Bruce Williams, DPM Breakthrough Podiatry 5/15/2012 BSMPG Lateral Ankle Sprain. Lateral Ankle Sprain Patellofemoral Inflammation

Transcription

1 Bruce Williams, D.P.M. Breakthrough Sports Performance Lumbar Sprain / Strain BSMPG

2 Sagittal Plane Progression Theory Pivot or Rocking Phases of Gait There are three primary pivotal phases: Lumbar Sprain / Strain Hamstring Strain Sagittal Summary the foot is viewed as a sagittal plane pivotal site which the body s centre of mass is permitted to move forward over the foot during the single support phase of gait. The swing limb helps to maintain propulsion of the body s center of mass....precise timing and direction of weight flow through the foot is needed to establish auto supportive functions Sagittal Plane Progression Theory In the foot, Sagittal plane progression may be blocked at the calcaneus, ankle joint, or the 1st MPJ (Perry J 1992 Gait analysis: normal and pathologic function. Slack, Thorofare, NJ) Assessment of Foot Pathology First MPJ Function Ankle Joint Midfoot Mechanics Limb Length Difference Sagittal Plane Mechanics ForeFoot Effects Heel Curve Gait Curve BSMPG

3 First MPJ Assessment If there is less than 65 degrees of available 1st mpj ROM during propulsion, the patient is considered to have structural hallux limitus. Root, Orien, Weed: Normal and Abnormal Function of the Foot. Level 3 Evidence First Ray Cutout A study by Hall and Nester, shows that a decrease in 1st mpj dorsiflexion motion leads to Sagittal plane compensations at the Ankle Joints, Knee Joint and Hip Joints.. Sagittal Plane Compensations for Artificially Induced Limitation of the First Metatarsophalangeal Joint, A Preliminary Study, C Hall, CJNester, JAPMA, Vol 94; No 3; May/June 2004 Level 2 First Ray Stability / Stiffness Stability of the medial forefoot is necessary from heel-rise to toe-off to support body weight and propulsive forces Excessive Movement of the first ray limits the effectiveness of the foot-lever system. The Reliability and Validity of a First Ray Measurement Device. WM Glasoe, HJ Yack. CL Saltzman. Foot & Ankle International / Vol. 21, No.3/March 2000 First Ray Cutout An unstable 1 st ray will lead to more weight shifted laterally towards the lesser metatarsal heads. Comparison of Two Methods Used to Assess First Ray Mobility. WM Glasoe, MK Allen, CL Saltzman. Foot & Ankle International Vol. 23, No.3 March Level 2 Evidence First MPJ Assessment Functional hallux Limitus (Fhl) represents a complete locking of the primary Sagittal plane pivotal site, the first MTP joint, strictly during all or portions of the single support phase of the gait cycle. This is true in spite of the fact that full range of motion occurs in the non-weight bearing examination. Lower back pain as a gait-related repetitive motion injury. H.J. Dananberg. Pages from movement Stability & Low Back Pain: The essential role of the pelvis. Edited by Vleeming, Mooney, Dorman Level 3 Evidence Midstance Mechanics Midstance Overlap Heel Curve Forefoot Curve Gait Curve BSMPG

4 Midfoot Mechanics The majority of motion that allows for dorsiflexion of the forefoot on the rearfoot comes from the medial and lateral columns of the foot, primarily the first and fifth rays, and not so much at the midtarsal joint. The rearfoot plays only a part of overall foot kinematics and we have consistently undervalued the contribution from mid- and forefoot articulations 17. Nester CJ, Liu AM, Ward E, et al. In vitro study of foot kinematics using a dynamic walking cadaver model. J Biomech 2007;40(9): Nester CJ. Lessons from dynamic cadaver and invasive bone pin studies: do we know how the foot really moves during gait? J Foot Ankle Res 2009 May 27;2: Lundgren P, Nester C, Liu A, et al. Invasive in vivo measurement of rear-, mid- and forefoot motion during walking. Gait Posture 2008;28(1): Wolf P, Stacoff A, Nester C, et al. Functional units of the human foot. Gait Posture 2008;28(3): All Level 2 Evidence at least Dorsiflexion Stiffness / Hypermobility Hypermobility of the first ray renamed by Kirby to Dorsiflexion Stiffness A stiffer 1 st ray means higher medial arch, in general. A less stiff 1 st ray means a hypermobile 1 st ray. Kirby KA, Roukis TS: Precise naming aids dorsiflexion stiffness diagnosis. Biomechanics, 12 (7): 55-62, 2005 Level 3 Evidence Peroneus Longus Biomechanics of the First Ray Part 1. The Effects of Peroneus Longus Function: A Three-Dimensional Kinematic Study on a Cadaver Model. CH Johnson, JC Christensen. The Journal of Foot and Ankle Surgery 38(5): , The peroneus longus stabilizes the medial column of the foot by everting and locking the 1 st ray of the foot. PL is active in midstance and heel-off and more active in flat footed patients. The muscle also abducts the FF on the RF. Root, M., Weed, J. W. Orien, Normal and Abnormal Function of the Foot, 1977 Tibialis Posterior Selective Activation of Tibialis Posterior: Evaluation by Magnetic Resonance Imaging. K Kulig, JM Burnfield, SM Requejo. Med. Sci. Sports Exerc., Vol. 36, No. 5, pp , Used MRI to determine how the Posterior Tibialis really functions. ForeFoot adduction is the primary action by this muscle. It helps to hold the lateral aspect of the foot against the medial aspect. Stabilizes the medial column while the Peroneus Longus stabilizes the lateral column. Achilles Affect Biomechanics of the First Ray Part V: The Effect of Equinus Deformity, A 3- Dimensional Kinemaitc Study on a Cadaver Model. CH Johnson, JC Christensen. The Journal of Foot & Ankle Surgery 44(1): , 2005 Increasing the load of the Achilles Tendon caused a reduction of the peroneus longus tendon on the medial column. Increased Achilles load caused an inversion of the 1 st metatarsal and also a flattening motion of the of the medial arch at the distal segments. BSMPG

