Movement Science - PDF

Movement Science Jesse R. Hodges Jr. D.C., M.S., C.S.C.S. Assessment Mid Term 100 points Final Exam 100 points 2 Practicals 50 and 50 100 points TOTAL POINTS 300 points Definitions Mechanics The study of forces and their effects...

Movement Science Jesse R. Hodges Jr. D.C., M.S., C.S.C.S. Assessment Mid Term 100 points Final Exam 100 points 2 Practicals 50 and 50 100 points TOTAL POINTS 300 points Definitions Mechanics The study of forces and their effects Branch of mechanics that deals with the Kinematics geometry of the motion of objects (incl. displacement, acceleration, velocity) The study of relationships between the Kinetics force system acting on the body and the changes it produces in body motion uses principles of mechanics for solving Biomechanics problems related to structure and function of biologic and physiologic systems 3 Laws of MOTION!!!  Newton's First Law of Motion aka the Law of Inertia Inertia = resistance to having its state of motion changed by application of a force AN OBJECT AT REST STAYS AT REST AND AN OBJECT IN MOTION STAYS IN MOTION WITH THE SAME SPEED AND IN THE SAME DIRECTION UNLESS ACTED UPON BY AN UNBALANCED FORCE A system in equilibrium is either at rest or moving with a constant velocity Astronaut tools floating in space 5 Newton’s Second Law of Motion aka Law of Force and Acceleration THE ACCELERATION OF AN OBJECT DEPENDS DIRECTLY UPON THE NET FORCE ACTING UPON THE OBJECT, AND INVERSELY UPON THE MASS OF THE OBJECT If the state of motion of the system changes, a force must have been applied The observed change in motion is called acceleration 6 Newton's Third Law of Motion aka Law of Action and Reaction FOR EVERY ACTION, THERE IS AN EQUAL AND OPPOSITE REACTION The size of the force on the first object equals the size of the force on the second object The direction of the force on the first object is opposite to the direction of the force on the second object Forces always come in pairs - equal and opposite action- reaction force pairs 7 Chiropractic and Velocity What does velocity have to do with DISPLACEMENT: Chiropractic? overall change in position VELOCITY: the rate HVLA at which an object changes its position High VELOCITY, Low Amplitude chiro_adjustment Rate of displacement = RAPID Amplitude = short depth 8  Friction Static Friction exists when two contacting surfaces are not currently sliding relative to each other but do possess the potential for movement Coefficient of (static) Friction (s) Ratio required to initiate a sliding motion between two bodies represents the difficulty of sliding any given surface over another because of their textures 0.0 (frictionless) - 1.0 (maximum friction) Example s Rubber on concrete 1.0 Sandpaper on wood.8 Steel on steel.74 Waxed wood on snow.14 Shoes on ice.1 McLester (2008). Applied Biomechanics: Concepts and Synovial joints.01 9 Connections, 1st Ed. Friction Continued… WHY??? ▪ grooves, scratches, and pores on the surface of the objects interacting are “interlocked” and provide resistance  Torque Force= Lever Arm = 1 ft 20 lbs Force= Lever Arm = 2 ft 10 lbs 11 Image from www.bridgestonetrucktires.com Joints in Motion Jesse Hodges M.S., D.C. Physiology of Joints ▪ A joint is also known as an “Articulation” ▪ Structural Classification- Basically how each joint is anchored to the other ▪ Functional Classification- How much movement each joint is allowed Structural Classification of Joints – Fibrous connective tissue- ▪ Fibrous Joint – Cartilage- ▪ Cartilaginous Joint – Fluid filled space AKA Joint Cavity- ▪ Synovial Joint Functional Classification of Joints ▪ Immovable- Synarthrosis ▪ Slightly Movable- Amphiarthrosis ▪ Freely Movable- Diarthrosis (Most Common) Joints are articulations (joining) of bones. Synarthrosis and Amphiarthrosis ▪ Synarthrotic joint: immovable (Sutures of the skull and Manubriosternal Joint) ▪ Amphiarthrotic joint: slightly movable (IVD and the Pubic Symphysis) – Syndesmosis- bound by ligaments (between the tibia/fibula, metacarpals, and metatarsals) – Synchondrosis– bound by cartilage (pubis symphysis)  Joints are articulations (joining) of bones. Diarthrosis (Most Common) ▪ Divided into 3 categories based on the number of axes of motion each is allowed to move. ▪ An AXIS is the joints movement reference to the 3 anatomical planes of motion. – Sagittal – Frontal/Coronal – Transverse Diarthrosis: Categories of Movement ▪ Uniaxial- Movement in 1 plane of motion- Elbow Joint and Knee Joint ▪ Biaxial- Movement in 2 planes of motion- Metacarpalphalangeal Joint ▪ Triaxial- Movement in all 3 planes of motion- Shoulder and Hip Joint Physiology of Bones ▪ Bones are living tissue ▪ They have their own blood vessels ▪ Proteins, Mineral, and Vitamins make up the bone ▪ We are all born with 300 soft bones and has we grow and some of those bones fuse together we end up with 206 bones as an adult. What is the main function of bone?? ▪ Protection of vital organs ▪ Structural support ▪ It is where blood cells are produced ▪ Storage area for Calcium Two main types of bone ▪ Cortical- Which is the hard outer layer ▪ Cancellous- Which is a spongy inner layer  Lever Systems in the BodyE/F  L/R rare E/F L/R  L/R E/F  Type 1 Lever: Most commo Type 1 Lever n Type 2 Lever: Type 2 Lever Type 3 Lever: Type 3 Lever 22 Image from sites.google.com/site/drnormanherr/CSCS-Activities/cscs---physics/torque; Behnke (2012) Kinetic Anatomy With Web Resource-3rd Ed 4 Functions of a Simple Machine ▪ The body is a series of semi- rigid links. As a result, the articulations can be modeled after the simple machine called levers. All simple machines must serve one or more of the following four functions: ▪ (1) Balance 2 or more forces ▪ (2) Change direction of the applied force ▪ (3) Favor speed and range of motion ▪ (4) Favor force production Functions of Levers ▪ Function 1- Balances forces- the force and the resistance can be balanced if the force and the resistance are equal and the distance each of them and the axis is the same. ▪ Function 2– Changes the effective direction of the applied force- if the force is pushing down, it is apparent that the resistance will go up. ▪ Function 3– Favors speed and range of motion- in order for this to be true, we must move the axis closer to the applied force. In this new configuration, moving the force a small distance will cause the resistance to move a greater distance than the force is moved. Furthermore, since the force and the resistance are connected by a rigid link, the time it takes to move the force the small distance is the same time that it will take to move the resistance through the greater distance. ▪ Function 4- Favors force production when the axis is closer to the resistance. The advantage of this new configuration is the force moment arm is considerably longer than the resistance moment arm. This allows a smaller force to move a larger load. 1st Class Lever ▪ F – is supplied by the cervical extensors ▪ A – is supplied by the spine/skull articulation ▪ R – is supplied by the weight of the head, considered to act at the center of gravity of the skull ▪ In this type of lever the axis is always between the force and the resistance. This is the most versatile lever because it can be manipulated to serve all four of the functions of a simple machine. 2nd Class Lever ▪ In this class lever, the resistance is always closer to the axis of rotation than the force. This means that the force lever arm will always be longer than the resistance moment arm. This configuration therefore favors force (moment) production, since a smaller force can move a larger load due to the longer moment arm of the force. 2nd Class Lever cont… ▪ Heel Raise ▪ A – is supplied by the toes ▪ R - is supplied by the COG ▪ F –is supplied by the calf muscles ▪ Push-up ▪ A – is supplied by the feet ▪ R – is supplied by gravity ▪ F – is supplied by the ground 3rd Class Lever ▪ In this lever the force is always closer to the axis and favors resistance, speed, and range of motion. If the force is moved a small amount the resistance will move a greater amount in the same amount of time. This is the most common configuration in the body 3rd Class Lever cont… ▪ Bicep curl ▪ A– is supplied by the elbow ▪ F– is supplied by muscle force ▪ R– is supplied by the load in the hand Creep, Relaxation, Hysteresis Continued deformation over time when constantly loaded Creep Creep in tissue occurs due to the expulsion of water the corresponding eventual decrease in stress Relaxation that will occur as fluid is no longer exuded energy loss exhibited by viscoelastic materials Hysteresis when they are subjected to loading and unloading cycles 31 Intervertebral Disc Disc to Vertebral Body Ratio : height of the IVD compared to the height of the vertebral body A greater ratio means greater spinal segmental mobility The ratio is greatest in the cervical spine (2:5), least in the thoracic spine (1:5), the lumbar spine (1:3) is in between 32 Disc Height-to-Body Ratios Cervical Thoracic Lumbar Most Mobile Least Mobile In-between 33 Image from Bergmann (2011) Nucleus Pulposus Centrally located Mucoprotein gel with fine fibrous strands 70-90% water content 90% at birth 80% at age 20 70% at old age Bigger discs have