Evaluation, Treatment, and Exercise Rx for Muscle Imbalance in the Lower Extremities April 5, 2014 AOCPMR Midyear Meetingr Rebecca Fishman, D.O.

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1 Evaluation, Treatment, and Exercise Rx for Muscle Imbalance in the Lower Extremities April 5, 2014 AOCPMR Midyear Meetingr Rebecca Fishman, D.O.

2 Biomechanics of the Lumbar Spine and Lower Extremities Lower Extremity Pulley System affecting pelvis and spine. Optimal Function with symmetrical balance, posture, stretch and strength. Spine designed for weight bearing in correct alignment-posture Evaluate for Structural Asymmetries (Leg Length, Fracture, post surgical, pronation unilateral foot, scoliosis, varus/valgus deformities etc ) Goal is to maximize function

Spine designed for weight bearing in correct alignment-posture Evaluate for Structural Asymmetries (Leg

3 Rx Writing Form of Communication with Health care Team Individually prescribed Patient must take ownership of rehabilitation Principles of treatment of muscle Imbalances Sensory Motor Balance Training Stretching of short, tight, hypertonic muscles to symmetry Strengthening of inhibited, weak, hypotonic muscles to balance Aerobic Conditioning

Imbalances Sensory Motor Balance Training Stretching of short, tight, hypertonic

4 Sensory Motor Balance Training Proprioceptor: Dysfunction following Joint Injury Automatic feedback mechanism to control muscular tone Evaluation and Training. May include special equipment as training progresses Barefoot, carpet, shortened foot (lift arch-no toe curling) One leg stance> cross arms> eyes closed (30 seconds) Progress to more challenging movements

May include special equipment as training progresses Barefoot, carpet, shortened foot

5 Muscle Imbalance Based on works of Vladimir Janda, MD Basic Concept is that there are two types of muscles: Short/tight, facilitated, hypertonic muscles Weak, inhibited, hypotonic muscles When Particular Muscles are shortened/tight, they will inhibit other muscles, making them weak and hypotonic. Stretch Shortened muscles to symmetry prior to strengthening Hypotonic Muscles and incorporate proprioceptive training

Particular Muscles are shortened/tight, they will inhibit other muscles, making them weak and hypotonic.

6 Stretching Short-Tight Muscles Muscles must be stretched to Symmetry Specific muscles respond to injury/structural change by becoming short, tight and hypertonic. In the lower quarter, these muscles include: Illiopsoas Rectus Femoris TFL QL Short Adductors Piriformis HS Lumbar Erector Spinae

7 Strengthen Inhibited Weak Muscles Specific Muscles respond to stress by becoming weak and hypotonic. These muscles are thought to become inhibited by the hypertonic, short and tight muscles previously mentioned and will not be able to maximize their strength until the inhibiting muscles are brought into balance. Muscles include: Gluteus Max/med/min Rectus Abdominis, Internal/External Obliques Peroneal Vastus Med/lat Tibialis Anterior

and will not be able to maximize their strength until the inhibiting muscles are brought into balance.

8 Lower Crossed Syndrome Weak Glut. Max/med/min, Abdominals Tight Psoas, Erector Spinae, TFL and QL Increased Lumbar Lordosis and anterior pelvic tilt Hypermobility of lower lumbar levels Difficulty supine to sit

9 Lower Crossed Syndrome Weak Glut. Max vs. Short Hip Flexors Weak Abdominals vs. Short Lumbar Erector Spinae Weak Glut. Med/min vs. Short TFL and QL Anterior Pelvic Tilt and increased Lumbar Lordosis Hypermobility of L4-5 and L5-S1 Runners with tight HS/tears a/c weak glut and anterior hip capsule restriction

10 Evaluation and Treatment of Lower Quarter Hypertonic Muscles Supine Evaluation: Hamstring: medial and Lateral Gastroc/soleus Piriformis (above and below 90 degrees) Adductors (long and Short) TFL/Quad/Psoas Posterior Hip Capsule

Gastroc/soleus Piriformis (above and below 90 degrees)

11 Evaluation and Treatment of Lower Quarter Hypertonic Muscles Lateral: QL Prone: Anterior Hip Capsule (runners, stretch prior to quadpsoas stretch) Quads External-Internal Hip Rotators

12 Evaluation and Treatment of Lower Quarter Seated Evaluation: Tibial Torsion Abdominal Strengthening: Sit Backs Leg Length Evaluation Scoliosis SIJ Evaluation Brace-belts-orthotics-heel lifts Foam Rollers, therabands Pilates, Yoga Interventional Techniques, MSK US, CT scanogram

Scoliosis SIJ Evaluation Brace-belts-orthotics-heel lifts Foam

13 Compensation for decreased turn out In an effort to gain increased external rotation of the lower extremities, dancers cheat by using faulty body mechanics which leads to poor postural alignment and muscle imbalance placing the dancer at risk for injury. Anterior pelvic tilt (increased lumbar lordosis) Screwing the knee (mm, mcl damage) Foot pronation aka: Rolling in (calcaneal apophysitis, lig laxity.weak > extrinsic foot muscles, tendon-synovial sheath irritation, shin splints, FHL and post tibial tendonitis, plantar fasciitis and strain to knee, subtalar and mid tarsal joints)

Anterior pelvic tilt (increased lumbar lordosis) Screwing the knee (mm, mcl damage) Foot pronation aka: Rolling in (calcaneal apophysitis, lig

14 Evaluation of the young dancer Flexibility Strength at appropriate level of training Turn Out and compensatory mechanisms Tibial Torsion Foot flexibility Male vs. female Training Intensity

15 Thank You NUMC!!!!!! In Loving Memory to my very special mentors Richard Bachrach, DO and Stanley Schiowitz, DO Special thanks to Philip Greenman, DO, William Hamilton, MD and to Mrs. Karen Lynch

Flat foot and lower back pain

Flat foot and lower back pain Dr James Tang, MBA, BDS, LDS RCS General Dental Practitioner, NASM Corrective Exercise Specialist with special interest in postural dysfunction & lower back problems, Level