Diagnosis & Treatment of Movement Dysfunction Syndroms 1

8/3/2019 Diagnosis & Treatment of Movement Dysfunction Syndroms 1

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Diagnosis and treatment ofMovement dysfunction

SyndromesPrepared byMohamed Abu Bakr PT OPD Annex

Sabeer Kanhirathodi PT OPD Annex


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Introduction


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Most of chronic musculoskeletalpain/chronic injuries in the spine

lower extremity and upper

extremity are caused or

perpetuated by muscle

imbalances/weaknesses in thecore musculature


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Individuals with a weak core

substitute/compensate during

dynamic functional movementsleading to overuse/chronic

injuries both upper and lowerextremity


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Definitions:

Function: Integrated proprioceptively

enriched mulidirectional movement

vs unidimentional, low proprioception, all three

planes

All functional exercises are triplanar (even

walking) appears unidirectional but need other

planes to stabilize (frontal & transverse).All functional movements required

acceleration, deceleration & dynamic

stabilization (typically concentrate in concentric

and acceleration in rehab)


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Cont.

Functional Strength - ability neuromuscular

system to produce dynamic eccentric

concentric and dynamic isometricstabilization contraction during all

functional movement patterns


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Cont.

Neuromuscular efficiency: the ability of

your entire kinetic chain to work as an

integrated functional movementThis will provide optimal dynamic stabilization

at right joint, right time, right plane of

movement

most athletes can produce the force but cannot

stabilize or control eccentrically thus increasing

stresses in different plane of movement and in

different joints (compensation)


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Biomechanics


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ActiveSubsystem( muscles )

PassiveSubsystem

ControlSubsystem

neural

The Stabilizing Subsystems

Self Locking Mechanism


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Kinetic Chain

When it works efficiently:

optimal control

distribute force appropriately

optimal efficiency during all movements

impact absorption/ground reaction forces

no excessive compressive transitory shear forcein kinetic chain

dynamic joint stabilization

neuromuscular control


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Patho-Kinesiological Model

Any change of the delicate balance of the 3

Stabilizing Subsystems will cause a Patho-

kinesiological Model or injuryExample: articular dysfunction with change

length tension ratio etc..


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Example: Pelvo-Occular reflex

(Janda) Cervical spine weak: during running fatigue

head will go into extension, thus to see

straight in front of you the pelvis tipsanteriorly

This changes length tension ratios of the

lower extremity, become less efficient, mayend up with hamstring injury


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Basic Concept of Stabilization -

Performance Paradigm

Stretch/shortening cycle (natural visco-

elastic properties of muscles)

The more efficient every single movement

through Dynamic Functional Pattern the

more efficient force can be created and/or

absorbed .

efficiency: less wasted movements

Example walking

Every single movement we do is the

performance paradigm


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Basic Concepts of Stabilization -

Continuum of Function

Must do movements and exercises in adynamic systematic program

Movements are not isolated unidirectional

Practically take the patient or athlete frommovement thinking to pattern thinking .the

challenging position they can control in afunctional pattern and progress them fromthere


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Paradigm Shift: NO longer

looking to improve strength in

one muscle but improvement inmultidirectional neuromuscular

efficiency (firing patterns inentire kinetic chain with complex

motor patterns). The body doesn't

just fire one muscle at a time for

movement


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Stabilization - Open and Closed

Chain

Functional movement is a succession ofopening and closing the chain

Functional activity is therefore a timing

issue within opening and closing the chain

Need core stability to stabilize transition


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Functional pattern: Three Phases

Pronation - deceleration/force reduction

phase (where most injuries occur due to

lack of eccentric control)For rehabilitation need to look at this phase

what muscles are decelerating and stabilizing to

create a rehabilitation program


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Three Phases Cont.

Supination - acceleration phase/force

production phase (most % time)

Coupling - stabilization, ability to change

from pronation to supination phase

(stronger the core more efficient

achievement thus less time spend in thisphase prevent overuse injuries)


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Patho-Kinesiological Diagnosis

Look Feel Analyze


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Anterior


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Foot

Compensation 1

Foot Turned Out

Possible Over Active Muscles

Tenser Fascia Laeta

Biceps Femoris

Lat.Gastronemius

Soleus


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Probable Underactive Muscles Med Gastrocnemius. Med.Hamstring

Gluteus Medius /Maxi. Gracilis. Popliteus

Flexibility Ex(SMR &Static.

