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PrintRunners: ITB Syndrome and the “Stiff” Pelvis
Useful tips to choosing your running shoes
It is common knowledge that excessive and long distance running can cause problems with the low back, hip, knees and feet. So how can we protect ourselves from these ailments? In addition to other factors such as regular stretches and effective warm ups and cool downs, a good pair of running shoes is vital to protect your joints in the lower limb.
What do we expect from a good pair of running shoes: stability, support and motion control.
In order to select an appropriate pair of running shoes, one must understand the principle of pronation.
The Normal Foot
Normal feet have a normal-sized arch and lands on the outside of the heel and rolls inwards slightly to absorb shock. It’s the foot of a runner who is biomechanically efficient and therefore doesn’t need a motion control shoe. A semi-curved stability shoe with moderate control features would be best for such runners.
The Flat Foot
This has a low arch, and is an overpronated foot – one that strikes on the outside of the heel and rolls inwards (pronates) excessively leading to potential injuries. The ideal running shoes for these runners would be straight shaped, motion control shoes, or high stability shoes with firm midsoles and control features that reduce the degree of pronation. Avoid highly cushioned, highly curved shoes, which lack stability features.
The High-Arched Foot
A highly arched foot is generally supinated or underpronated making the foot an uneffective shock absorber. For these runners well Cushioned (or ‘neutral’), curved shoes with plenty of flexibility to encourage foot motion is recommended. Avoid motion control or stability shoes, which reduce foot mobility.
Factors to consider when shopping for new running shoes:
- Your feet are at their largest in the last afternoon, and this will be the best time to shop as your feet will expand while running.
- Bring your old shoes to check where the most wear and tear on the sole is
- Bring your orthotics and usual running socks to try on with your new shoes
Recurrent 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
What is the difference regular injuries and sports injuries?
“I have some shoulder pain and was wondering what is the difference between a regular injury and sports injury? Do I see a regular physiotherapist or a sports physiotherapist?”
- Joel
Hi Joel,
The terminology used by physiotherapists can ben confusing sometimes. Body parts other than the main body trunk such as your spine and hips are referred to a peripherals by physiotherapists. So a shoulder injury such as yours is a peripheral injury.
Regular peripheral and sports injuries over-lap significantly. You can get knee ACL injury from incidents that are not sports related even though ACL injuries are common seen in athletes.
The main difference in approach in treating regular injuries and sports injuries are
- the speed of recovery
- the intensity of the treatment
Speed of Recovery
The pace of sports therapy is generally much quicker and more aggressive. This is due to the demands of the sports. The longer the athlete is down and out from training, the harder and longer it is for them to return to peak performance as their conditioning can deteriorate quite quickly. So treatment sessions tend to closer together and more frequently, several times a day in some cases.
Regular therapy would be spread out over a longer period of time to allow the body to heal more gradually.
Intensity of Treatment
Also, the demands of the sports can place a lots of stress on the injuries body part. As such the treatment such as strength and conditioning are generally more intensive to build up support – stronger muscular balance and finer motor control to prevent re-injury.
Such treatments is generally not called for with regular injuries as high-stress is not expected to the placed on the injured body part.
MRI’s overused in Sports Injuries?
In a previous article, we highlighted the issue of MRIs scan leading to un-necessary back surgeries (Does more MRI scanners do more good or harm?). The issue now seems to be spreading to the sporting arena.
MRI-shoulder
A sports medicine orthopedist, Dr. James Andrews, wanted to test his suspicion that M.R.I. scans given to almost every injured athlete or casual exerciser, might be a bit misleading. He MRI-ed 31 pitchers who were perfectly healthy, and had no problems with pain, discomfort, or performance in their pitching arm. As suspected, the MRI picked up problems in the rotator cuff and shoulder cartilage of nearly 90 percent of these asymptomatic pitchers. For more about this story, read “Sports Medicine Said to Overuse M.R.I.’s“
This is a disturbing trend in medicine where we develop and build ever increasingly more accurate or more precise machines but our diagnostic ability to interpret the results is not always developing at the same pace. This phenomenon is known as “false precision” in science and engineering fields where data is presented in a manner that implies better precision than is actually the case; since precision is a limit to accuracy, this often leads to overconfidence in the accuracy as well.
