OTM Lecture Gait and Somatic Dysfunction of the Lower Extremity

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1 OTM Lecture Gait and Somatic Dysfunction of the Lower Extremity Somatic Dysfunction Tenderness Asymmetry Range of Motion Tissue Texture Changes Any one of which must be present to diagnosis somatic dysfunction. Tenderness Post exercise soreness Fibromyalgia Tenderpoints Trigger points Post Exercise Soreness Delayed onset Occurs after unaccustomed exercise connective tissue breakdown Blood lactic acid concentration measured from serum is not related to exercise-induced delayed muscle soreness Initial injury from mechanical damage or overstretch of the contractile apparatus Inflammatory response follows Invasion of neutrophils Release of cytokines that attract additional inflammatory cells Neutrophils release oxygen free radicals and lysosomal proteases Macrophages invade damaged fibers to phagocytose cellular debris Counterstrain Tenderpoints Muscle or tendon insertion sites Ligament attachment sites Muscle belly Shortening followed by rapid lengthening of muscle/ligament results in reflex guarding/shortening and inappropriate nociceptive reflex 1

2 Acute Ankle Sprains Up to 40% of individuals have residual symptoms due to chronic instability Most frequent in individuals with irregular activities Common Lower Extremity Tenderpoints Inversion ankle sprains - medial ankle and medial calcaneus Trochanteric bursitis lateral trochanter and posterior lateral trochanter Plantar fasciitis Flexion calcaneus Long Term Somatic Dysfunction Pathogenesis Neural segmental facilitation localized hyperexcitation Local impingement of neural, vascular, and lymphatic elements Altered biomechanics affecting mechanical loading of structures Altered biomechanics affecting muscular balance Altered biomechanics result in anatomical changes over time. Motions and Somatic Dysfunctions of the Lower Extremity Major vs Minor Motions Major motions are assessed by gross range of motion Minor motions are assessed by the quality of the barrier end feel. Glides are assessed as minor motions. Compare side to side. Femoral Acetabluar Joint Major motions of the hip: Flexion extension Abduction-adduction External rotation-internal rotation Minor motions: Anterior glide with external rotation Posterior glide with internal rotation Passive Range of Motion of Hip Abduction - 45 Adduction - 25 Flexion (with knee bent) Extension 30 Internal Rotation 35 External Rotation 45 2

3 Tibiofemoral Joint The major motions of the tibiofemoral joint are flexion and extension. The minor motions are the glides and rotations. These include: 0 Extension 135 Flexion Flexion results in anterior Extension results in posterior Abduction results in medial Adduction results in lateral 3

4 10 External Rotation of tibiofemoral joint 10 Internal Rotation of tibiofemoral joint External rotation results in anteromedial glide Internal rotation results in posterolateral glide Fibulotibial Joint Reciprocal motion present between proximal fibular head and distal fibula (lateral malleolus). Plantar flexion glides the fibular head posteromedially Dorsiflexion glides the fibular head anterolaterally Talotibial Joint 20 Dorsiflexion 50 Plantarflexion Dorsiflexion glides the talus posteriorly Plantar flexion glides the talus anteriorly 4

5 Interosseus Membrane (syndesmosis) Restricted motion of the interosseus membrane Affect ankle motion both proximally and distally Talocalcaneal Joint Eversion 5 Inversion 5 Eversion results in anteromedial glide of the talus with internal rotation at the tibia Inversion results in posterolateral glide of the talus with external rotation at the tibia Left Posterior View Left Posterior View Forefoot Primarily dorsal and plantar glides at the intertarsal joints. Compound Foot Motion Foot motion is a composite of motions of the hind foot (subtalar and tibiotalar) and the forefoot. Supination = Inversion + Plantar flexion + Adduction Pronation = Eversion + Dorsiflexion + Abduction 5

6 Gait Gait is divided into two main actions. The stance phase occurs on the weight bearing side (the side in contact with the ground). The stance phase is divided into four main actions - heel strike, flat foot (mid-stance), heel off and toe off. The swing phase occurs on the non-weight bearing side. The swing phase has three main actions - acceleration, mid swing and deceleration. As the quadriceps tighten at toe off to accelerate the leg into early swing phase, the tightening of the hip flexors causes anterior rotation of the innominate around an inferior transverse axis. During deceleration, the quadriceps extend the knee to prepare for heel strike. Upon heel strike the hamstrings contract causing the innominate to rotate posteriorly on an inferior transverse axis. Right Toe Off Right Heel Strike After heel strike the center of gravity shifts to the weight-bearing leg. As the center of gravity shifts, the lumbar spine sidebends towards the supporting side and rotates away. The upper pole of the ipsilateral sacroiliac joint becomes locked causing anterior rotation around an oblique axis extending from the ipsilateral upper pole to the contralateral lower pole. The resulting sacral rotation is opposite that of the lumbars. For example at right heel strike a right oblique axis is induced with the sacrum rotating to the right while the lumbar are rotating to the left. The sidebending of the lumbar spine that occurs with the shifting of the center of gravity is the basis of the Hip Drop Test. The Hip Drop Test screens for the ability of the lumbar region to sidebend away from the side of the hip drop (towards the weight-bearing side). Right Heel Strike 6

7 Ankle Sprains Inversion ankle sprain Supination = Inversion + Plantar flexion + Adduction Eversion ankle sprain Pronation = Eversion + Dorsiflexion + Abduction Inversion Ankle Sprains Inversion of subtalar joint Planter flexion of talotibial joint Posterior proximal fibula External tibial rotation Internal femur rotation Posterior innominate rotation Inversion Ankle Sprains More common because the foot is less stable in plantarflexion Anterior margin of the talus is wider than the posterior margin Anterior talofibular ligament most commonly injured Eversion Ankle Sprains Eversion of subtalar joint dorsiflexion of talotibial joint Anterior proximal fibula Internal tibial rotation External femur rotation Anterior innominate rotation Deltoid ligament most commonly injured Knowing the mechanics should allow you to predict compensatory dysfunctions to almost any injury 7

Balanced Body Movement Principles

Balanced Body Movement Principles How the Body Works and How to Train it. Module 3: Lower Body Strength and Power Developing Strength, Endurance and Power The lower body is our primary source of strength,