more capacity to change size (creep) 34 Annulus Fibrosus Gradual differentiation from the nucleus Fibrous tissue in concentric laminated bands Same direction within a band Opposite directions in any two adjacent bands 35 Overnight Hydrostatic pressure  Osmotic pressure  Fluid volume in disc  Disc expands Result: Increased resistance to forces 36 During Daytime Fluid exits the disc Disc space narrows Loss in seated height  20mm Tension of ligaments  ROM  Lumbar flexion up to 50% 37 Elasticity With age and exposure to biomechanical stresses, the chemical nature of the disc changes and becomes more fibrous As a result, flexibility is diminished and more pressure is exerted on the annulus and peripheral areas of the endplate. A disc that has been injured deforms more than a healthy one 38 Loading Nucleus resists compressive forces Pushes out against annular fibers Annular fibers resist tensile forces Annular fibers “contain” nucleus because they resist being “stretched” 39  40 Image from ittcs.wordpress.com  Spinal Flexion on IVD ▪ Annulus ▪ Anterior Compression ▪ Posterior Tension ▪ Nucleus ▪ Anterior compression ▪ Posterior displacement ▪ Canals ▪ IVF increased 24% ▪ Central canal widened ▪ Tension applied to ▪ Ligamentum Flavum ▪ Z Joint capsule ▪ PLL  Spinal Extension on IVD ▪ Annulus ▪ Posterior Compression ▪ Anterior Tension ▪ Nucleus ▪ Anterior negative pressure draws forward ▪ Superior Vertebra tilts and glides posteriorly ▪ IVF narrowed 20% ▪ Central canal narrowed ▪ Motion limited by facet joints – ALL is only ligament limiting extension Tendons/Ligaments Fibrous tissue connecting muscle to bone (tendon) and bone to bone (ligament) Composed of collagen and fibrocytes Tendons joined to skeletal muscle at the musculotendinous junction 43 Biomechanical Behavior of Nerves Trauma and nerve entrapment may produce mechanical deformation of the nerves that results in the deterioration of function Common modes of nerve injury are stretching and compression 44  Image from commons.wikimedia.org Coordinate Systems  Cartesian Coordinate System aka Orthogonal or Rectangular Coordinate System Orthogonal coordinate system means its coordinate surfaces meet at right angles to one another The 3 axes of motion (x, y, and z) are each formed by the junction of 2 planes 46  Axes of Motion and Movement Translation movement in a straight line ALONG an axis Rotation movement occurs AROUND an axis Curvilinear Motion aka coupled movement combines rotation and translation (most common motion in the body) The potential exists for each joint to exhibit 3 translational movements and 3 rotational movements, constituting “6 DEGREES OF FREEDOM” 47  Relationship Between Body Planes and Axes of Motion X-axis: junction of the coronal and transverse planes Y-axis: junction of the coronal and sagittal planes Z-axis: junction of the sagittal and transverse planes 48 Image from bayswater.ca  S X-axis: always horizontal L A side to side Y-axis: always vertical Z-axis: R perpendicular to P X, front to back I 49 Image: Bergmann (2011). Chiropractic Technique Principles and Procedures, 3rd ed  3-D Cartesian Coordinate System TRANSLATION S (+) X-axis: (+) toward left (+) L A (-) toward right (+) Y-axis: (+) toward sup (-) toward inf Z-axis: (–) (–) (+) toward ant P I (–) R (-) toward post 50 Image: Bergmann (2011). Chiropractic Technique Principles and Procedures, 3rd ed  3-D Cartesian Coordinate System TRANSLATION + X-axis: + (sup) (+) toward left (ant) (-) toward right Y-axis: (+) toward sup (-) toward inf + (left) Z-axis: (+) toward ant * RIGHT hand (-) toward post 51 Image from law.resource.org  Body Planes and Movement Sagittal Divides: Plane Right-Left Frontal Divides: (coronal) Anterior- Plane Posterior Divides: Transverse Superior- Plane Inferior 52 Image from bayswater.ca Planes of Motion ▪ Sagittal or Medial Z Axis ▪ Frontal or Coronal X Axis ▪ Horizontal or Transverse Y Axis Understanding Restriction vs. Fixation  PRS Left Rotation Left Lateral Extension Fixation- Fixation-Right Bending Fixation- Flexion Restriction Rotation Right Lateral Restriction Bending Restriction  PRI Left Rotation Right Lateral Extension Fixation- Fixation-Right Bending Fixation- Flexion Restriction Rotation Left Lateral Restriction Bending Restriction  PLS Right Rotation Right Lateral Extension Fixation- Fixation-Left Bending Fixation- Flexion Restriction Rotation Left Lateral Restriction Bending Restriction  PLI Right Rotation Left Lateral Extension Fixation- Fixation-Left Bending Fixation- Flexion Restriction Rotation Right Lateral Restriction Bending Restriction  The elbow joint can only move in its Anatomical sagittal plane (local reference) no Position matter what position the body is placed within the classroom. (Universal Even when the elbow is flexing in a Starting (global) frontal, sagittal, or Position) transverse plane, it is still rotating in it’s (sagittal plane) local reference.  Image from www.buzzle.com Biomechanics of the Cervical Spine Cervical Spine More muscles associated with this region than any other Most mobile region of vertebral column Job is maintaining head posture while allowing for a great deal of mobility 62 Cervical Lordosis Cervical curve is least distinct of spinal curves Considered a secondary (compensatory) curve Helps absorb loads applied to spine Weight of head and neck Pull of spinal muscles 63 Image from wwww.cafechiropractorwalnutcreek.com Upper Cervical Spine Occiput-Atlas-Axis Most complex region of axial skeleton Atlanto-occipital and atlanto-axial articulations Anatomically and kinematically unique No IVD at either articulation 64 Image: Bergmann (2011). Chiropractic Technique Principles and Procedures, 3rd ed  Upper Cervical ROMs Representative Articulation Type of Motion Angle (degrees) Combined θX 25 Occiput-C1 One Sided θZ 5 One Sided θY 5 Combined θX 20 C1-C2 One Sided θZ 5 One Sided θY 40 65 White, AA., Panjabi, MM. Clinical Biomechanics of the Spine, 2nd ed. Lippincott Williams & Wilkins. 1990. Motion at Occiput - Atlas The anatomical structure at C0/C1 is “cuplike” in both the sagittal and frontal planes The lateral mass of C1 is shaped like a peanut This allows for little rotation 66 Image: Bergmann (2011). Chiropractic Technique Principles and Procedures, 3rd ed 67 Y Axis Rotation: Axial Occiput - Atlas rotation is limited The movement that does occur is predominantly in the elastic range at the end of total cervical rotation, where it is usually coupled with some small degree of lateral flexion Limited by Anterior and posterior walls of the C1 sockets Joint capsule tension Alar Ligament tension Ranges Recent studies have demonstrated a range of 4 to 8° to each side 68 Z Axis Rotation: Occiput - Atlas “Lateral flexion under physiological conditions has not been systematically demonstrated and studied” Mercer 2001 Although not physiologically accomplished, the motion can be induced One condyle elevates out of its socket, while the other serves as a Both condyles slide up their walls pivot Ranges 4-11° (induced in cadavers) 69 Z Axis Rotation: Occiput - Atlas The attachments of the alar ligament limit this motion The small amount that does occur is typically associated with some small degree of coupled rotation in the opposite direction This leads to rotation of the chin away from the side of lateral flexion 70 Y Axis Rotation: C1-C2 Role of C2: Transmit the axial load of the head to the cervical spine Permit lots of Y axis rotation “At the limits of rotation, the lateral atlanto-axial joints are almost subluxated” (Mercer 2001) Alar ligaments restrain this motion Range 43°  5.5° (Mercer 2001) Over 50% of the rotation of the neck! 1st 45% occurs at C1/C2 prior to any lower cervical contribution 71 Y Axis Translation: C1-C2 θY is coupled with Y translation Because the articular surfaces are both convex, as the atlas rotates on the axis, a subtle vertical displacement occurs, causing the two segments to approximate one another. 