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Sacroiliac Joint Dysfunction and Hamstring Strains

Posted by atc_education on June 11, 2013 at 1:50 PM Comments comments (89)


SUBJECTIVE COMPLAINTS

Patients frequently complain of tight hamstrings. They “stretch them all the time” without any change. During the evaluation, they tend to present with normal soft tissue lengths of the hamstrings during the straight leg raise test. Yet, therapists will often give them hamstring stretches to work on as part of the home exercise program.

CLINICAL REASONING

The therapist must use sound clinical decision making in this case. By simply prescribing hamstring stretches treats the symptom but does not address the underlying dysfunction. The patient must be educated on why the hamstrings feel tight.

IDENTIFYING DYSFUNCTION

Patients complaining of hamstring tightness often present with anterior pelvic tilts. Their daily activities have created a muscular imbalance between the rectus femoris and the hamstrings group. This may occur due to prolonged sitting as with a desk job or it may be a response to training, especially in runners.

THE SEE-SAW AFFECT


Most of the joints in the body can be viewed as a see-saw. The joint itself is represented as the fulcrum or axis of the see-saw. The seats are representative of the muscles. When a child is placed on each end, the see-saw should remain relatively balanced. However, if a smaller child is put on one end against a larger child on the other side, a great imbalance occurs. The bigger child represents the short, hypertonic muscle, in this case, the rectus femoris. As the RF pulls inferiorly on the ilium at the AIIS, it can lead to anterior rotation of the ilia on the sacrum that produces subsequent sacroiliac joint dysfunction. As the AIIS moves inferiorly, the other side of the see-saw, the ischial tuberosities, moves superiorly. This increases the tension on the hamstrings that attach there. As tension increases, the hamstrings feel tight from being overstretched.

RETHINKING EXERCISE PRESCRIPTION

For the patients who are given hamstring stretches, they will experience short-term symptomatic relief from relaxation of the hamstrings. However, during this time, the rectus femoris can exert a great pull inferiorly due to the lack of resistance from the relaxed hamstrings. Over time, the pelvis will continue to rotate anteriorly and inferiorly and the hamstrings will continue to be overstretched. The chronic ovestretching can lead to tendonitis, tendonosis or strains (tearing) of the hamstrings. A more appropriate approach is to address the short, hypertonic structures: the rectus femoris. Initial treatment should consist of soft tissue techniques such as instrument assisted soft tissue mobilization can be utilized to quickly address any myofascial adhesions that are creating the shortening. The patient should be instructed on passive, non-weight-bearing stretches keep the length to the rectus femoris. Kinesiology taping with RockTape could also be utilized to change the tone of the rectus femoris as well. As the patient responds to treatment via improved soft tissue lengths of the rectus femoris, they may also require muscle energy technique to restore normal SI alignment. They would then be progressed to hamstring strengthening exercises to maintain neutral pelvic alignment. Rocktape may still be utilized for neuromuscular re-education to recondition the nervous system to hold the neutral pelvic alignment.

AUTHOR’S NOTE:

For patients who present with a posterior pelvic tilt, their hamstrings are actually short and hypertonic. However, they tend to complain of tightness in the front of their thighs for the same reason. Initial treatment should focus on restoring normal hamstring lengths and progress to strengthening the rectus femoris as it is the only quadriceps muscle that attaches to the pelvis.

Why do we have poor posture?

Posted by atc_education on May 25, 2013 at 9:05 PM Comments comments (55)

Does this Does this posture look familiar? 


Drs. Feitis and Schultz authored "The Endless Web" which discusses dysfunctions beginning in the womb. During this time, the flexors of the hips, shoulders, elbow and spine are in a shortened position for 9 months. This is also called the anterior fascial line by Thomas Myers in his book, "Anatomy Trains".

During the past, people did manual labor. During paleolithic times, people did manual labor such as squatting instead of sitting, climbing trees to retrieve food and lifting animals that were killed on hunts. In more recent times, they cut and lifted wood or hay. These activities would strengthen the posterior kinetic chain to offset the shortening of the flexors.

