonly enough unilateral OA tends to develop into bilateral osteoarthritis.
To explain the development of bilateral OA, the theory that excessive abduction can also lead to bilateral hip OA due to the increase compressive loading has therefore been proposed. Therefore clinically once again routine hip abduction exercise targeting the superficial UGM provided for osteoarthritic patients may not be beneficial.
The emphasis is moving more towards strengthening hip extensors (LGM) and the deep abductors G.MED, G.MIN and piriformis over superficial hip abductors (UGM). The deep muscles of the hip are believed to have a part in absorbing ground reaction forces at heel strike during gait. The inabilty of these muscles to do this effectively may explain the degenerative process and pain of the hip joint.
In contrast to the above, the has also been suggestions that post total hip arthro-plasty in OA patients, GM plays an vital role in preventing surgical implants from loosening and hasten the recovery. When looking at the energy transfer and mitochondria function of a diseased OA hip, GM appeared to show greater deterioration of the intracellular energy transfer processes. The authors of this study concluded that arthroplasty undertaken before development of the grade 3 OA may improve greater post surgically as there would be fewer changes at a cellular level to the muscle.
A following article will demonstrate useful hip strengthening exercises and stretches
References
Grimald, A., Richardson,C.,Durbridge,G. Donnelly, W., Darnell, C., Hides, J (2009) The association between degenerative hip joint pathology and size of the gluteus maximus and tensor fascia lata muscles, Manual therapy
Eimre, M., Puhke, R., Alev, K., Seppet, E., Sikkut, A., Peet, N., Kadaja, L., Lenzner, A., Haviko, T., Seene, T., Saks, V.A., Seppet, E.K., (2006) Altered mitochondrial apparent af?nity for ADP and impaired function of mitochondrial creatine kinase in gluteus medius of patients with hip osteoarthritis, Am J Physiol Regul Integr Comp Physiol 290: R1271–R1275
Pilates and Physiotherapy
What is Pilates?
Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.
Background
Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.
Clinical Pilates vs Pilates
Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.
In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.
Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery.
The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.
Peripheral injuries
When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries.
Spinal Injuries
Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.
In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.
Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.
In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.
If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt.
The benefits of Pilates
• General fitness and body awareness greater strength and muscle tone
• Improved flexibility
• A flatter stomach
• Improved efficiency of the respiratory, lymphatic and circulatory systems
• Better posture and awareness
• Less incidence of back pain
• Increased joint mobility
• Lower stress level
Which clients would benefit from Pilates?
• Males and females
• Pregnant: Pre and post natal
• Athletes and dancers
• Amputee and stroke rehabilitation clients
• Elderly
• Children 12 years-old +
Clinical pilates therefore targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.
If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!
Knock Knees – Can I reverse it? (Part 2)
In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.
The Problems of this condition
The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.
How do I get rid of it?
External aids:
1. Orthotics
The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.
2. Knee braces
These can help prompt correct alignment of the knee joint, but may create a degree of dependency.
3. Strengthening
A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.
4. Stretching
Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.
Knock Knees – Can I reverse it? (Part 1)
Knock knees is a phenomenon where it appears as though your knees are at an inwards angle in relation to your feet. Most kids under the age of 6 appear to have knock knees, but grow out of it as their body shape changes. An adult with knock knees may or may not have pain – mostly depending on the severity.
In this article, we would discuss on the different types of knock knees and the contributing factors that may develop with this condition.
When discussing the reasons for knock knees, structure of the bones and joints must be assessed. Structural reasons for knock knees are not normally reversible, unless surgery is indicated. When it comes to the strength, control and stiffness of muscles that control the alignment of the knee, a full assessment must take place so that a corrective program can be enforced.
Structural reasons:
Genu varum: … Not Reversible
A structural deformity of the knee joint, causing the lower leg to be angled inwards and the upper thigh to be angles outwards, causing a bowing effect.
Tibial valgus: … Not Reversible
This is a deformity of the tibia.The bone angles outward towards the end furthest from the knee joint.
Coxa Varum: … Not Reversible
A deformity of the femur; the angle between the head and shaft of the femur is more acute, making the shaft of the femur angle inwards.
Q angle: … Not Reversible
This is the angle between the line of the femur, and the line of the mid patella – tibial tuberosity. A larger Q angle will mean more biomechanical problems within the knee joint.
Poor strength of:
Hip external rotators: … Reversible
- Gemellus inferior & superior
- Obturator internus & externus
- Quadratus femoris
- Piriformis
- Gluteus maximus
- Gluteus medius posterior fibers
- Sartorius
Weakness in these muscles will cause the femur to internally rotate causing an increased ‘knock knee’ effect.
Hip abductors: … Reversible
- Gluteus medius
- Gluteus minimus
- Tensor fasciae latae
- Sartorius
Without the strength of these muscles, the femur is more likely to adduct, increasing the knock knee appearance.
Quadriceps: … Reversible
- Rectus femoris
- Vastus medialis, lateralis & intermedius
Asymmetry in the strength of this muscle group may result in misalignment of the knee joint, giving the appearance of knock knees. Generally it will be the inner most compartment of this muscle that is weak.
Hamstrings: … Reversible
- Biceps Femoris
- Semitendinosis
- Semimembranosis
Similar to the quadriceps, asymmetry in the strength of this muscle group i.e. inner most compartments (semitendinosis and semimembranosis) may lead to this appearance.
Poor control of:
Hip External rotators: … Reversible
Hip abductors: … Reversible
Lumbo/pelvic muscles: … Reversible
If these muscles are not controlled well because they have poor activation or endurance, they muscles will not be able to hold the knee joint in a correct alignment constantly. In other words, the muscles will get tired, and they will not be doing their job.
Stiffness in the:
Hip: … Reversible
Tight muscles in the hip region may limit the range of motion available. If the joint is not moving correctly, the required muscles will not be able to work to correctly align the knee joint.
Ankle Overpronation and Injuries video
Have you wondered why overpronation (rolling inward) of your ankles can cause injuries? Click on the video to find out more.
Surgical Procedure of Total Hip Replacement video
Do you have hip osteoarthritis and is so painful that you are considering to have a Total Hip Replacement surgery? Click on the following link to understand more about the surgical procedure of the Total Hip Replacement.