72 Image: Bergmann (2011). Chiropractic Technique Principles and Procedures, 3rd ed Checking θZ θZ is limited to  5 Why is lateral bending limited? The alar ligaments and the bony anatomy 73 The main ligament that limits upper cervical movement is the ligament. A. Apical B. Alar C. Transverse atlantal D. Vertical crus 74 The occiput-C1 joint favors which movement? A. Flexion/extension B. Lateral bending C. Y axis rotation 75 C1-C2 favors which motion? A. Flexion/extension B. Lateral bending C. Y-axis rotation 76 Ligamentous Influence on Motion Ligament Motion Limited Anterior Longitudinal Negative θX (Extension) (ALL) Posterior Longitudinal Positive θX (Flexion) (PLL) Slows the last few degrees of Ligamenta Flava Positive θX (Flexion) Interspinous Positive θX (Flexion) Ligamentum Nuchae Positive θX (Flexion) Intertransverse Contralateral Lateral Flexion (θZ ) 77 Coupled Motion: C2-T5 ▪ Lateral bending to one side will result in rotation to the same side. Coupled Motion: T6-L5 ▪ Lateral bending to one side will result in rotation to the opposite side. Facet Orientation Facet Orientation Mnemonic: Superior Facet Inferior Facet Inferior orientation Facet Orientation orientation Cervicals – Thoracics – Lumbars Posterior AIL Anterior Superior AIM Inferior AIL Medial Superior facets will be Lateral OPPOSITE 80  Cervical Spine Proprioception Proprioception Sensory perception of movement or position within the body  Intervertebral Disc  Facet Joints Cervical Musculature 81  Pain Gate Theory Proprioceptive input flowing into the dorsal horn serves to disallow or modulates nociceptive input into the CNS The more open the "gates", the more pain messages pass through to the brain. Therefore, the person experiences high levels of pain The more closed the 'gates', the fewer messages can get through and the person experiences less pain 82  “Adjustments to decrease nociceptor input to the spinal cord seem to be an effective way to decrease ‘the hyperexcitable central state’” 83 Patterson M. The spinal cord: participant in disorder. J Spinal Manip: 1993:9(3)2-11 84 What structure that we discussed is responsible for LIMITING Y-axis and Z- axis rotation at C0-C1, and Y-axis rotation at C1-C2? A. Alar ligament tension B. Joint capsule tension C. Posterior cervical musculature tension D. Suboccipital muscle compression 85 What is the primary motion found at C1-C2? A. X-axis translation B. Y-axis translation C. Z-axis translation D. X E. Y Axial rotation F. Z 86 What is the primary motion found at Occiput-C1? A. X-axis translation B. Y-axis translation C. Z-axis translation D. X Flexion/Extension E. Y F. Z 87 What is the direction of orientation of the superior facets in the Cervical spine? A. Anterior/Superior/Medial B. Anterior/Superior/Lateral C. Anterior/Inferior/Medial D. Anterior/Inferior/Lateral E. Posterior/Superior/Medial F. Posterior/Superior/Lateral G. Posterior/Inferior/Medial H. Posterior/Inferior/Lateral 88 Cervical Curvature Begins to develop prior to birth Cervical lordosis aids in absorbing spinal loads Curve and the vertebral bodies dissipate loads 89 Anatomy Review with associated conditions  Suboccipital Rectus Capitis Posterior Major: – Origin: Originates from the spinous process of the axis (C2) vertebra. – Insertion: Inserts on the inferior nuchal line of the occipital bone. – Action: Extends and rotates the head. Rectus Capitis Posterior Minor: – Origin: Originates from the posterior tubercle of the atlas (C1) vertebra. – Insertion: Inserts on the medial part of the inferior nuchal line of the occipital bone. – Action: Extends and rotates the head.  Suboccipital continued Obliquus Capitis Superior: – Origin: Originates from the transverse process of the atlas (C1) vertebra. – Insertion: Inserts on the occipital bone between the superior and inferior nuchal lines. – Action: Rotates the head ipsilaterally (to the same side) and laterally flexes the head. Obliquus Capitis Inferior: – Origin: Originates from the spinous process of the axis (C2) vertebra. – Insertion: Inserts on the transverse process of the atlas (C1) vertebra. – Action: Rotates the head contralaterally (to the opposite side) and laterally flexes the head.  SCM Origin: Originates from two sites: the sternal head originates from the top of the manubrium of the sternum, and the clavicular head originates from the medial third of the clavicle. Insertion: Inserts on the mastoid process of the temporal bone and the lateral half of the superior nuchal line of the occipital bone. Action: Acting individually, each SCM muscle rotates the head to the opposite side and tilts it to the same side. When both SCM muscles work together, they flex the neck and extend the head.  Scalene Origin: The anterior scalene muscle originates from the anterior tubercles of the transverse processes of the cervical vertebrae (C3-C6). The middle scalene muscle originates from the posterior tubercles of the transverse processes of the cervical vertebrae (C2-C7). The posterior scalene muscle originates from the posterior tubercles of the transverse processes of the cervical vertebrae (C5-C7). Insertion: All three scalene muscles converge and insert on the first rib. Action: The scalene muscles, acting together, elevate the first rib during inspiration, assisting in expanding the thoracic cavity. They also flex and laterally bend the neck when acting unilaterally.  Pec Major Origin: Originates from two sites: the clavicular head originates from the medial half of the clavicle, and the sternocostal head originates from the sternum, upper costal cartilages (1st to 6th ribs), and aponeurosis of the external oblique muscle. Insertion: Inserts on the lateral lip of the intertubercular groove (bicipital groove) of the humerus. Action: The pectoralis major muscle is responsible for various movements of the shoulder joint. It flexes the arm at the shoulder joint, medially rotates the arm, and adducts the arm across the chest.  Pec Minor Origin: Originates from the anterior surface of the third to fifth ribs, near their cartilaginous extensions. Insertion: Inserts on the coracoid process of the scapula. Action: The pectoralis minor muscle plays a role in stabilizing and depressing the scapula. It also assists in protraction (forward movement) and downward rotation of the scapula.  Image from rehab.blogfa.com Biomechanics of the Thoracic Spine  Thoracic Spine Thought to be designed for rigidity Ribcage!! Protection of the thoracic viscera takes precedence over intersegmental spinal mobility LEAST mobile part of the spinal column Serves as a transition area between the Cervical and Lumbar Spines 98  Thoracic Spine is Transitional The upper thoracic spine tends to resemble the cervical spine The lower thoracic spine tends to resemble the lumbar spine 99  Thoracic Spine Addition of the articulations for the ribs makes the thoracic region unique Prone to chronic postural problems and myofascial pain syndromes Clinically important: biomechanical changes may result in effects to sympathetic nervous system (T1-L2) 100  Unique Functional Anatomy Spinous processes long and slender point obliquely downward overlap in the midthoracic spine LIMIT EXTENSION Transverse processes thick, strong, and relatively long concave facet on the anterior side Rib articulations!! 101 Image from Bergmann (2011) Facet Orientation Fairly steep 60° from the horizontal plane There is also a 20° Y axis rotation from the frontal plane Toward the midline Inferior articular process orientation: Anterior – Inferior – Medial AIL-AIM- AIL Superior articular process orientation: Posterior – Superior – Lateral 102 Image from Bergmann (2011) Thoracic IVD The IVDs are comparatively thin The disc height–to–body height ratio is 1:5 smallest spinal ratio This low ratio contributes to the least flexibility in the spine The nucleus is also more centrally located within the annulus than in other regions 103  Thoracic Curve Alterations in the kyphosis can be anatomic (structural) or postural (functional) A change in the primary thoracic curve is likely to produce a change in the secondary curves in the cervical and lumbar spine Often associated with chronic stretch of trapezius, posterior back and neck muscles which can induce local myofascial pain syndromes and headaches As the thoracic kyphosis increases, it crowds the thoracic viscera, interfering with normal physiologic functioning Juvenile kyphosis (Scheuermann disease) and osteoporosis can result in an increased thoracic kyphosis 104 1 12 Images radiopaedia.org 105  Old Scheuermann Disease 106 Image from www.methodistorthopedics.com Image from Palmer clinic patient Ranges of Motion Flexion and Flexion/Extension is restricted Extension is the most limited because of Extension the impaction of the articular processes (θX) and spinous processes Axial Rotation Rotation and lateral bending demonstrate nearly equal movement, with each (θY) exhibiting nearly twice as much movement as flexion and extension Primary movement T/S = Lateral Lateral Bending Coupled with Axial Rotation Bending (θZ) 107  Thoracic Lateral Bending/Axial Rotation Coupled Movement Lateral Bending (θZ) is always coupled with axial rotation (θY) Most apparent in the upper thoracic spine The coupling pattern is variable T1 – T4 spinous to contralateral side (like cervical spine) T5 –T8 spinous toward either the contralateral or Sometimes just split T/S in half: T1-6 like cervicals, T7-12 like lumbars ipsilateral side T9 – T12 spinous more to ipsilateral side (more likely to follow lumbar spine pattern) 108 Images from Bergmann (2011)  Functional Anatomy and Biomechanics of the Rib Cage: Anterior Ribs 1-7 connect to the True Ribs sternum directly via costal cartilage Ribs 8-10 attach False Ribs indirectly via shared costal cartilage Ribs 11-12 are free Floating Ribs floating, with no anterior attachment 109 Image from Bergmann (2011)  Functional Anatomy of the Transitional Areas Thoracocervical Junction (C6–T3) Movements are  between C6 and T3, but the coupled movements are the same as for the typical cervical region (e.g., lateral flexion is coupled with spinous rotation to the opposite side). The thoracocervical junction has been deemed a difficult area to adjust because of the structural characteristics for transition from the most mobile area of the spine to the least mobile area, as well as the external characteristics of distribution of body fat (dowager hump) and the shoulder and scapular muscles. 