5 Limb Length Difference Heel Curve Heel Off Gait Curve Limb Length Assessment Leg length inequality (LLI) is so common that it is considered the normal variant. Clinical Symptoms and Biomechanics of Lumbar Spine and Hip Joint in Leg Length Inequality. Friberg. Spine, Vol 8, No 6, Level 3 Evidence LLD is found in 90% of the population. Reported in Limb Length Discrepancy and Electrodynographic Analysis, D Amico, Dinowitz, Polchannoff. JAPMA Dec Level 3 Evidence The asymmetry of leg length is a common phenomenon, the left leg being longer in the majority of cases. Leg length asymmetry in stress fractures A clinical and radiological study. Friberg J. Sports Med., 22, 1982 LLD Gait Patterns Functional, or apparent LLD is a result of muscle (tightness/weakness) or (tightness/weakness) across any joint in the lower extremity or spine. Some of the more common causes can be pronation or supination of one foot in relation to the other Hip abduction/adduction or tightness/contracture Knee hyperextension due to quadriceps femoris weakness or early knee flexion Lumbar scoliosis. Review: Leg length discrepancy. Burke Gurney. Gait and Posture 15 (2002) Limb Length Difference They also found that the ankle joint of the long side leg demonstrated increased dorsiflexion at terminal stance and a delay in the timing of this peak, while the short leg ankle produces early heel rise and greater degrees of plantarflexion during stance. References from Leg length discrepancy an experimental study of compensatory changes in three dimensions using gait analysis. M. Walsh, P. Connolly, A. Jenkison, T. O Brien. Gait and Posture 12 (2000) Knee kinematics showed that the long limb side knee became more and more flexed during stance, double support and swing to clear the limb. The short side knee stayed extended late into midstance as the heel lift increased. There were no significant changes in the frontal or transverse planes. References from Leg length discrepancy an experimental study of compensatory changes in three dimensions using gait analysis. M. Walsh, P. Connolly, A. Jenkison, T. O Brien. Gait and Posture 12 (2000) Lateral Ankle Sprain In closed kinetic chain, Achilles preload from equinus deformity will magnify forefoot load to the lateral column and indirectly resist the action of peroneus longus via ground reaction. By dampening frontal plane function of peroneus longus, equinus apparently affects the locking mechanism of the medial column. This investigation suggests that equinus reduces peroneus longus locking influence of the first ray which may also lead to hyper-mobility. Biomechanics of the First Ray Part V: the Effect of Equinus Deformity, A 3-Dimensional Kinematic Study on a Cadaver Model. C. Johnson, J. Christensen. JACFAS 44(1): , 2005 BSMPG

6 Lateral Ankle Sprain The tibiofibular-talar unit does not function independently of the subtalar or midtarsal joint but acts cooperatively in closedkinetic chain performance. The various changes in ankle joint function influence the functional performance of the entire tarsus. citing Inman. Tarsal Functions, Movement, and Stabilization Mechanisms in Foot, Ankle, and Leg Performance. HW Vogler, F. Bojsen-Moller. (JAPMA 90(3): , 2000) Level 2-3 Evidence Causes of Anterior Knee Pain Trauma Extensor Knee Muscle Weakness Vastus Medialis Oblique (VMO) Increased Varus alignment of the lower extremity Tight Iliotibial Band Abnormal Q angle debated involvement Weak Hip Abductors Excessive STJ pronation in Stance Phase Plantar pressure measurements were taken of military recruits before 6- week basic training. During training 36 recruits developed patellofemoral pain. A Prospective Study on Gait-Related Intrinsic Risk Factors for Patellofemoral Pain. Y. Thijs, D. Van Tiggelen, P. Roosen, et al. Clin J Sport Med, Vol 1, No 6, Nov Results of Plantar Pressure measurements in subjects with patellofemoral pain: More laterally displaced pressure at initial foot contact Significantly shorter time to maximum pressure on the 4 th metatarsal A significant slower maximum velocity of the lateral to medial center of pressure movement A Prospective Study on Gait-Related Intrinsic Risk Factors for Patellofemoral Pain. Y. Thijs, D. Van Tiggelen, P. Roosen, et al. Clin J Sport Med, Vol 1, No 6, Nov The study authors concluded: Patients with anterior knee pain have a heel strike in a less pronated position Roll over more on the lateral side compare to controls A Prospective Study on Gait-Related Intrinsic Risk Factors for Patellofemoral Pain. Y. Thijs, D. Van Tiggelen, P. Roosen, et al. Clin J Sport Med, Vol 1, No 6, Nov What does this mean? BSMPG