Modern society’s problem is the amount of computer work done. Many people sit for a minimum of 8 hours a day while at work and go home to their personal computer for more hours. The position in which most sit at a computer feeds into the long held dysfunctions that originated in the womb. A smaller screen causes movement closer to it.

Doing little to offset these shortenings is detrimental to our overall health and longevity. Numerous research studies link prolonged sitting with increases in morbidities.

Treatment guidelines should work on restoring length to the flexors. As soft tissue length improves, joint restrictions can be addressed to restore normal joint mobility. Also, treatment should focus on strengthening the extensors. Adjunctive treatments may include instrument assisted soft tissue mobilization and Fascial Movement Taping (FMT).

Reciprocal Inhibition and Pain Syndromes

Posted by atc_education on September 14, 2012 at 9:55 AM Comments comments (46)

The human body was designed for mobility, especially the musculoskeletal and myofascial systems. Yet, movement can often be a primary pain generator.

When normal movement occurs, reciprocal inhibition takes place to allow the muscles around a joint to act as a see-saw or pulley to move the bones. As the agonist of the movement shortens through concentric contraction, the antagonist of the movement must lengthen via eccentric contraction. The two muscles, along with synergists and stabilizers, work to provide a smooth, continuous movement.

For example, the primary muscle for hip flexion is the psoas as it is the local, single joint muscle at the front of the hip. The gluteus maximus serves as the primary hip extensor as, again, it is the only single joint muscle located posteriorly. During the swing phase of the gait cycle, the psoas concentrically contracts to move the femur into flexion while the gluteus maximus eccentrically contracts to allow the movement to occur.

At the time the foot contacts the ground, the muscles change roles as the femur changes direction. To propel the body forward, the gluteus maximus now performs a concentric contraction to pull the femur into extension. The psoas now switches to an eccentric contraction to stabilize the joint.

However, there are times when reciprocal inhibition can be detrimental to the body. One of the primary areas in athletes is medial tibial stress syndrome (MTSS aka “shin splint” characterized by pain on the anterior portion of the tibia. This often occurs in runners or jumpers (i.e. basketball or volleyball) and is due to either a change in training surface or a remarkable increase in activity over a short period of time.

The majority of these activities require a heavy reliance on ankle plantarflexion mitigated by the triceps surae (soleus and gastrocnemius). Simply looking at the lower leg, the triceps surae comprises the bulk of the soft tissue. Through training, the body further increases the neuromuscular stimulation to this region which increases tone and activation potential. However, as tone increases to the posterior shin, it decreases to the anterior shin. The posterior muscles become dominant, the ankle is pulled into plantarflexion which stretches the anterior fibers (figure 1). The Golgi tendon and muscle spindle, sensing the increase in tension, increases tone to prevent plantarflexion from occurring. However, this increase tone, specifically in the anterior tibialis, tensions the periosteum of the tibia creating shearing forces and subsequent pain.

Most treatments focus on addressing the symptoms: ice massage and ultrasound for the anterior tibialis eventually progressing to stretching the anterior tibialis via ankle plantarflexion. While this does cause short-term symptom relief, it ultimately feeds into the dysfunctional pattern. The more relaxed the anterior tibialis becomes, there is an increase in the tonus of the triceps surae.

A better approach: reversing the reciprocal inhibition.

The tone of the triceps surae needs to be decreased and the tissue lengthened. The calcaneal tendon is one of the strongest structures in the body, responsible for lifting the weight of the body hundreds to thousands of times a day through normal walking. It does not respond well to standard static stretching.

Gua sha or instrument assisted soft tissue mobilization (IASTM) is the recommended treatment approach. With the patient prone, begin applying the technique to the calcaneal tendon (figure 2). As the fascia loosens, passively move the ankle into dorsiflexion to increase the length of the calcaneal tendon and its fascia.

Once the appropriate amount of petechiae has formed, continue to apply a passive stretch for 1-2 minutes to re-enforce the new length. Further inhibition of the triceps surae can be obtained via kinesiology taping. A “Y-strip” can be utilized to inhibit both heads of the gastrocnemius (figure 3). However, a single “I-strip” can also be used to inhibit either the medial or lateral head (the subject in figure 3 demonstrates calcaneal inversion and would benefit from an “I-strip” to inhibit the medial head).