110 Bergmann (2011)  Functional Anatomy of the Transitional Areas Thoracolumbar Junction (T10–L1) The most significant structural characteristic in this area is the change from the coronal facet plane in the T- spine to the sagittal plane facets in the L-spine (typically occurs at T11 – 12) Posterior primary rami of the spinal roots of T12–L2 form the cluneal nerves and innervate the skin and superficial structures of the upper posterolateral buttock, posterior iliac crest, and groin area Dysfunction within the lower T-spine may refer pain into these regions and be mistaken for disorders of LS or SI regions Maigne believes this syndrome can account for up to 60% of chronic and acute back pain → Maigne Syndrome 111 Bergmann (2011)  Lower Thoracic Pain Distribution and Sensory Changes 112 Image from Bergmann (2011) What is the primary movement of the thoracic spine? A. Axial Rotation B. Flexion/extension C. Lateral Bending D. Coupled Axial rotation/lateral bending 113 What movement is most limited in the thoracic spine? A. Axial Rotation B. Extension C. Flexion D. Lateral Bending 114 What is the direction of orientation of the superior articular surface of the facet joints in the T/S? A. Anterior-inferior-medial B. Anterior-inferior-lateral C. Posterior-superior-medial D. Posterior-superior-lateral 115 What is the average angle of orientation of the facet joints in the T/S? A. 30 B. 45 C. 60 D. 90 116 Anatomy Review with associated conditions  Supraspinatus Origin: Originates from the supraspinous fossa of the scapula. Insertion: Inserts on the greater tuberosity of the humerus, superior to the insertion of the infraspinatus. Action: Initiates abduction of the arm at the shoulder joint and helps stabilize the humeral head in the glenoid cavity.  Infraspinatus Origin: Originates from the infraspinous fossa of the scapula. Insertion: Inserts on the greater tuberosity of the humerus, posterior to the insertion of the supraspinatus. Action: Externally rotates the arm at the shoulder joint and helps stabilize the humeral head.  Teres Minor Origin: Originates from the lateral border of the scapula, near the axillary border. Insertion: Inserts on the greater tuberosity of the humerus, inferior to the insertion of the infraspinatus. Action: Externally rotates the arm at the shoulder joint and assists in stabilizing the humeral head.  Teres Major ▪ Origin: The teres major muscle originates from the inferior angle of the scapula. Specifically, it attaches to the dorsal surface of the inferior angle and the lower portion of the lateral border of the scapula. ▪ Insertion: The muscle inserts onto the medial lip of the intertubercular sulcus (also known as the bicipital groove) of the humerus. It is situated just below the insertion of the latissimus dorsi muscle. ▪ Action: The main actions of the teres major muscle are: 1. Medial rotation of the humerus: The teres major helps in the internal or medial rotation of the arm at the shoulder joint. This action is commonly involved in movements like throwing a ball or reaching behind the back. 2. Adduction of the humerus: The muscle contributes to the adduction of the arm, bringing it closer to the midline of the body. This action is used, for example, when bringing the arm back to the body after a lateral raise. 3. Extension of the humerus: The teres major assists in the extension of the arm at the shoulder joint. It helps in movements like pulling or rowing motions.  Subscapularis Origin: Originates from the subscapular fossa of the scapula. Insertion: Inserts on the lesser tuberosity of the humerus. Action: Internally rotates the arm at the shoulder joint and helps stabilize the humeral head.  Levator Scapula ▪ Origin: The levator scapulae originates from the transverse processes of the upper cervical vertebrae. Specifically, it originates from the posterior tubercles of the transverse processes of the C1-C4 vertebrae. ▪ Insertion: The muscle inserts onto the superior angle of the scapula. More specifically, it attaches to the medial border of the scapula, between the superior angle and the spine of the scapula. ▪ Action: The main actions of the levator scapulae muscle are: 1. Elevation of the scapula: When both sides of the muscle contract simultaneously, they help raise the scapula toward the head, facilitating movements like shrugging the shoulders or lifting heavy objects. 2. Lateral flexion of the neck: When only one side of the muscle contracts, it tilts the neck to the same side. This action is involved in movements such as looking over the shoulder or tilting the head to the side. 3. Medial rotation of the scapula: The levator scapulae contributes to the inward rotation of the scapula, helping to stabilize and control its movement during various shoulder motions.  Biceps Origin: Long head originates from the supraglenoid tubercle of the scapula. Short head originates from the coracoid process of the scapula. Insertion: Both heads merge and insert on the radial tuberosity of the radius. Action: Flexes the elbow joint and supinates the forearm.  Triceps Origin: Long head originates from the infraglenoid tubercle of the scapula. Lateral head originates from the posterior humerus. Medial head originates from the posterior humerus, below the radial groove. Insertion: All three heads merge and insert on the olecranon process of the ulna. Action: Extends the elbow joint.  Pronator Teres Origin: Originates from two sites: the medial epicondyle of the humerus (common flexor tendon) and the coronoid process of the ulna. Insertion: Inserts on the lateral surface of the radius. Action: The pronator teres muscle is responsible for pronation of the forearm, which involves rotating the palm of the hand from a supinated (palm facing up) position to a pronated (palm facing down) position. It also assists in flexion of the elbow joint.  Supinator Origin: Originates from the lateral epicondyle of the humerus (common extensor tendon) and the radial collateral ligament. Insertion: Inserts on the lateral and posterior surface of the proximal radius. Action: The supinator muscle primarily acts to supinate the forearm, which involves rotating the palm of the hand from a pronated (palm facing down) position to a supinated (palm facing up) position. It works in conjunction with the biceps brachii muscle during supination and assists in elbow flexion.  Image from neurosciences.beaumont.edu Biomechanics of the Lumbar Spine  Lumbar Spine The most important characteristic of the L/S is that it must bear tremendous loads created by body weight that interact with forces generated by lifting and other activities involving powerful muscle actions In addition, the lumbar spine is largely responsible for trunk mobility These roles place significant biomechanical demands on this region 129  Lumbar Motions Flexion/Extension (θX) is primary movement in L/S 75% of trunk Flex/Ext TWICE as much occurs in L/S FLEXION as extension Axial rotation (θY) limited overall due to sagittal facet orientation 130  Intervertebral Disc Lumbar IVDs are well developed Nucleus is localized somewhat posteriorly in the disc Disc height–to–body height ratio is 1:3 This relationship allows for more movement than T/S (but less than C/S) and gives the disc greater resistance to axial compressive forces 131  Secondary Lordotic Curve Starts to develop  9 - 12 months of age/beginning to sit up Becomes established as learn to stand,  18 mos Apex of curve is L3–4 disc Normal lumbar lordosis should be 20 - 60° 132 Image from Bergmann (2011)  Importance of Sacral Base Angle In the upright bipedal posture, the Changes in the sacral base angle can lumbar curve, as well as the rest of the influence the depth of the A-P curves in spine, is balanced on the sacrum the spine The sacral base angle  with a posterior The sacral base angle  with an anterior pelvic tilt, resulting in a  in the lumbar pelvic tilt, resulting in an  in the lumbar lordosis, placing more weight-bearing lordosis, which places more weight- responsibility on the disc and  the bearing responsibility on the facets spine's ability to absorb axial compression forces 133 Image from fixtheneck.com  Kinetics of the Lumbar Spine Quadratus lumborum (QL) is the major stabilizer of the L-spine During flexion, extension, and lateral bending tasks, QL is always active 54% during 42% during 74% during isometric standing heavy lifts lateral bending isometric twists holds 134 Quadratus Lumborum 135 Image from www.i-l-fitness-jp.com  Ligament Damage Trauma most likely causes ligament damage Joint laxity is the result Joint degeneration follows “Ligament damage marks the beginning of the end” -- McGill 136 What is the primary motion in the lumbar spine? A. X B. Y C. Z D. All motions occur equally 137 What motion in the lumbar spine is most limited? A. X B. Y C. Z D. All motions limited equally 138 What structure is responsible for limiting Y in the lumbar spine? A. Facets B. IVDs C. Spinous processes D. Uncinate processes 139 What is the angle of orientation of the facets in the lumbar spine? A. 30 B. 45 C. 60 D. 90 140  Image from teachmeanatomy.info Biomechanics of Pelvis and Sacrum  Pelvic Joints 3-joint complex, with much the same function as the typical vertebral functional unit The 2 SI joints + the pubic symphysis Probably the