Calf stretch

Hamstring stretch

Standing TFL stretch

Strengthening Exs;

Single Leg Balance


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Example Flexibility Ex(SMR

&Static


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Example Strengthening Ex


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Knee


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Moves Inward


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Probable Over Active Muscles

Adductor Complex

Bicep Femoris(Short Head)

TFL

Vas- Lateralis

Lat Gastrocnemius


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Probable Underactive Muscles

Gluteus Medius /Max

VMO

Med Hamstring

Med Gastrocnemius


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Flexibility Exs (SMR & Static ) Add &TFL

Add Stretch


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Ball Bridge Lateral Tube Walking

Ball Squat W/Abduction


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Moves Outward


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Piriformis

Biceps Femoris

TFL

Gluteus Menimus/Medius


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Add Complex

Med Hamstring

Gluteus Max


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Example Flexibility Ex

(SMR &Static) Piriformis Stretch

Hamstring Stretch

TFL Stretch


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Ball squat Ball Bridge

W/Add


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Posterior


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Foot

Foot flattens


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Peroneals

Lat.gastrocnemius

Bicep Femoris(Short head)

TFL


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Ante Tibialis

Post Tibialis

Med Gastrocnemius Gluteus Medius

Flexibility Exs (SMR & Static )


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Flexibility Ex s (SMR & Static )

Hamstring Stretch


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Single Leg Balance Reach

Single Leg Medial

Calf raise


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Heel Rises


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Soleus


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(SMR &Static) Soleus Stretch


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Reach

Single Leg squat


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Check Point

L-P-H-C


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Asymmetrical Weight Shift


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Add Complex

TFL (Same Side)

Piriformis

Biceps Femoris

Glutius Medius(Same side)


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Gluteus Medius (Same side)

Add Complex (Opposite Side)


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(SMR &Static) Adductor Stretch

TFL Stretch (Same Side)

&

Piriformis Stretch

Hamstring Stretch (Opposite Side)


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Gluteus Medius(Same Side)

Add Complex (Opposite Side)


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Lateral View

Lateral ( L P H C )


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Lateral ( LP- HC )

Compensation 1

Excessive forward leanProbable overactive muscles : soleus

GastrocnemiusHip flexor complex

Abdominal complex ( Rectus

abdominus , External oblique ) .

Probable hypoactive muscles : Anterior

TibialisGluteus MaximusErector

Spinae .

Flexibility exs ( SMR & Static ) : Calf

StretchHip Flexor StretchBall

Abdominal stretch

Strengthening exs : Ball Squat

Stretching Exs ( SMR &Static) Calf Hip flex


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Stretching Ex s ( SMR &Static) Calf Hip flex

- Abdominal
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Strengthening Exs : Ball Squats
http://www.sparkpeople.com/resource/exercises.asp?exercise=189http://www.sparkpeople.com/resource/exercises.asp?exercise=65


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Lateral ( LPHC ) Cont

Compensation 2

Low Back ArchesProbable overactive muscles : Hip Flexor

ComplexErector SpinaeLatissimus

Dorsi

Probable hypoactive muscles : Gluteus

MaximusHamstringsIntrinsic CoreStabilizers ( transversus abdominus

multifidusinternal oblique

transversospinalispelvic floor muscles )

Flexibility Exs ( SMR&Static ) : Hip Flexor

StretchLatissimus Dorsi StretchErectorSpinae Stretch

Strengthening Exs : Ball SquatFloor

BridgeBall Bridge

Stretching Exs (SMR & Static ) Latissimus &


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Stretching Ex s (SMR & Static ) Latissimus &

Erector Spinae

Strengthening Exs ( Ball Squat , Floor


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g g ( q ,

Bridge & Ball Bridge )

Lateral (L P H C ) Cont


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Lateral (LPHC ) Cont.

Compensation 3

Low Back Rounds

Probable Overactive Muscles :

HamstringsAdductor Magnus

Rectus AbdonimusExternal

Obliques .

Probable Hypoactive Muscles :

Gluteus MaximusErector Spinae

Intrinsic Core Stabilizers .