Often, the inhibitory techniques are sufficient to correct the problems. If pain persists, the anterior tibialis may need to be addressed specifically. However, an inhibitory technique would not be benefical for the anterior structures. A facilitation technique would be (figure 4). If there is still localized pain after facilitating, then spacing techniques could also be utilized at 40-60% tension (not shown).

These techniques are very specific and highly affective in treating MTSS. If the patient does not respond to treatment or presents with bilateral symptoms, referral to a physician for a CT scan to rule out stress fractures would be encouraged.

References

1. Borgini, E. Stecco, A. Day, JA. Stecco, C. How much time is required to modify a fascial fibrosis? J Bodywork Mvmnt Therap. 2010. 14:318-325.

2. Cheung, JTM. Zhang, M. An, KN. Effects of plantar fascia stiffness on the biomechanical responses of the ankle-foot complex. Clin Biomech. 2004. 19:839-46.

3. Huijing, PA. Baan GC. Myofascial force transmission via extramuscular pathways occurs between antagonist muscles. Cells Tissues Organs. 2008. 188:400-14.

4. Kaczander, BI. Shapiro, J. Consider systemic causes of heel pain. Biomech. 2005. 12(2):59-61.

5. Kottke, FJ. Pauley, DL. Ptak, RA. The rationale for prolonged stretching for correction of shortening connective tissue. Arch Phys Medic Rehab. 47:345-52. 1966.

6. Liptan, GL. Fascia: a missing link in our understanding of the pathology of fibromyalgia. J Bodywork Mvmnt Therap. 2010. 14:3-12.

7. Looney, B. Srokose, T. Fernandez-de-las-Penas, C. Cleland, JA. Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. J Manipulative Physio Ther. 2011. 34:138-142.

8. Mahowald, S. Legge, BS. Grady, JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011. 101(5):385-389.

9. Moseley, AM. Herbert, RD. Nightingale, EJ. Taylor, DA. Evans, TM. Robertson, GJ. Gupta, SK. Penn, J. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial. Arch Phys Med Rehabil. 2005 86:1118-26.

10. Neuman, DA. Ankle and Foot. In: Neuman, DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis, MO:Mosby. 2002. 477-521.

11. Schleip, R. Duerselen, L. Vleeming, A. Naylor, IL. Lehmann-Horn, F. Zorn, A. Jaeger, H. Klingler, W. Strain hardening of fascia static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. J Bodywork Mvmnt Therap. 2012. 16:94-100.

12. Simmonds, N. Miller, P. Gemmel, H. A theoretical famework for the role of fascia in manual therapy. J Bodywork Mvmnt Therap.2012. 16:83-93.

13. Sutherland, DH. An electromuyographic study of the plantarflexors of the ankle in normal walking motion. J Bone Joint Surg. 48A:66-71. 1966.

Biomechanics of the Foot and Ankle

Posted by atc_education on September 10, 2012 at 12:00 AM Comments comments (95)

"Barefoot" or "minimalist running" is the current lingo in the fitness world. It is designed to encourage "natural running motion". Yet, not many people understand what this actually means.

"Traditional" running shoes have a heel that is higher than the toes. This encourages a heel strike which, for years, experts have agreed was the ideal walking pattern. Gait evaluation in athletic training and physical therapy curricula describe the heel-to-toe gait approach as part of their lower extremity assessment courses. To provide cushioning, shoe manufactures have continued to add padding and height to the heel region of the shoe which now mimic women's wedge heels.

Most runners develop knee, hip and low back pain at some point. This is not because running is bad, as many physicians and other experts have said in the past; it is because traditional running shoes encourage heel striking which is bad. Furthermore, many shoes have added medial arch supports to prevent the arch from flattening during ambulation.

When the heel is the first part of the foot to contact the ground, the body must dissipate the forces in some way. The next shock-absorber in the body is the medial and lateral meniscii of the knee which, with wear and tear of overuse, can lead to osteoarthritis. Farther up, the sacroiliac joints can act as a shock absorber by moving superiorly. However, this is not ideal because it can lead to sacroiliac joint dysfunction with subsequent low back pain and/or "sciatica".