least understood and most controversial function of any area in the musculoskeletal system 142  Pelvic Joints SI joint originally viewed as an immobile syndesmotic joint Now know that the SI joints are mobile synovial joints, important to the statics and dynamics of posture and gait Provide support for the trunk, guide movement, and help to absorb the compressive forces associated with locomotion and weight-bearing Dysfunction of the SI joint is often ignored by other health care practitioners as an insignificant feature of musculoskeletal problems 143  SI Joint Development At birth, the joints are undeveloped, smooth, and flat After ambulation starts, the joints begin to take on their adult characteristics In teen years, the joint surfaces begin to roughen and develop their characteristic grooves and ridges In later years, high % of (male) patients will have interarticular adhesions across the SI joints and will have lost SI joint motion 144  Sacroiliac Motions SI joint is a movable joint, but there is controversy as to exactly how it moves, how much it moves, and where axes of motion might be located Recent models also stress the SI joint's important role in maintaining stability during the transfer of forces between the lower extremity and the spine The SI joint is most active during locomotion During locomotion the SI joints Movements of flexion/extension in one flex/extend in unison with the joint are mirrored by the opposite corresponding hip joint movement at the other joint 145  Illi's Model of SI Motion Reciprocal innominate and Counter- Nutation sacrum motion during hip/SI nutation P joint flexion/extension: As the left innominate moves posteriorly/inferiorly, the left sacral base moves anteriorly/inferiorly (nutation) As the right innominate moves anteriorly/superiorly, the sacral base moves R L posteriorly/superiorly (counternutation) AS Ilium A PI Ilium 146 Image from Bergmann (2011) 147 148  “The function of muscles is not to generate motion at the SI articulation; rather, muscle function is to brace the area and create stability for effective load transfer” - Harrison 149 150 Sacral Fixation SAL SAR 151 AKA: AKA: Flexion malposition Extension malposition Nutation Counternutation APEX Posterior (?) Neutral BASE Posterior (BP) 152 The sacral listing SAR refers to: A. Sacrum anterior right B. Sacral apex right C. Sacro-iliac anterior right D. So absolutely right 153 The function of muscle and fascia in the sacroiliac region is to: A. Increase mobility B. Induce greater moment arms C. Increase stability 154 Anatomy Review with associated conditions  Quadratus Lumborum Origin: Originates from two sites: the posterior iliac crest (lower fibers) and the transverse processes of the lumbar vertebrae (upper fibers). Insertion: Inserts on the twelfth rib and the transverse processes of the upper lumbar vertebrae. Action: The quadratus lumborum muscle has several actions depending on the movement of one side or both sides: – Acting unilaterally (one side): It laterally flexes the vertebral column to the same side, aids in ipsilateral (same side) rotation of the lumbar spine, and elevates the hip on the opposite side. – Acting bilaterally (both sides): It helps in extension of the lumbar spine, assists in stabilizing the 12th rib during inspiration, and supports posture.  TFL ▪ Origin: The TFL muscle originates from two main points: 1. Anterior superior iliac spine (ASIS): The TFL attaches to the ASIS, which is a bony prominence located at the front and top of the pelvis. 2. External lip of the iliac crest: The muscle also originates from the outer edge of the iliac crest, which is the curved ridge on the upper part of the hip bone. ▪ Insertion: The TFL inserts onto the iliotibial tract (IT band), which is a thick band of connective tissue that runs down the side of the thigh. The IT band extends from the hip to the knee and serves as a point of attachment for several muscles. ▪ Action: The main actions of the TFL muscle are: 1. Hip flexion: The TFL assists in flexing the hip joint, which involves bringing the thigh forward towards the abdomen. It works in conjunction with other hip flexor muscles during activities like walking, running, and cycling. 2. Hip abduction: The TFL is a primary muscle responsible for hip abduction, which involves moving the thigh away from the midline of the body. This action is particularly important during activities like side stepping, lateral lunges, and maintaining balance on one leg. 3. Medial rotation of the hip: The TFL contributes to the internal or medial rotation of the hip joint. This action occurs when the thigh turns inward towards the midline of the body.  Piriformis Origin: Originates from the anterior surface of the sacrum, specifically the second to fourth sacral segments, as well as the sacrotuberous ligament, which connects the sacrum to the ischial tuberosity. Insertion: Inserts on the greater trochanter of the femur, which is located on the lateral side of the femur. Action: The piriformis muscle primarily acts as an external rotator of the hip joint. It laterally rotates the thigh when the hip is extended and abducts the thigh when the hip is flexed. Additionally, it assists in stabilizing the hip joint and contributes to the maintenance of proper pelvic alignment.  Psoas Origin: Originates from the lumbar vertebrae, specifically the transverse processes of the T12-L5 vertebrae, as well as the sides of the vertebral bodies of the T12-L5 vertebrae. Insertion: Inserts on the lesser trochanter of the femur, which is located on the posterior aspect of the femur. Action: The primary action of the psoas major is hip flexion, which involves lifting the thigh towards the abdomen. It also contributes to lateral flexion of the vertebral column and assists in stabilizing the lumbar spine.  Hamstring Origin: Semitendinosus and semimembranosus originate from the ischial tuberosity. Biceps femoris (long head) originates from the ischial tuberosity, and the short head originates from the linea aspera of the femur. Insertion: Semitendinosus inserts on the medial surface of the tibia, and semimembranosus inserts on the posterior medial condyle of the tibia. Biceps femoris inserts on the head of the fibula. Action: Flexes the knee joint and extends the hip joint. The long head of the biceps femoris also laterally rotates the leg.  Quadriceps Origin: Rectus femoris originates from the anterior inferior iliac spine and acetabular rim. Vastus lateralis, vastus medialis, and vastus intermedius originate from the femur. Insertion: All four muscles merge and insert on the tibial tuberosity via the patellar tendon. Action: Extends the knee joint and assists in flexion of the hip joint.  Popliteus ▪ Origin: The popliteus muscle originates from the lateral condyle of the femur, specifically from the lateral epicondyle and the posterior surface of the lateral meniscus within the knee joint. ▪ Insertion: The muscle inserts onto the posterior surface of the tibia, near the medial side of the tibial plateau. Its insertion point is just below the lateral condyle of the tibia. ▪ Action: The main actions of the popliteus muscle are: 1. Knee flexion: The popliteus muscle initiates the movement of knee flexion. It works to unlock the knee joint by laterally rotating the femur on the tibia, allowing for easier flexion and extension of the leg. 2. Medial rotation of the tibia: The popliteus muscle internally rotates the tibia, which aids in unlocking the knee joint and initiating the flexion movement. It also helps to prevent excessive lateral rotation of the tibia during weight-bearing activities. 3. Stabilization of the knee joint: The popliteus muscle provides stability to the knee joint by controlling the movements of the femur and tibia during various activities. It helps to prevent excessive rotation and maintain proper alignment of the knee.  Tibialis Anterior Origin: Originates from the lateral condyle and proximal half of the tibia, as well as the interosseous membrane. Insertion: Inserts on the medial cuneiform and base of the first metatarsal bone. Action: Dorsiflexes and inverts the foot at the ankle joint.  Peroneus Longus ▪ Origin: The peroneus longus muscle originates from the head and upper two-thirds of the lateral surface of the fibula bone, which is one of the two lower leg bones. ▪ Insertion: The muscle inserts onto the medial cuneiform bone of the foot and the base of the first metatarsal bone, which is the bone connected to the big toe. ▪ Action: The peroneus longus muscle has the following main actions: 1. Eversion of the foot: The muscle helps in moving the foot outward, away from the midline of the body. This action is particularly important during weight-bearing activities, providing stability and preventing the foot from rolling inward (pronation). 2. Plantar flexion of the foot: The peroneus longus contributes to pointing the foot downward, known as plantar flexion. It assists in movements such as pushing off the ground during walking, running, or jumping. 3. Assists in maintaining the longitudinal arch of the foot: The peroneus longus muscle helps support and stabilize the arches of the foot, contributing to proper foot biomechanics and shock absorption.  