Flexibility Exs (SMR & Static ) :

Hamstring StretchAdductor

Magnus StretchBall Abdominal

Stretch

Strengthening Exs : Floor Cobra

Ball CobraBall Back Extension

Stretching Exs (SMR &Static) HamstringsAdd


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g ( ) g

MagnusBall Abdominal Stretch

Strengthening Exs Floor CobraBall CobraBall Back


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Extension


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Lateral Upper Body

Lateral Upper Body


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Lateral Upper Body

Compensation 1

Arms Fall ForwardProbable Overactive Muscles :

Latissimus DorsiPectoralisMajor / Minor - Teres MajorCoracobrachialis .

Probable Hypoactive Muscles :Mid / Lower TrapeziusRhomboidsRotator CuffPosterior Deltoid .

Flexibility Exs ( SMR& Static) :Latissimus StretchPectoralisStretchSMR Thoracic Spine .

Strengthening Exs : Floor CobraBall CobraSquat To Row .

Stretching Exs (SMR & Static) Latissimus Pec SMR T Spine


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Stretching Ex s (SMR & Static) Latissimus Pec SMR T Spine


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Strengthening Exs Floor CobraBall Cobra

Squat To Row

Lateral Upper Body Cont.


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pp y

Compensation 2

Forward Head

Probable overactive Muscles: Levator

Scapula - Sternocleidomastoid

Scalenes .

Probable Hypoactive Muscles : Deep

Cervical Flexores .

Flexibility Exs ( SMR &Static ) :

Levator Scapula StretchSCM

StretchScalenes Stretch .Strengthening Exs : Tuck Chin ,

Keeping Head in Neutral Position

during All Exs

Stretching Exs ( SMR & Static) Levator ScapulaSCM - Scalenes
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Strengthening Exs Deep Cervical Flexores

Lateral Upper Body
http://www.chiroweb.com/common/viewphoto.php?id=10805


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Lateral Upper Body

Compensation 3

Shoulder ElevationProbable overactive Muscles : Upper

TrapeziusSCMLevator Scapula

.

Probable Hypoactive Muscles : Mid /Lower TrapeziusRhomboids

Rotator Cuff

Flexibility Exs (SMR & Static ) :

Upper Trapezius StretchSCMStretchLevator Scapula Stretch .

Strengthening Exs : Floor Cobra

Ball Cobra


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LPH Complex

Stabilization system(Core System) if notfunctioning

optimally will endneuromuscularsubstituting to utilizethe strength power

and neuromuscularcontrol in the rest ofthe body


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http://www.chiroweb.com/common/viewphoto.php?id=10805


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LPH Complex Cont.

Otherwise will get neuromuscular inhibition and

CNS will shut down the prime movers if LPH not

stabilized, thus minimizing the kinetic chain.

Muscle strength is not enough to achieve the

normal efficient functional movements e.g most

athletes have functional strength and control in

prime movers but not stabilization in spine(C,T,L)

C S bili i F i


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Core Stabilization Function

Remember 29 muscles connected to each

side of your pelvis. These work

synergistically with entire kinetic chain

Primary Function: maintain center of

gravity over base of support during dynamic

movement (Example gait cycle - loss of

balance)

Stability & control offers more

biomechanically correct position for

function of entire core and lower extremity

muscles


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Muscle Fatigue

Ability to generate or maintain decreaseability to require correct muscle

Ability to maintain dynamic muscle force

decreases

Example: fatigue running unable to stabilize

core: get shear forces and compressive

forces in lumbar spine:- reason why see many LB comp0laints and

hamstring strains (actually attributed to weak

abdominals)

Transverse Abdominis and


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Internal Obliques during

functional activityOnly 2 abdominal muscles that attach to the L-spine

Attach thorocolumbar facia (L-spine) via lateral

rafia attach to transverse processes

Thus when they fire they create a tension affect

inherent STABILITY in L-Spine

These prevent rotational and transnational forces

If these muscles are not stabilized the Psoas is used

to create a compressive force and mimic stability



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Internal Obliques during

functional activity Actually creates anterior shear force and

extension force

Leading to reciprocal inhibition of lowerabdominals

The pelvis will tip forward

Leading to reciprocal inhibition of thegluteals (extensor mechanism)

This can cause hip internal rotation knee

overuse syndromes etc..

Basic Concepts of Core


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p

Stabilization - Planes of

MovementWith any movement all three planes areworking together concurrently

Even through you may be moving in one plane

the other 2 planes must stabilize and workeccentrically for stabilization

Example: Posterior Pelvic tilt laying on the

floor changes the relationship, thus whenstanding he relationship again changes the

exercises have not been functional and will not

work in the altered position. Again it

changes when you lift one leg etc.


