New Hampshire Musculoskeletal Institute 17 th Annual Symposium, 2010 Michael J. Mullin, ATC, LAT, PTA OA Centers for Orthopaedics Physical Therapy

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1 New Hampshire Musculoskeletal Institute 17 th Annual Symposium, 2010 Michael J. Mullin, ATC, LAT, PTA OA Centers for Orthopaedics Physical Therapy Center Portland, Maine

2 Discuss manual therapy and other techniques to reduce dysfunction. Review involvement of other systems in treatment. Provide insight on positional and movement considerations with corrective exercises. Outline therapeutic exercise program to recondition lower extremity control.

3 Manual soft tissue techniques Myofascial release Positional release therapy Mobilizations With Movement Self mobilizations Passive and active Taping technique

4 Soft tissue massage (STM) to the medial posterior > lateral capsule and joint line. Begin with more superficial tissue (MFR) and work deeper Work slowly into direction of resistance and incorporate tri planar releases Utilizes rotation STM to popliteus, medial > lateral gastroc, and HS/pes Popliteus is often thickened and therefore lost some contractile qualities Becomes positionally inefficient

5 Positional release is often referred to as strain/counterstrain Philosophy is to based on the theory that tissue can develop tone or a shortened state in a specific location which can only be reduced by breaking the hyperactive (gamma gain) cycle. This is achieved by placing the affected tissue in a shortened state of comfort to reduce the tone (gamma efferent activity) and disrupting the dysfunctional position essentially tricking it into submission. While palpating the area of irritation, the practitioner moves bones to manipulate the tissue into a shortened state which typically eliminates the point tenderness. This position is maintained and held for at least 90 seconds. The body is then slowly taken out of this position which decreases the possibility that the affected tissue will return to its previously shortened state.

MCL point/medial knee capsule Patient supine with leg off side of table and bent 20 30 degrees Palpate the point of tone/pain at medial joint line Place a varus load

6 MCL point/medial knee capsule Patient supine with leg off side of table and bent degrees Palpate the point of tone/pain at medial joint line Place a varus load onto the knee than IR lower leg until tone is reduced Hold 90 seconds, slowly release Not uncommon to have to make subtle re adjustments of position during the treatment

7 ACL point/inferomedial fat pad. Patient supine with towel roll under the distal femur Palpate point of tone/pain Lower leg held in IR by practitioner s body then posterior glide of tibia with IR at the same time Hold 90 seconds, slowly release

ankle impingement with calf stretching Often poor balance with Elvis ankle Perform MWM s to

8 Can be assessed by palpation, especially with passive ankle dorsiflexion Can also be recognized by: Inability to squat fully Anterior ankle impingement with squatting Anterior ankle impingement with calf stretching Often poor balance with Elvis ankle Perform MWM s to the talus focusing on posterior gliding as they actively PF and DF Follow up with HEP of selfmobilizations.

9 Starting position Finishing position

11 Starting position Finishing position

13 Patient standing with tibia in IR, foot flat and turned inward and femur in ER Start with tape at fibula head and grasp distal femur and pull into ER Pull tape medially across front of tibia with some degree of force, maintaining force onto distal femur

Try and have tape lie flush on the skin without tape gaps or

14 Pull around back of knee, coming upwards at an angle, to back of thigh and finish at lateral mid thigh. Try and have tape lie flush on the skin without tape gaps or folds. Can be worn for a couple of days and often carryover benefit once removed.

15 Discuss manual therapy and other techniques to reduce dysfunction. Review involvement of other systems in treatment. Provide insight on positional and movement considerations with corrective exercises. Outline therapeutic exercise program to recondition lower extremity control.

actions are: compression of abdominal contents aiding the

16 Respiration? The power of breath Inhalation oxygenates blood, full exhalation promotes optimal diaphragmatic, and therefore abdominal muscle involvement Abdominal muscles major actions are: compression of abdominal contents aiding the diaphragm in exhalation maintaining stability between ribs and pelvis coordinating movement between ribs and pelvis

On inhalation, the diaphragm contracts and lowers while the pelvic floor relaxes and lowers On exhalation, the diaphragm relaxes and rises with the help of the abdominals while the pelvic floor

17 On inhalation, the diaphragm contracts and lowers while the pelvic floor relaxes and lowers On exhalation, the diaphragm relaxes and rises with the help of the abdominals while the pelvic floor contracts and raises Diaphragm s mechanical action has a direct relationship to pelvic floor, spine and rib cage Stabilizers?! Weak core? Abdominals need to learn how to function eccentrically upon inhalation to stabilize the ribs and pelvis from becoming too lordotic.

Poor respiratory control produces: Inspiratory muscle fatigue Paradoxic breathing Increased pressure to the system Deeper diaphragmatic breathing with full exhalation allows for optimal respiratory

18 Poor respiratory control produces: Inspiratory muscle fatigue Paradoxic breathing Increased pressure to the system Deeper diaphragmatic breathing with full exhalation allows for optimal respiratory and circulatory activity as well as reducing muscle hypertonicity Many people never completely empty the lungs, and the bottom of the lungs is a rich environment for bacteria growth it also holds the most oxygenated blood due to gravity.