Peroneus Brevis ▪ Origin: The peroneus brevis muscle originates from the lower two-thirds of the lateral surface of the fibula, below the origin of the peroneus longus. ▪ Insertion: The muscle inserts onto the base of the fifth metatarsal bone, which is the bone connected to the little toe. ▪ Action: The peroneus brevis muscle has similar actions to the peroneus longus: 1. Eversion of the foot: The muscle assists in moving the foot outward, away from the midline of the body. 2. Plantar flexion of the foot: The peroneus brevis contributes to pointing the foot downward, aiding in movements such as pushing off the ground during walking or running. 3. Assists in maintaining the longitudinal arch of the foot: Similar to the peroneus longus, the peroneus brevis muscle helps support and stabilize the arches of the foot.  Gastrocnemius Origin: Medial head originates from the medial femoral condyle, and the lateral head originates from the lateral femoral condyle. Insertion: Both heads merge and insert on the calcaneus via the Achilles tendon. Action: Plantarflexes the foot at the ankle joint and assists in flexing the knee joint  Soleus Origin: Originates from the posterior surfaces of the head of the fibula and the upper third of the tibia, as well as from the soleal line of the tibia. Insertion: Inserts on the posterior surface of the calcaneus (heel bone) via the Achilles tendon. Action: The soleus muscle is primarily responsible for plantarflexion of the foot at the ankle joint. It works in conjunction with the gastrocnemius muscle to exert force on the heel, allowing us to rise onto our toes, push off during walking or running, and maintain balance during standing and other weight-bearing activities. The soleus is especially active during activities that require prolonged plantarflexion, such as walking or standing for extended periods.  Flexor Digitorum longus ▪ Origin: The flexor digitorum longus muscle originates from the posterior surface of the tibia, near the middle third of the leg. It also has a small attachment to the interosseous membrane, which connects the tibia to the fibula. ▪ Insertion: The muscle inserts onto the plantar surface (underside) of the foot. Specifically, it attaches to the bases of the distal phalanges (toe bones) of the four smaller toes (second to fifth toe). It sends long tendons that travel along the foot and pass through the flexor digitorum longus tendon sheath. ▪ Action: The main actions of the flexor digitorum longus muscle are: 1. Toe flexion: The flexor digitorum longus flexes the four smaller toes, causing them to curl downward towards the sole of the foot. This action is involved in activities like gripping the ground while walking, running, or standing on tiptoe. 2. Plantar flexion: The muscle assists in plantar flexion of the foot, which involves pointing the foot downward. It contributes to movements such as pushing off the ground during walking or jumping. 3. Inversion of the foot: The flexor digitorum longus also assists in inverting the foot, which is the inward rotation of the sole towards the midline of the body.  Qualitative Biomechanical Analysis Jesse R. Hodges Jr. D.C., M.S.  Reciprocal Inhibition ▪ A decrease in the force production or neural drive in the functional movement of the antagonist (hamstring and quad or the biceps and triceps) caused by a tight muscle on the opposite side of the joint.  Synergistic Dominance ▪ Is a process in which the stabilizer, neutralizer, or synergist muscles take over for the inhibited prime mover. This can lead to an over use syndrome of that stabilizer, neutralizer, or synergist.  Arthrokinetic inhibition ▪ Caused by a dysfunction within a joint of the articular system. This can result in decreased range of motion and poor biomechanical movement patterns.  Relative Flexibility ▪ The body will seek the least amount of resistance during a functional movement. This results from muscle imbalances within the kinetic chain. (Michael Clark, director, national academy of sports medicine).  Cumulative Injury cycle ▪ This is a cycle of continued biomechanical dysfunction within the kinetic chain in the form of length tendon relationships, muscular imbalances, or articular deformation as a result of the injury sustained. Muscles only pull Key Term ▪ concentric muscle action: A muscle action in which the muscle shortens because the contractile force is greater than the resistive force. The forces generated within the muscle and acting to shorten it are greater than the external forces acting at its tendons to stretch it. Key Term ▪ eccentric muscle action: A muscle action in which the muscle lengthens because the contractile force is less than the resistive force. The forces generated within the muscle and acting to shorten it are less than the external forces acting at its tendons to stretch it. Lower crossed syndrome Posture Military Posture Tight Weak Low Back Abdominals Hip Flexors Hamstrings Kypholordotic Posture Suboccipitials Hip Flexors Pec Tight Traps Neck flexors Abdominals Weak Glutes Sway Back Posture Tight Weak Hamstrings Hip Flexors Low back Trap Neck flexors Glute Med Lets put the muscle and joint together  Qualitative analysis ▪ Divide the movement into Temporal phases ▪ Identify the joints involved and the movements occurring at those joints ▪ Determine the type of muscle contraction – Identify the predominant active muscle group at each joint ▪ Concentric ▪ Eccentric ▪ Isometric ▪ Determine Speeding up or slowing down of joint motions and where they occur ▪ Identify any extremes in joint range of motion  The bench press Joint Phase of Joint Motion Muscle Active Rapid Extreme motion Contraction Muscle acceleration range of Group or impact motion Elbow Down Flexion Eccentric Extensors At end of Full flexion at phase the end of Up Extension Concentric Extensors At start of phase phase Shoulder Down Horizontal Eccentric Horizontal At end of Full extension flexors phase horizontal Up Horizontal Concentric Horizontal At start of extension at flexion flexors phase the end phase  Standing Vertical Jump Joint Phase of Joint Muscle Active Rapid Extreme Motion Motion Contraction Muscle Acceleratio Range of Group n or Impact Motion Ankle Down Dorsiflexion Eccentric Plantar End phase Flexors Up Plantarflex Concentric Start phase Knee Down Flexion Eccentric End phase Extensors Up Extension Concentric Start phase Hip Down Flexion Eccentric End phase Extensors Up Extension Concentric Start phase Shoulder Down Hyperextend Concentric Extensors End phase Full Hyperext Up Flexion Concentric Flexors Start phase References ▪ Kendall,McCreary,Provance,Rodgers,and Romani; “Muscles: Testing and Function with Posture and Pain.” Fifth Edition ▪ Souza; “Differential Diagnosis and Management for the Chiropractor.” ▪ Liebenson; “Rehabilitation of the Spine.” ▪ Netter; “Atlas of Human Anatomy” ▪ Evans; “Illustrated Orthopedic Physical Assessment.” ▪ Vizniak; “Quick Reference Evidence Based Muscle Manual.” Arthrokinematics 189  Pelvis motion during open chain kinetic motion ▪ Anterior Tilt: – ASIS moves anteriorly and inferiorly ▪ Posterior Tilt: – ASIS moves posteriorly and superiorly ▪ Lateral lift to the right/left – One ASIS is higher than the other ▪ Rotation to the right/left – One ASIS is anterior to the other Pelvis ▪ Anterior Tilt- – Hip = Flexed – Spine = Hyperextended ▪ Posterior Tilt- – Hip = Extended – Spine = Flexed ▪ Left Lateral Tilt- – Hip = R Abd L ADD – Spine = Right Lateral Flexion 192 Pelvic motion related to trunk motion Pelvic motion related to hip motion  Cervical Shoulder Elbow Wrist Chest Common Issues and solutions Thoracolumbar Hip Knee Leg  Headaches- Suboccipital Torticollis- Levator Scap Cervical TOS- Scalene/Pec Minor  Radial Nerve (axillary)- Infraspinatus Radial Nerve (hand)- Teres major @ the corner of the scapula Shoulder Supine active or passive external rotation pain- Subscapularis Anterior lateral pain- External rotator cuff complex  Lateral Epicondylitis- Extensors and Supinator Medial Epicondylitis- Flexors and Pronator Elbow Carpal Tunnel- Pronator Teres  Wrist Majority of pain and lack of motion in the wrist is directly related to forearm tightness.  