Rotator Cuff – The Shoulder Stabilisers
When therapist and medical professionals talk about shoulder stability, they tend to stress the importance of proper rotator cuff function. What exactly is a rotator cuff? What is its role in shoulder stability?
What is the rotator cuff?
The rotator cuff is a layman term given to a group of 4 muscles and their tendons that connects the humerus and scapula. They essentially work to pull the humerus head into the glenoid cavity, providing integrity to the shoulder joint through its entire movement range.
The four muscles are the Supraspinatus muscle, Infraspinatus muscle, Teres minor muscle and Subscapularis muscle.
The rotator cuff muscles are relatively smaller than the ‘big’ shoulder muscles such as the deltoids, trapezius. While their role in the large movements of the arm are smaller in terms of ‘force’ exerted, they play a crucial role in enabling those movements. They keep the glenohumeral joint stable allowing the bigger muscles to work more effectively. As you can see from the diagram above, the four muscles are arrange to almost around all the point of the humeral head. This allows at least one of the four muscles to be able to ‘pull-in’ the humeral head into the glenoid cavity.
Why is stability of the joint important in terms of effective movement?
A key principle that the body employs is the lever and fulcrum principle. This allows us to move large objects with a smaller amount of force. And one of the key efficiency factor is the stability of the fulcrum. The lever principle depends on a firm and stable fulcrum to rest the lever of one through the movement. So how does the rotator cuff contribute towards the shoulder joint stability?
Take for a example when we raise our arm up from the side. This movement is primarily driven by our bigger deltoid shoulder muscle. However, given the shape and the angle of the glenoid cavity, this movement pulls the humeral head upwards out of the gleniod cavity. So without the rotator cuff muscles, the shoulder joint would ‘slip’ upwards and outwards a little from the glenoid cavity, changing the fulcrum position, resulting a poor performance of the deltoid muscles in raising the arm.
Take a look at our previous article to discover how to best strengthen your rotator cuff muscles: The rotator cuff stability
Another source for shoulder pain: Could it be the AC joint?
Rotator cuff tears, frozen shoulder and impingement are all very common and well known conditions that may produce dysfunction at the shoulder. Less common but still potentially problematic and therefore another important consideration when determining the source of shoulder pain is the Acromion clavicular (Ac) joint.
Anatomy
The clavicle (collar bone) has 2 joints a medial (to sternum) and lateral end (to the acromion of the scapula-shoulder). The Ac joint refers to the lateral articulation with the acromion of the scapula. The joint is stabilised via the acromioclavicular, coracoacromial and coracoclavicular ligaments and the upper and middle fibers of trapezius muscles aswell as well as the deltoids.
Injuries
Ac joint dysfunction is a result of a sprain, dislocation, fracture or osteoarthritis at this joint
Dislocation and sprain
The Ac joint is usually injured by a direct fall onto the top of the shoulder, cycling injuries, or associated with over head throwing (Javelin) athletes. The shoulder blade (scapula) is forced downwards and the clavicle (collarbone) appears prominent. The degree of injury at the joint is classified by the separation of the joint and damage to ligaments supporting it. A sprain suggests ligament injury whereas a dislocation refers to the clavicle moving upwards and backwards out of its normal alignment. The degree of this separation between the clavicle and acromion is graded on a 6 point scale, with grade 3-4 or higher requiring surgery.
The altered position of the clavicle, disrupts the normal rotation action of thr clavicle that is required to achieve end range forward flexion (overhead ROM). Pain will occur as a result of over stretched/ ruptured ligamemts (depending on the severity) and a stretched joint capsule. As a protective mechanism, pain tends to lead to altered postures which may comtribute to neck pain and altered muscles activity of muscles that attach to the clavicle; such as the pecs, trapezius and sternocleidomastoid.
Fracture
The fracture may occur at the distal end of the clavicle following contact sports injuries, bicycle and car accidents.
Arthritis
The incidence of arthritis at this joint has been shown to be about 50% in MRI studies of elderly populations, however these people may be asymptomatic.
Just like any arthritis this refers to degeneration of the cartilage at the ends of the clavicle and acromion. Normal day-to-day activities that require repetitive arm motion can cause cartilage loss (primary osteoarthritis). In addition arthritis may be due to cartilage degeneration after an injury to the joint (post traumatic arthritis). Regardless of the cause, predominately the normally smooth cartilage, as well as the meniscus between the bones breakdown leading to pain, due to increased friction and thus creating an inflammatory response at the joint.