19 Right vs. left diaphragm Rib position affecting function?

20 Normal vs. optimal breathing rate Sitting, decreased overall activity and convenience have shaped some of our habits and patterns Good ergonomics?! Our own society helps create the suboptimal environment for us to function in They mean well... Our brain was designed for efficiency but our bodies were made for movement The brain will always win

22 Our body is designed as a system based on pressure. It is what controls or ability to maintain our functions effectively. Our ability to control this pressure gradient through how we exert our system is one of the key things that further separates us from the rest of the animal world. Garden Hose analogy Double E s: Exhale with Effort

23 We live and function in a hyperinflated, asymmetrical compensatory pattern with locked joints exacerbated by a loss of intrinsics use and general muscle control Garbage in, garbage out

24 So then what is considered the core? Transversus abdominus & obliques Multifidi Diaphragm Muscles of the pelvic floor What about iliopsoas, hamstrings and ischiocondylar adductors? Foot intrinsics? Scapular and cervical stabilizers? Thoracic intercostal muscles?

26 Discuss manual therapy and other techniques to reduce dysfunction. Review involvement of other systems in treatment. Provide insight on positional and movement considerations with corrective exercises. Outline therapeutic exercise program to recondition lower extremity control.

27 Important to correct positional faults prior to instituting any progressive therapeutic exercise program Build a progressive base before getting them up into more advanced (i.e. weightbearing) exercises where compensation is more prevalent Educate athletes as to the nature of their injury, anatomical considerations, and what you are trying to accomplish so they are better able to: Institute it into their ther. ex. program, HEP, and ADL s Promote compliancy Reduce substitution

28 Facilitation and inhibition techniques Perturbation and rhythmic stabilization techniques once proper positioning has been established Regardless of level of function Self rhythmic stabilization techniques Full diaphragmatic inhalation and exhalation with pause Aids in setting the pattern Induces inhibition, thus allowing optimal facilitation Look to antagonist or contralateral side for reciprocal inhibition options Shut em off and turn em on

29 Get good frontal plane stability before progressing to weightbearing and/or multidirectionally mobile training (i.e. physioball, balance pads) If frontal plane control is not established, than it only continues to allow for substitution Good to train most therapeutic exercises with some IR and ER facilitation (i.e. bolster between knees, TB at knees) Most often more on one side then the other

Pelvis and core stabilization should begin with exercises in supine then sidelying to reestablish good pelvic control before instituting more

30 Pelvis and core stabilization should begin with exercises in supine then sidelying to reestablish good pelvic control before instituting more advanced exercises Focused work on some posterior pelvis tilting, positioning and control to reduce extension bias is essential. Make sure they re breathin!

31 Clam exercise note tibial IR Don t t let pelvis roll back Preferable clam due to WB simulation

32 R abduction lift with L adduction/ir Optimal plank position

33 Proper training and recruitment of the intrinsic foot muscles independent of the extrinsics is critical for stability and control when getting your patients into more WB exs. Differentiating between intrinsics and extrinsics when training is essential Should be done with neuromuscular re training and proper shoes vs. inserts as much as able

34 Incorporate some upper body into exercises as soon as able Introduce a counter rotation as able to control with previous exercise

TB resisted HS curls with IR Sitting on edge of chair first and progressing to physioball Band around heel and another wrapped around both legs just below knees.

35 TB resisted HS curls with IR Sitting on edge of chair first and progressing to physioball Band around heel and another wrapped around both legs just below knees. Flex knee while maintaining IR of tibia and outward pressure against band on same side. Maintain good positioning with slight posterior tilt and avoid shifting weight laterally. This shows set up position.

36 TB resisted HS curls with IR Starting position TB resisted HS curls with IR Finishing position

37 Half kneeling screen doors Half kneeling on one leg with TB wrapped around outside of leg just above knee. Shift weight forward a bit so equal weight on both legs while keeping planted foot flat. Rotate leg outwards against band. Bring thigh back to neutral, while avoiding femoral IR. This shows set up position.

38 Half kneeling screen doors Starting position Half kneeling screen doors Finishing position

40 Plank hip extensions Starting position Plank hip extensions Finishing position

41 Plank hip extensions with knee flexion Starting position Plank hip extensions with knee flexion Finishing position

42 It is important that careful instruction and monitoring of all exercises occurs to ensure optimal benefit and avoidance of desired compensatory patterns. Note starting position of feet with knees and heels separated but forefeet turned in towards each other. This IR is maintained throughout the exercise of extending hip and then going from flexion into extension and back.

45 Squats with TB at knees and bolster at feet Starting position Squats with TB at knees and bolster at feet Finishing position

47 Leg press with TB resistance Starting position (note foot position) Leg press with TB resistance Finishing position (note foot position)

48 Leg press with TB resistance Starting position (note changed foot position) Leg press with TB resistance Finishing position (note changed foot position)

56 TB resisted step ups Starting position TB resisted step ups Finish position

70 On the field considerations Early assessment of positional fault essential Utilization of manual corrective techniques immediately Muscle energy and facilitory/inhibatory techniques most effective for early correction Consider joint distraction to reduce compressive loading Let my iliopsoas go Get the athlete to practice smooth inhalation and exhalation techniques to reduce tone and spasticity

71 Important to understand the integration of all systems to effectively be able to rehabilitate and train an athlete The development of a therapeutic exercise program which includes selfmobilization techniques, careful instruction of an HEP and review of mechanics is essential. It is important to get your hands on the patient to feel for soft tissue thickening, joint mobility restrictions, and try to manually normalize dysfunction. Developing a smart, progressive rehab program, beginning with exercises which will produce the least amount of substitution Facilitatory techniques to aid in control Proper instruction on optimal recruitment techniques when performing ther ex is integral to recovery Where do you feel that? Reinforcement of alignment and recruitment with ADL s to reduce setbacks Get em all aligned, get em educated and get em moving

Snow Angels on Foam Roll

Snow Angels on Foam Roll Thoracic Mobilization on Foam Roll Lie on your back with a foam roller positioned horizontally across your mid back, and arms crossed in front of your body. Bend your knees so your feet are resting flat