Majority caused by upper crossed syndrome Chest Crutches can lead to pec minor issues ▪ Thoracic strain- It will hurt in the area of involvement, treat there. ▪ Lumbar strain- QL ▪ SI joint- QL and Glute med Thoracolumbar and low ▪ Piriformis- mimics back disc, usually better with activity, pain stops at knee but can go to the foot- treat Piriformis  ▪ Lateral knee pain- IT band- TFL and Glute Med ▪ Pain with active knee flexion, and passive knee flexion with internal hip rotation- PSOAS Hip  Patellar Tracking- Vastus Lateralis If you cannot sit on your foot- Quadriceps (can be patellar Knee tendonitis) Posterior lateral knee pain- Popliteus  Shin splint- Anterior Tib and Soleus Plantar fasciitis- Flexor Digitorum and Calves Leg Achilles- Gastric and Soleus Ankle Sprain- Peroneal and Calves Functional Movement Assessments FMS (and equivalent), SFMA ▪ FMS and SFMA are two different systems used in the field of movement assessment and screening. While they share a common goal of evaluating movement patterns and FMs and SFMA defined identifying limitations or dysfunctions, they differ in their approach and scope. Over Head Squat ▪ Setup – Shoulder width Stance (armpit must be lined up with the medial part of the foot) – Feet forward – Arms at 90 degrees holding a bar and then press over head ▪ Findings – Patient cannot make parallel or has a decreased hip hinge= Psoas/Quad dominance – Knee valgus stress = Glute med/min weakness – Feet externally flare out on the way down = Piriformis – Patient falls forward or backward or cannot maintain neutral spine= Core weakness – Heels come up= ankle mobility/plantar fasciitis/ achilles tendonitis ▪ Rule out ankle and move up from that point Step Down ▪ Setup – Have patient on flat surface or on a 6-inch box – Have them step down, standing on the affected leg and take their unaffected heel on the ground and return to the starting position. ▪ Findings – Medial deviation of the affected knee = Glute Med/Min – Lateral knee pain on the affected side the whole way down = IT Band – Posterior lateral knee pain on the affected side upon unlocking the knee = Popliteus – Heel lifts and pain in heel on the affected side is relieved = Achilles – Heel lifts but pain increases on the affected side = Plantar fasciitis Wall Angel ▪ Setup – Heel, Butt, Low back, Upper back, Head, against the wall – Shoulders in 90-degree angle and flat against the wall ▪ Findings – Pain in shoulder when placing the setup actively = external rotators – No pain but inability to place shoulder is setup position = internal rotators – Pain over acromion process when placing shoulders = impingement – Scapula not on the wall in setup or wall slide = rotator cuff syndrome /scapula dysfunction – Low back not in contact with the wall even after feet are moved forward to allow pelvic tilt = psoas contracture  FMS Assessment The purpose of FMS is to provide a quick and systematic assessment of basic movements, highlighting areas of dysfunction or limitation that may increase the risk of injury or compromise performance. FMS does not provide a diagnosis but serves as a screening tool to determine whether an individual needs further evaluation or corrective exercises Deep Squat The deep squat assesses bilateral mobility and stability of the hips, knees, and ankles. The individual is asked to squat down as low as possible while keeping the feet flat on the ground and maintaining an upright posture. Scoring criteria: 3 points: Ability to perform the deep squat with proper form, maintaining a neutral spine, and keeping the heels on the ground. 2 points: Inability to maintain proper form but able to squat too at least parallel. 1 point: Inability to squat to parallel or significant compensation patterns observed. 0 points: Pain during the movement. Hurdle Step The hurdle step evaluates bilateral stability, balance, and mobility of the hips, knees, and ankles. The individual steps over a hurdle while maintaining a stable posture and avoiding compensatory movements. Scoring criteria: 3 points: Able to step over the hurdle with proper form, maintaining balance and stability throughout the movement. 2 points: Minor compensation patterns observed, but able to clear the hurdle without touching it. 1 point: Significant compensation patterns observed or inability to clear the hurdle without touching it. 0 points: Pain during the movement. Inline Lunge The inline lunge assesses bilateral hip mobility, knee stability, and dynamic balance. The individual lunges forward with one foot positioned in line with the other, while maintaining proper alignment and stability. Scoring criteria: 3 points: Able to perform the lunge with proper form, maintaining balance and stability throughout the movement. 2 points: Minor compensation patterns observed, but able to complete the lunge without losing balance. 1 point: Significant compensation patterns observed or loss of balance during the lunge. 0 points: Pain during the movement. Shoulder Mobility The shoulder mobility test evaluates bilateral mobility and stability of the shoulders and scapulae. The individual is asked to reach behind the head with one hand and behind the back with the other hand, while maintaining proper alignment and without compensations. Scoring criteria: 3 points: Able to perform the movement with proper form, reaching the required positions without compensations. 2 points: Minor compensation patterns observed, but able to achieve the required positions. 1 point: Significant compensation patterns observed or inability to reach the required positions. 0 points: Pain during the movement. Active Straight Leg Raise The active straight leg raise assesses bilateral hamstring and hip mobility, as well as core stability. The individual lies flat on their back and lifts one leg off the ground while keeping the knee straight, while the other leg remains flat on the ground. Scoring criteria: 3 points: Able to raise the leg to at least 80 degrees while keeping the opposite leg flat on the ground and without compensations. 2 points: Minor compensation patterns observed, but able to achieve at least 70 degrees of leg raise. 1 point: Significant compensation patterns observed or inability to raise the leg to at least 70 degrees. 0 points: Pain during the movement. Trunk Stability Push-up The trunk stability push-up evaluates core stability and upper body strength. The individual assumes a push-up position with hands and feet on the ground, while maintaining a straight line from head to heels, and performs a push-up. Scoring criteria: 3 points: Able to perform a push-up with proper form, maintaining a straight line from head to heels without compensations. 2 points: Minor compensation patterns observed, but able to complete a push-up with a relatively straight body. 1 point: Significant compensation patterns observed or inability to perform a push- up with a relatively straight body. 0 points: Pain during the movement. Rotary Stability The rotary stability test assesses core stability and rotary mobility. The individual assumes a quadruped position and reaches with the opposite hand and knee in a diagonal pattern, while maintaining stability and avoiding compensations. Scoring criteria: 3 points: Able to perform the movement with proper form, maintaining stability and reaching the required positions without compensations. 2 points: Minor compensation patterns observed, but able to achieve the required positions. 1 point: Significant compensation patterns observed or inability to reach the required positions. 0 points: Pain during the movement.  Selective Functional Movement Assessments (SFMA) Used to diagnose the patient’s primary reason for their movement dysfunction. SFMA aims to identify dysfunctional movement patterns and provides a framework to prioritize treatment based on the findings. It focuses on locating the primary source of movement dysfunction and applies targeted interventions to address the underlying causes.  Functional Nonpainful (FN) Functional Painful (FP) SFMA Grading Dysfunctional Nonpainful (DN) Dysfunctional Painful (DP)  Efficient Pain-free Functional and Nonpainful Optimal Dead End  Full Range of Motion Marker for pain Functional and Painful Movement and pain are linked Corrective exercise is not helpful  Is pain causing poor movement, or is No corrective poor movement exercises causing pain? Dysfunctional and Painful Treatment Manual therapy Psychological Taping Factors Modalities  Corrective Exercise is the WAY!!! With no pain, we focus on Dysfunctional and the movement Non-Painful pattern. Choose the largest limitation Pick the simplest exercise Steps: Asymmetrical > Symmetrical dysfunction/limitation Redundancy (Check and Recheck)  Cervical Patterns: Limited cervical range of motion: Positive result may indicate restrictions in neck mobility, such as reduced ability to rotate, flex, or extend the cervical spine. Pain with cervical movements: Positive finding suggests the Cervical presence of pain or discomfort during specific cervical movements, which may indicate underlying musculoskeletal or neural issues. Patterns Asymmetries in movement quality or range of motion: Positive result may highlight differences in movement quality or range of motion between the left and right sides of the cervical spine. Compensatory movements: Positive findings may include excessive involvement of the shoulders or thoracic spine during cervical movements, indicating a lack of isolated neck movement. Upper extremity patterns Limited shoulder range of motion: Positive result may indicate restrictions in shoulder mobility, such as reduced ability to flex, extend, abduct, or internally/externally rotate the shoulder. Pain with specific upper extremity movements: Positive finding suggests the presence of pain or discomfort during specific shoulder or arm movements, which may indicate underlying joint or soft tissue issues. Asymmetries in movement quality or range of motion: Positive result may highlight differences in movement quality or range of motion between the left and right upper extremities. Compensatory movements: Positive findings may include excessive wrist or spinal involvement during upper extremity movements, indicating compensatory strategies or movement patterns.  