Signs and Symptoms
Arthritis
Pain and stiffness of the joint is a common symptoms as is catching and “clicking” at the shoulder. Usually, these complaints are worst with overhead activity or with positioning the arm across the body. These are both common positions of the arm- from daily activities such as brushing your hair or reaching your back pocket, putting a shirt on, to sports activities such as a golf swing.
Dislocation and sprain
Pain initially may be widespread throughout the shoulder until the acute phase resolves, following this stage the person will demonstrate specific tenderness at the site of the end of the clavicle. Swelling and depending on the the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted (as in the case of a dislocation) and is seen in more severe injuries. Similar to arthhiritis the individual will report pain on moving the shoulder, especially with overhead activities and across your body motion.
Treatment
Acute injuries will respond to ice therapy, anti-inflammatory medications and a sling is often used.
Electrotherapy could be utilised to prevent the formation of scar tissue in the ligament and promote healing and decrease swelling.
Exercise therapy to restore strength and range of motion of both the neck and shoulder is vital. Strengthening exercises include lateral rotator work, as well as shoulder blade pinching exercises.
Taping can be applied to offload and realign the Ac joint.
Mobilisation of the Ac joint (clavicle) at painful ranges is also a common intervention used by physiotherapist to restore normal and pain free alignment.
If your not too sure whats causing your shoulder to hurt- book in to see a therapist for a shoulder assessment and treatment.
Suction Power – The Glenoid Labrum
The shoulder is a quite a unique joint in comparison to the rest of the joints in the human body. For example, what holds it up? Let’s take a deeper look. Deep beneath the skin and muscles, things turn out to be quite surprising.
The Shoulder Joint
The shoulder joint is simply the joint where the head of your upper arm (the humerus) meets your shoulder blade (the scapula). (shoulder joint comprises of 3 joint. glenohumeral joint -Where humerus meets the glenoid cavity of the scapula, acromionclavicular joint – collar bone to acromion of scapula, sternoclavicular joint. All contributes to movements of shoulder in varying degree. The generic term shoulder joint usually refers to the glenohumeral joint). The collar bone does not form part of the joint but instead joins the shoulder blade and the sternum, the large hard bony portion in the centre of your chest.
Two things about the shoulder joint that is different from the other big joints are
- The groove that the head of the humerus bone sits (glenoid cavity) in is extremely shallow (compared to say the hip joint).
- And compared to other joints, the joint is not held together by a set of ligaments found in other joint like the knee joint (anterior-cruciate and posterior-cruciate ligaments and the medial and lateral collateral ligaments). If the shoulder joint was held together by this
If the groove is very shallow and the joint is not bound by a set of strong tough ligaments, what holds up the shoulder joint that bears a lot of physical stress daily?
The answer is suction power.
The glenoid-labrum (a fibrous cartilage-like material) and joint fluid work together to create a suction-cup holding effect on the humerus head. The gleniod-labrum essentially deepens the sockets by acting like a skirting around the shallower glenoid cavity. The joint fluid through adhesive-and-cohesive forces holds the joint together even under great stress. This is akin to ‘wetting’ the suction-cup hook to stick better to a wall. (Watch the video).
Source: University of Washington, School of Medicine
Why is it different?
All this leads to the question, why is this joint different from the hip or knee joint? Why do it differently in the first place?
The answer is the degree of free the shoulder enjoys and the roles that freedom plays in the activities we do daily. If the glenoid cavity was deeper or the joint was held together with a set of strong ligaments, the amount of freedom of movement we now enjoyed would be severely limited.
Gym Users – Are you OVER-working the PECS?
If your gym workout is giving you neck and shoulder pains, you could be over-training your chest muscles. The key is a balanced training program that focuses on several muscle groups to prevent muscle imbalance developing and the consequent dysfunction
The effects of over developing one muscle group i.e. your chest muscles (pectorals) in the gym, whilst neglecting your back muscles, often affect your posture resulting in neck, back, and shoulder pain
To understand why this occurs, you must be familiar with the notion that most joints in our body have two or more separate and opposing sets of muscles acting on the joint. Take the elbow as an example.