Barefoot running uses the body's natural shock absorption system: the medial longitudinal, lateral longitudinal and transverse arches of the foot. With midfoot striking, the arch of the foot should go through a controlled flattening (mitigated by eccentric contractions of the anterior and posterior tibialis as well as the plantar fascia) to absorb the impact. This greatly reduces the stress on the rest of the lower extremity.

Yet, many people that try the barefoot approach run into injuries. It isn’t because barefoot running is inherently bad but because it is a major transition to go from normal running shoes to minimalist shoes. A gradual transition is best recommended starting with a shoe like the Nike Free or Saucony Kinvara with a gradual transition to a Merrell Glove or Vibram Five Finger.

Also, many people have arches that are hypomobile (pes cavus) due to traditional shoes. The high arch supports have lead to shortening of the tibialis muscles and, possibly, the plantar fascia. The elevated heels have lead to shortening of the calcaneal tendon which limits dorsiflexion and leads to hyperflexion of the tarsals.

As clinicians, we can encourage this transition through a variety of techniques. Instrument assisted soft tissue mobilization can quickly lengthen the calcaneal tendon to restore normal dorsiflexion while relieving pain. IASTM or myofascial release can be used to ensure adequate length to the tibialis muscles. If the midfoot is rigid, joint mobilizations/manipulations of the navicular inferiorly can encourage proper pronation.

To facilitate correction and maintain longer results from the treatment, RockTape can also be used as an effective adjunct. By running a continuous 2 inch strip from the superior portion of the lateral malleolus under the foot where it then attaches onto the skin above the navicular. As the tape contracts back to its origin, it facilitates the inferior translation of the navicular which encourages pronation.


References:

1. Cheung, JTM. Zhang, M. An, KN. Effects of plantar fascia stiffness on the biomechanical responses of the ankle-foot complex. Clin Biomech. 2004. 19:839-46.

2. Cheung, JTM. Zhang, M. An, KN. Effects of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech. 2006. 21:194-203.

3. Giacomozzi, C. D’Ambrogi, E. Uccioli, L. Macellari, V. Does thickening of the Achilles tendon and plantar fascia contribute to the alteration of the diabetic foot loading? Clin Biomech. 2005. 20:532-9.

4. Iaquinto, JM. Wayne, JS. Computational model of the lower leg and foot/ankle complex: application to arch stability. J Bioimech Engin. 2010. 132:021009-1 – 6.

5. Mahowald, S. Legge, BS. Grady, JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011. 101(5):385-389.

6. Moseley, AM. Crosbie, J. Adams, R. Normative data for passive ankle plantarflexion-dorsiflexion flexibility. Clin Biomech. 2001. 16:514-21.

7. Natali, AN. Pavan, PG. Stecco, C. A constitutive model for the mechanical characterization of the plantar fascia. Connective Tissue Res. 2010. 51:337-46.

8. Towers, JD. Deible, CT. Golla, SK. Foot and ankle biomechanics. Sem Musculoskeletal Radio. 7(1):67-74.

Sports Specific - Inversion Ankle Sprains

Posted by atc_education on August 29, 2012 at 11:00 PM Comments comments (55)

Sports Specifics: Ankle Sprains

Why do we limp after an ankle sprain? The primary mechanism of injury is inversion and dorsiflexion (the ankle rolling in) which stresses the anterior talo-fibular (ATF) ligament. However, as the anterior drawer test shows us, the ATF’s role is to keep the talus from sliding anteriorly. This, theoretically, should not lead to a limp.

In 2010, a group of researchers(1) examined why this happens. They determined the stress of the sprain causes reorganization of the central nervous system. In turn, this causes inhibition of the ipsilateral gluteus medius whose functional role during gait is to prevent hip adduction(2). When the muscle becomes inhibited, the contralateral pelvis drops as that leg moves into flexion during the gait cycle. This is also known as a Trendelenburg gait.