7 Since we need the STJ to pronate to provide adequate shock absorption, less pronation may set these patients up for more impact or shock at the knee. This study found that runners suffering from anterior knee pain had 25% less pronation during the first 10% of support phase. Etiologic factors associated with anterior knee pain in distance runners. MJ Duffey, DF Martin, DW Cannon. Med and Sci in Sport Exercise, Knee Flexion Functional Data Analysis of Running Kinematics in Chronic Achilles Tendon Injury. OA Donoghue, AJ Harrison, N Coffey. Medicine & Science in Sports & Exercise Vol. 40, No. 7, pp , The study found that Achilles Tendon subjects were found to have greater peak, and range of Ankle DFion, Knee Flexion, and Eversion during stance. This resulted in collapse of the knee and foot into prolonged knee flexed, everted and dorsiflexed movement patterns. There is a continuation of the deep fascia linking the ipsilateral gluteus maximus and latissimus dorsi, with the sacroiliac joint at the center of the connection. The long head of the biceps femoris then continues on from the sacrotuberous ligament down to the head of the fibula. Vleeming et al. The Role of Sacroiliac Joints in Coupling Between Spine, Pelvis, Legs and Arms. From the head of the fibula the peroneal musculature descends to the midfoot and blends with the posterior tibial and anterior tibial musculature to complete the foot to back connection. Weakness in any segment of this connection can greatly contribute to subtle gait abnormalities. The Role of the Sacroiliac Joints in Coupling Between Spine, Pelvis, Legs and Arms. A. Vleeming et al. The Biceps tendon becomes relaxed as it inserts into the pelvis. With a decrease in hip extension this allows flexion of the torso, instead of hip extension. This then causes tension in the biceps tendon which then restricts the anterior rotation of the pelvis on that side. BSMPG

8 Gait Analysis Studies Hallux Limitus and Non-Specific Gait Related Bodily Trauma. H.J. Dananberg, M. Lawton, D. DiNapoli The authors describe the relationship of gait to chronic postural pain. They performed a study involving 18 patients with non-specific pain disorders ranging from knee pain, hip pain, chronic low back pain, and TMJ / Neck pain. In this study, 42% of the patients got % better, 35% got 50-75% better, and 23% got 0-25% better. None of the patients symptoms got worse! Chronic Low-Back Pain and its Response to Custom-Made Foot Orthoses. H. Dananberg et al This study utilized 32 subjects, average elapsed time was 13.8 months. Of the initial 32 subjects 84% experienced improvement. Of the follow up group, there was a 40% improvement in the outcomes in comparison to the Kobec study utilizing the Quebec pain questionnaire. The improvement was nearly two times as great as compared to traditional back pain care ( Physical Therapy). Therefore, pts utilizing gait analysis had twice as much improvement from the gait analysis alone, without any other concurrent treatment modalities, and only utilizing the custom orthotic devices! Lumbar Sprain / Strain Hamstring Strain Predictors of hamstring injury at the elite level of Australian football, Scand J Med Sci Sports 2006: 16: 7 13 ; B. J. Gabbe, K. L. Bennell, C. F. Finch, H. Wajswelner, J. W. Conclusions: Restricted ankle dorsiflexion range of movement warrants consideration in the development of prevention programs for hamstring injury. Potentially, dorsiflexion stiffness is a marker for an as yet unidentified or unmeasured factor such as proprioception. Poor proprioception or neuromuscular control could impact hamstring function and timing during the terminal phase of swing during sprinting, increasing the likelihood of hamstring injury at this time. Further studies needed. New Studies in Athletics 1 (March 1995), Vol. 10, Relative activity of hip and knee extensors in sprinting - implications for training by Klaus Wiemann and Günter Tidow BSMPG

9 Lumbar Sprain / Strain Hamstring Strain Adductor Injuries Hallux Limitus and it s Relationship with the Internal Rotational Pattern of the Lower Limb; J Am Podiatr Med Assoc 101(6): , 2011; G Lafuente,P Munuera, G Dominguez, M Reina, B Lafuente Results: The capacity of internal rotation of the lower limb was significantly lesser in patients with mild hallux limitus (P,.0001). Conclusions: Patients with mild hallux limitus had a lesser capacity of internal rotation of the lower extremity than did individuals in the control group. The more limited the internal rotational pattern of the lower limb, the more limited was hallux dorsiflexion. Adductor Injuries Adductor strain and hip range of movement in male professional soccer players; Journal of Orthopaedic Surgery 2007;15(1):46-9 Decreased range of movement (ROM) of the hip has been suggested as a risk factor for sportsrelated chronic groin pain in athletes. Decreased internal rotation and ROM of the hip are associated with chronic groin pain. Patients who have recovered from groin pain have a greater hip ROM than those who are still having pain. BSMPG