Limited thoracic spine extension: Positive result may indicate restrictions or reduced mobility in the thoracic spine, limiting the ability to extend the upper back. Pain or discomfort during extension movements: Positive finding suggests the presence of pain or discomfort during movements involving thoracic Multi-segmental extension. extension patterns Compensatory movements: Positive findings may include excessive lumbar extension or difficulty maintaining proper alignment during extension, indicating compensatory strategies or faulty movement patterns.  Limited lumbar or thoracic spine flexion: Positive result may indicate restrictions or reduced mobility in the lumbar or thoracic spine, limiting the ability to flex the spine forward. Pain or discomfort during flexion movements: Positive finding suggests the presence of pain or discomfort Multi-segmental during movements involving spinal flexion. flexion patterns Compensatory movements: Positive findings may include excessive hip or knee flexion or difficulty maintaining a neutral spine position during flexion, indicating compensatory strategies or movement compensations. Multi-segmental rotation patterns Limited thoracic or lumbar spine rotation: Positive result may indicate restrictions or reduced mobility in the thoracic or lumbar spine, limiting the ability to rotate the spine. Pain or discomfort during rotation movements: Positive finding suggests the presence of pain or discomfort during movements involving spinal rotation. Asymmetries in rotation range of motion or movement quality: Positive result may highlight differences in rotation range of motion or movement quality between the left and right sides of the spine. Compensatory movements: Positive findings may include excessive hip or shoulder involvement during rotation movements, indicating compensatory strategies or movement compensations.  Balance deficits: Positive result may indicate difficulties maintaining balance and stability while standing on one leg, suggesting potential deficits in proprioception or neuromuscular control. Difficulty maintaining single-leg stance: Positive finding suggests challenges in maintaining stability and control in a single-leg position. Instability or wobbling during the test: Positive result may indicate an unstable base of support or difficulties in weight shifting and maintaining equilibrium Single leg stance during single-leg stance. patterns Compensatory movements or muscle activation patterns: Positive findings may include compensatory strategies, such as excessive movements in the hips or trunk, or altered muscle activation patterns during the single-leg stance. Pain or discomfort during the test: Positive result suggests the presence of pain or discomfort during the single-leg stance, which may indicate underlying issues in the lower extremity or core stability. References All material was taken from Rehabilitation of the Spine, written by Dr. Craig Liebenson All information given is for educational use only A Functional Approach to Gait Analysis Jesse R. Hodges, D.C., M.S., C.S.C.S. REARFOOT FOREFOOT Inversion/Eversion vs. Supination/Pronation ▪ Calcaneus = Inversion ▪ Find limited – Causes subtalar joint Eversion/Inversion supination – Adjust/Treat = Calcaneus ▪ Calcaneus = Eversion ▪ Find limited – Causes subtalar joint Pronation/Supination pronation – Adjust/Treat = Subtalar joint Stance vs. Swing Phase Stance Phases ▪ Contact – Absorbing the shock ▪ Midstance – Store energy absorbed in contact to return it in the propulsive phase ▪ Propulsive – Utilize the energy to move up and forward Contact ▪ Begins at “heel strike” ▪ Ends at full forefoot loading ▪ 30% of the Stance Phase ▪ The subtalar joint moves from supination to pronation Midstance ▪ Primary Function – Store energy absorbed in contact to return it in propulsive phase ▪ Begins when the entire foot contacts the ground ▪ Ends when the heel leaves the ground ▪ HOLDING PERIOD – Subtalar joint position maintained – Rearfoot inverted – Forefoot supinated Propulsive ▪ Begins when the heel leaves the ground ▪ Ends with “Toe-off” ▪ Big Toe Dorsiflexion= 60-65 degrees ▪ The foot lock its articulations. – Rapid supination of the subtalar joint at heel lift – Center of pressure maintained beneath the lateral foot – Cuboid dorsiflexes and everts into the calcaneus – Locks forefoot and rearfoot The Impact ▪ The single most important factors in absorbing the shock are: pronation of the subtalar joint and eccentric muscle actions More later… Heel Strike/Initial Contact ▪ Anterior Tibialis concentrically contracts ▪ Quads eccentrically contact to minimize the amount of knee flexion ▪ Glutes are eccentrically contracted to assist with ground force reactions Flat Foot/Load Response ▪ Anterior Tibialis eccentrically contracts to prevent foot from slapping on the floor. ▪ Quads and glutes contract eccentrically. Midstance ▪ Plantar flexors contract eccentrically to control the rate at which the leg moves over the ankle. ▪ Quads concentrically contract to extend the knee. Heel Off/Terminal Stance ▪ Plantar flexors concentrically Stance Phase ▪ The stance phase involves: – Contact, Midstance, and Propulsive Periods HS FFL HL TO Contact Period Midstance Period Propulsive Period Toe Off/Pre-Swing ▪ Plantar flexors continue to contract concentrically ▪ Hip flexors begin to contract concentrically Acceleration/Initial Swing ▪ Rectus femoris, iliopsoas, hamstrings, and anterior tibialis all contracting concentrically Mid Swing ▪ Rectus femoris, iliopsoas, hamstrings, and anterior tibialis all contracting concentrically ▪ Glute med/min are concentrically contracted on the standing leg to prevent the opposite hip from falling while that leg is lifted. Deceleration/Terminal Swing ▪ Anterior Tibialis concentrically contracts to keep the ankle in a neutral position in preparation for the heel strike ▪ The knee is extending, so the quads are contracting concentrically ▪ The hamstrings are contracting eccentrically to keep the knee from snapping into extension  Swing Phase Adequate ground clearance ▪ Early (prior) – Gastrocnemius pushes the foot vertical and flexes the knee ▪ Midway – Iliopsoas induces hip flexion – Hamstring continues knee flexion ▪ Later, just prior to heel strike – Tibialis Anterior dorsiflexes and inverts the foot – Getting ready to absorb the impact Swing Phase Lower Extremity Musculoskeletal System Hip Extensor Hip Flexor Ankle Plantar Flexor  Swing Forward Ankle Plantar-Flexion Concentric Action Rapid rotation of the foot pushing the leg forward  Weak Ankle Plantar Flexion Hip Flexor Concentric Contraction pulling the thigh forward Lack of Ankle Plantar-Flexion Hip flexors must now contract stronger to swing the leg forward Lack of Knee Flexion Greater Hip Extension Energy stored in tight hip flexors Lacking Flexion Open Chain motions Calcaneus Calcaneus inversion eversion adduction abduction plantarflexion dorsiflexion supination neutral pronation Closed Chain motions Tibia Tibia External Rotation Internal Rotation Talus Talus Dorsiflexion Plantarflexion abduction adduction Calcaneus Calcaneus inversion eversion supination pronation Tight Shoes Normal Forces From heel strike, midstance, to the propulsive period, the forces move across the plantar surface of the foot in a typical pattern. Windlass Effect ▪ Dorsiflexion of the toes during propulsion results in the approximation of the rearfoot and forefoot ▪ This allows for the increased arch height necessary for stability Windlass Effect ▪ Midstance position ▪ This ends with the heel lifting off the ground  Windlass Effect  Toes eccentrically dorsiflexed  Pulls the plantar fascia  Approximated Rear – Forefoot  Increased arch height needed for stability Tens i on Making a Rigid Lever 1. By supinating the subtalar joint when the heel lifts, the cuboid and calcaneous lock – Close pack position 2. The plantar fascia is pulled tight during the “Windlass Effect” These two events are crucial in creating the rigid lever needed for ambulation  θZ and θY lumbar rotation Ipsilateral hip drop Chain reaction to internal femoral rotation pronation valgus knee stress internal tibial rotation subtalar pronation Functional Movement Assessment 269 Over Head Squat ▪ Setup – Shoulder width Stance (armpit must be lined up with the medial part of the foot) – Feet forward – Arms at 90 degrees holding a bar and then press over head ▪ Findings – Patient cannot make parallel or has a decreased hip hinge= Psoas/Quad dominance – Knee valgus stress = Glute med/min weakness – Feet externally flare out on the way down = Piriformis – Patient falls forward or backward or cannot maintain neutral spine= Core weakness – Heels come up= ankle mobility/plantar fasciitis/ achilles tendonitis ▪ Rule out ankle and move up from that point Step Down ▪ Setup – Have patient on flat surface or on a 6-inch box – Have them step down, standing on the affected leg and take their unaffected heel on the ground and return to the starting position. ▪ Findings – Medial deviation of the affected knee = Glute Med/Min – Lateral knee pain on the affected side the whole way down = IT Band – Posterior lateral knee pain on the affected side upon unlocking the knee = Popliteus – Heel lifts and pain in heel