How this happens was addressed by Thomas Myers(3). The sprain involves the lateral fascial line: the peroneal group, ilitotibal (IT) band, external obliques, intercostals, scalenes group and scalp fascia. The inversion of the ankle often leads to adduction of the hip which also strains the IT band. Rapid movements of the fascia lead to tearing with subsequent soft tissue remodeling involving scarring(4). The scarring leads to a loss of mobility and synergestic dominance of synergestic (helpler) muscle groups(5). Often, physicians will place the patient in a brace or, in more severe cases, a walking boot that further exacerbates the problem via immobilization(6). This leads to further shortening which can alter the alignment of the lumbo-pelvic-hip complex creating an anterior pelvic tilt or lateral tilt of the ilium on the sacrum. This changes the alignment of the myofascia where the IT band becomes the primary hip stabilizer during ambulation and, in advanced stages, hip flexor. This leads to further inhibition of the gluteus medius as stabilizer and the psoas as a hip flexor.

Often, rehabilitation specialists inadvertently facilitate dysfunction. Too often, patients are progressed to standing balance activities before there is appropriate strength, endurance and neuromuscular control to maintain proper hip position. This can lead to chronic hip instability and continued limping even after the ankle sprain has resolved. Also, “Monster Walks”/lateral walking with a Thera-band loop further increases the activation of the IT band because of the knee and hip flexion which leads to increased activation of the IT band and gluteus medius inhibition. Often, patients with past inversion ankle injuries tend to have recurring sprains due to the lateral tilt of the SI joint which leads to hip adduction changing foot strike from the plantar surface to the lateral portion of the foot which predisposes it to recurrent eversion. Others will present with calcaneal eversion due to shortening of the lateral fasical line or, more often, Thera-band exercises that teach the peroneals to be everters instead of a stabilizer to prevent inversion.

A better approach:

Kinesiology taping can be utilized to facilitate lymphatic drainage during the acute phase (fig 1). Once the edema and pain have begun to resolve, functional or rehabilitative tapings can be utilized. The peroneals can be treated by combining a facilitation technique with a mechanical correction to pull the calcaneus into eversion thus limiting further inversion (fig 2). To address the Trendelenburg gait, a facilitation technique can be used on the gluteus medius as well (fig 3). In Fascial Movement Taping, both of these techniques could be combined into a single strip via a lateral chain correction (fig 4).

For rehabilitation, have the patient supine with a Thera-Band loop around the feet. The supine position places the hip in slight extension to better activate the gluteus medius and limit the role of the IT band in the movement. The patient must hold the feet in neutral (no inversion/eversion, no plantar/dorsiflexion) (fig 5a). The patient proceeds to abduct the hips to hip width apart holding for 2 seconds initially with a progression to a 5 second hold for 10 reps (fig 5b). This works to increase the activation of the entire lateral line, specifically the gluteus medius and peroneals, as stabilizers instead of conditioning them to be phasic muscles.

References

1. Hass, CJ. Bishop, MD. Doidge, D. Wikstrom, EA. (2010). “Chronic ankle instability alters central organization of movement.” Am J Sports Med. 38(4):829-34.

2. Neuman, DA. Ankle and Foot. In: Neuman, DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis, MO:Mosby. 2002. 477-521.

3. Myers, TW. (2001) Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. China:Churchill-Livingston.

4. Mollier (1938) Plastiche Anatomie.

5. Kottke, FJ. Pauley, DL. Ptak, RA. (1966) The rationale for prolonged stretching for correction of shortening connective tissue. Arch Phys Medic Rehab. 47:345-52.

6. Kottke, FJ. Lehman, JF. (1990) Kruzen’s Handbook of Physical Medicine and Rehabilitation, 4th edition. Philadelphia:Sanders.

Posture - The Basic Evaluation Tool Everyone Should Have

Posted by atc_education on August 10, 2012 at 2:00 PM Comments comments (35)

Clinicians often talk about having and maintaining good posture with their patients. Yet, few actually do a detailed assessment of posture during the initial or subsequent evaluations. Most are eager to get to the "important" part of the evaluation: range of motion assessment, muscle testing/grading, orthopedic tests or, currently in vogue, functional movement screens.