When the biceps contracts and shortens, it bends the elbow joint. As the elbow bends, the opposing triceps, must relax and lengthen to allow this movement to occur. And vice-versa, for the elbow to straighten; the triceps contracts and shortens and the biceps must relax and lengthen.
To gain a well rounded physique you must consider strengthening more than just one, if not all the muscle groups. An over developed muscle (group) will create more tension on one side of the joint. Over developed muscles are also often tighter (shorter) than normal. The balance between muscles at the joint is lost, pulling the joint away from its mid-line and changes the angle of rotation at the joint.
The Shoulder
The shoulder is a more complicated joint, however the same principles apply.
From personal experience as a physiotherapist, one of the most common mistakes in the gym is over-training the chest muscles. This causes an imbalance between the muscles at the front of the body and those at the back. The shoulders with time are pulled forwards as the chest muscles get stronger, bigger and shorter, making the posture more rounded, creating pain and potential pathology.
Lateral postural Picture
Why is a rounded posture problematic?
Rounded postures place the shoulder joint in a unbalanced position away from the ideal centred position. This unbalanced position leads to increased compression at the shoulder, resulting in pain and reduced function:
- Compression of muscles and other structures at the front of the shoulder joint, may cause pain in the neck, and or down the front of the shoulder and side of the arm. Pain is usually worse with overhead activities. If the compression of the tendons continues for long enough, tears of the tendons (rotator cuff) may occur.
- Rounded postures often lead to neck pain. A large number of muscle that attach to the shoulder also attach to the neck at the other end. If these muscles are affected (lengthened and weakened by the pull of the shoulders) the neck often tends to rest into a head forward ‘chin-poke’ position. This increases the pressure on the neck joints and also other pain sensitive structures around the neck that can cause symptoms (Szeto, 2005).
- The shoulder’s range of movement is significantly reduced as a result of having less space for the joint to move. (Bullock et al, 2005)
Additional contributing factors leading to rounded shoulders
Modern Lifestyles
Think about all your daily activities; washing your face and hair, driving, sitting at the computer. People are becoming chair-shaped, and this keeps the shoulder in a rounded position.
Pain Response
Your body’s response to pain is another factor. When you have neck and shoulder pain we often adapt a rounded posture. This initially is good protective mechanism to prevent further damage for the first few days post-injury, however in the long term this posture keeps the shoulder in a poor/compressed position and will hinder healing.
How to correct your rounded posture?
As a guide, when looking from a side view your shoulders should be fairly central compared to the trunk, and the head should be central on the shoulders. A ‘plumb line’ from the centre of the ear should fall through the centre of the shoulder.
To get into this position roll your shoulders all the way forwards, then all the way back (your shoulder blades should touch), then find the mid-point between these two position. When you have this, gently tuck your chin in, so that your head is positioned on top of your shoulders.
Workout program to prevent the over-training
Weight-training:
If you work the chest 2 x weekly, doing 6-9 sets of 12 repetitions, then do the same amount of work, at the same load and intensity for the opposing muscle groups – the upper back muscles. Most chest exercises involve pushing – therefore to balance this and work the upper back you must include pulling type activity. Some ideas are provided below.
- Lat pull down
- 45 degree angle lat-pull down
- Seated row
- Bent over row
- Pull ups
- Shoulder external rotation
Stretching
As well as strengthening (which contracts and thereby shortens muscles), you should ALWAYS stretch all the muscles you have trained (lengthen the shortened muscles ) at the beginning and end of your workout to reduce tightness of these muscles. In this scenario it is therefore strongly recommended to stretch both the pecs and back muscles.
- Hold 30 seconds
- rest 30 seconds
- repeat x 3 (4 x daily)
References:
- Brukner and Khan. Sports Medicine
- Bullock, M., Foster, N., Wright, C., (2005). Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Manual Therapy 10, 28–37
- Kwok Tung Lau, Ka Yuen Cheung, kwok Bun Chan, Man Him Chan, King Yuen Lo, Thomas Tai Wing Chiu (2010). Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Manual Therapy 15 . p457-462
- Szeto, G., Straker, L., O’Sullivan, P., (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: Neck and shoulder kinematics. Manual Therapy. Vol 10. p 281–291
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