"Movement becomes habit, which becomes posture, which becomes structure.” - Thomas Myers, author "Anatomy Trains"

Posture is a vital tool that can inform the clinician of underlying problems in the fascia and joints. Taking the traditional view of posture from the lateral side (a 2nd post will address posture from the anterior/posterior views), a straight line should be able to be drawn from the external auditory meatus to the acromioclavicular joint. The line should be just anterior to the thoracic spine and just posterior to the lumbar spine. The line will bisect the greater trochanter before passing just posterior to the tibio-femoral (knee) joint and the anterior to the talo-crural (ankle) joint.

However, with our poor movement patterns of either repetitive movements or inactivity, the muscles (and fascia) will lengthen in some areas while shortening in others to make or daily activities easier. However, "easier" does not mean "efficient" as it leads to poor movement patterns.

In the picture below, the left side is standing posture. Starting at the feet and moving superiorly, the gastocnemii are short leading to both knee hyper extension and plantar flexion. The knees are also influenced by the recturs femoris superiorly to further facilitate knee extension as well as feeding into an anterior pelvic tilt. Superiorly, the anterior pelvic tilt is also increased by shortening of the gluteal (primarily gluteus maximus), the lumbar erectors and the latissimus dorsi. The lats are also negative influencing the glenohumeral (shoulder) joints into protraction and internal rotation.

  • If this dysfunctional system is put into motion, such as with an overhead squat, it confirms the previously identified dysfunctions. The gastrocnemii, specifically the lateral portion, is limited hip flexion and encouraging pes planus. The short rectus femoris is leading to limited knee flexion and increase trunk flexion. The gluteus maximus is lmiting hip flexion as he is unable to reach parallel. Lastly, the latissimus dorsi is limiting shoulder flexion.

    Even if it seems too basic, a proper posture evaluation can identify many dysfunctions and compensations in the body. Often, a noted dysfunction, when asked about, will trigger an older injury or surgery that may be feeding into the current pain. Unless it is resolved as well, the current complaints will never fully resolve.

    Women, Hormones and Headaches

    Posted by atc_education on August 9, 2012 at 3:10 PM Comments comments (0)
  • Fascial Lines

    The Spiral Line

    How many women have been told by their physicians that the headaches/migraines associated with their menstral cycles are "hormonal"? Probably quite a few. The problem with this is that there is no way to confirm or rule out the role of hormones.

    Another interesting topic of conversation that presented itself today is the role of the spiral line (Anatomy Trains, Myers, T) in fascial and somatic pain. The spiral line consists of an line of fascia that tends to follow the splenii muscles into the rhomboids before moving anteriorly into the serratus anterior. From there, it connects into the ipsilateral external oblique and abdominal fascia where it crosses the body into the contralateral internal oblique before moving inferiorly into the iliotibial tract and crossing anteriorly into the tibialis.

    It then forms one of the many slings of the body by wrapping under the foot before it begins moving superiorly again. On the lateral side of the foot, the line follows the peroneal group and into the biceps femoris. It moves further superiorly from the posterior-superior iliac spine (PSIS) following the erectors to their insertion on the base of the skull.

     

    A female presented today with such complains of "migraines" associated with the onset of her menstral cycle. By following the line (see Photo Folder: "Spiral Line and 'Menstral' Headaches") we see that the line goes from her right

    occipital region posteriorly (where she states the headaches radiate towards) to her left ovary. The pictures show instrument assisted soft tissue mobilization (gua sha) of the spiral line inidicating significant petechiea and, therefore, significant fascial adhesions. She will be seen 1 time a week for the next 4 weeks and her progress will be updated to the "Spiral Line..." folder.

  • Check back for updates!

    Women, Hormones and Headaches

    Posted by atc_education on August 9, 2012 at 3:10 PM Comments comments (54)
  • Fascial Lines

    The Spiral Line

    How many women have been told by their physicians that the headaches/migraines associated with their menstral cycles are "hormonal"? Probably quite a few. The problem with this is that there is no way to confirm or rule out the role of hormones.

    Another interesting topic of conversation that presented itself today is the role of the spiral line (Anatomy Trains, Myers, T) in fascial and somatic pain. The spiral line consists of an line of fascia that tends to follow the splenii muscles into the rhomboids before moving anteriorly into the serratus anterior. From there, it connects into the ipsilateral external oblique and abdominal fascia where it crosses the body into the contralateral internal oblique before moving inferiorly into the iliotibial tract and crossing anteriorly into the tibialis.

    It then forms one of the many slings of the body by wrapping under the foot before it begins moving superiorly again. On the lateral side of the foot, the line follows the peroneal group and into the biceps femoris. It moves further superiorly from the posterior-superior iliac spine (PSIS) following the erectors to their insertion on the base of the skull.

     

    A female presented today with such complains of "migraines" associated with the onset of her menstral cycle. By following the line (see Photo Folder: "Spiral Line and 'Menstral' Headaches") we see that the line goes from her right

    occipital region posteriorly (where she states the headaches radiate towards) to her left ovary. The pictures show instrument assisted soft tissue mobilization (gua sha) of the spiral line inidicating significant petechiea and, therefore, significant fascial adhesions. She will be seen 1 time a week for the next 4 weeks and her progress will be updated to the "Spiral Line..." folder.

  • Check back for updates!

    Movement dysfunctions in a 6 year old male

    Posted by atc_education on August 8, 2012 at 2:50 PM Comments comments (12)
  • At what age do movement dysfunctions begin?

     

    In their book entitled "The Endless Web: Fascial Anatomy and Physical Reality", Drs. Shultz and Feitis propose that a lot of the dysfunction that occurs in the body begins when we are still in th

    e womb. The fetal position that we grow into leads to shortening of the anterior fascial lines (chest, abdomen, quads) and lengthening of the posterior fascial lines (hamstrings, glutes, erectors) leading to the poor posture seen later (or sometimes earlier) in life.

     

    Another area of concern is when we are first learning to walk. We are designed to walk in a "fall forward" pattern where our head leads the way and should be positioned above where our foot is going to strike. This is not the same as the forward head posture we see in many of out patients as the "fall forward" mechanism keeps the head and cervical spine in proper alignment. The problem arises when we quickly learn that it hurts more to fall forward onto our faces as opposed to falling backwards on the padding of the gluteals. To encourage falling backwards, we arch our lumbar spines creating increased activation of the erector spinae, the thoraco-lumbar fascia and the latissimus dorsi.

     

    This leads to mobility issues in the sacroiliac joints of the pelvis, the hips, the lumbar spine and the glenohumeral (shoulder) joints. This can present as low back pain, sacroiliac joint dysfunction and/or glenohumeral impingement. To fully resolve the condition, gait retraining is essential to prevent a recurring and chronic condition.

    Focus on Fascia

    Posted by atc_education on August 6, 2012 at 5:10 PM Comments comments (33)

    Fascia is a thin layer of connective tissue found between the skin and the muscle. It is similar in thickness and color to Saran-Wrap; for years, researchers and anatomists working on aged cadavers thought that was all it was: an extra structure to help hold us together.

    However, more research is quickly be amassed that is changing the minds of researchers and clinicians alike. It appears that fascia helps coordinate our movements. The debate is now starting as far as how fascia works. One study proposes the fascia is an extension of the central nervous system.

     

    Through injury and overuse, we develop adhesions (small knots) in the fascia. If we take the Saran-Wrap from earlier and wad it up, it doesn't open back up very easily. This is similar to how fascia responds to injury: it becomes "sticky" through the release of various chemicals from the cells. The fascia sticks to itself as well as the skin superficially and the muscle deep. This limits movement and causes pain as the fascia pulls on the surrounding tissues. The fascia also attaches to the bone and can pull bones and joints out of alignment, further contributing to pain and dysfunction in even distal regions of the body. This is because fascia is one continuous sheet so tension or adhesions in one area will tension the entire tissue towards that area of pull.

     

    Most clinics take a "traditional" approach to rehabilitation by focusing on muscle weaknesses. However, appropriate treatment of fascial adhesions requires a high level of skill in both manual evaluation and manual therapy techniques. Tissue must be lengthened to return to its normal length and to return joint to their proper postural position. Only then is it appropriate to begin a therapeutic exercise program.


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