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Muscle Function Cont.

Stabilization: Prone to develop weakness

and inhibition, less activated during most

movement patterns, fatigue easily, primarilyfunction during stabilization movement

Peroneals, anterior tibialis, posterior tibilalis,

VMO, gluteus medius/maximus, transverse

abdominis, int/ext obliques, serratus anterior,

rhomboids, middle, lower trap, deep neck

flexors, longus capitus

Sheringtons Law of Reciprocal


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Sherington s Law of Reciprocal

Inhibition: tight muscles will inhibit its

functional antagonist. Example:ThePsoas (most athletes) inhibit functional

antagonists - deep abdominal wall,

transverse abdomnis, internal oblique,multifidi, deep transverse spinalis,

gluteus maximus. Thus the stabilization

and coupling phase will be reducesincreasing the movement phase and

muscle forces and decreasing efficiency.


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Muscle Functions - Abdomen:

Internal Oblique -

Decelerate transverse

plane rotation, frontal

plane and transverse

plane stability

Rectus Abdominis:

Decelerate Extension,create pelvic stability

during dynamic

movement

External oblique -

Decelerate transverse

plane rotation some

extension


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Muscle Functions - Abdomen:

Transverse Abdominis - The most important

abdominal muscle (attach to lumbar spine)

contract in feed forward mechanismcontract 1st before any other muscle

(research following back pain the transervse

abdominis is inhibited, thus when you move

for example an arm, your transverse

abdomnis does not stabilize thus the psoas

fires - compensation


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Muscle Function: Lumbar Spine

Superficial Erector Spinae: Extends Spinecreates extension force and shear force at

L4-S1 works with the Psoas (when Psoas

tight it facilitates erector spinae furtherincreasing the shear forces and inhibit

posterior muscles)

Deep erector Spine: Posterior translationand L4-S1, if weak or inhibited cannot

counterinteract affect or superficial erector

and get shearing forces


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Muscle Function: Lumbar Spine

Transversal Spinalis Muscles (Rotatories,

Multifidi, interspinalis, interanversari)

Provide intrisic, intrasegmental stabilityproprioceptive feedback since constantly

under compression and torsinal forces. If

these muscles are inhibited, loose the ability

to create dynamic stabilization from lack of

proprioceptive feedback.

SPINE MUSCLES


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Heads

1.Iliocastalis

LumborumThoracis

Cervicis

2.Longissimus

ThoracisCervicis

Capitis

3.Spinalis

Thoracis

Cervicis

Capitis

ANATOMY

Macro anatomy. Multifidus


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ac o a ato y. u t dus

(MF) is the largest and most

medial of the lumbar paraspinal

muscles. Each muscle consistsof five separate, overlapping

bands that form a triangle as

these bands run caudo laterally

from the midline.

Insertion: spinous process at

caudal tip.

Origin: transverse process at

mamillary process, iliac crest,and sacrum (polysegmental: 2-4

segments below insertion at

spinous process).


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Joint Dysfunction Example

Joint dysfunction example: lock up SI joint

plant and twist, Multifitus is inhibited

complains for low back pain, the erectorswill fire and attempt to stabilize (therefore a

muscle is doing opposite of its muscle

function). This is why pain syndromes are

perpetuated

Muscle Function: Hip


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Musculature: Gluteus Maximus: decelerate hip flexion,

decelerate hip internal rotation during heel

strike. Psoas tightness creates inhibition of gluteus

maximus (anterior tilt)

Muscle Function: HipM l t


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Musculature:

If the gluteus maximus is inhibited or weakwill loose ability to control femur, femur

will internally rotate:

Microtruma can be created on medial capsule

of knee

Patellar tendonitis non-contact ACL injuries

posterior tibial tendonitis, plantar facitis

Hamstrings become tight in an attempt to createposterior stability of the pelvis (instead of

focusing on hamstring flexibility, work on

pelvic stabilization and flexibility will return)


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Lack of flexibility is often a

phenomenon created by lack ofstability in an attempt to stabilize

the body for activity


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Gluteus Maximus and minimus

are inhibited in most athletes due

to tight psoas (Summer, 1988).



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musculature

Gluteus medius: provides frontal planestabilization, decelerate femoral adduction, assistin deceleration femoral internal rotation (duringclosed chain activity)

VB/BB with patellar tendonitis originate from tightpsoas and lack of core strength

attempting to get triple extension during jumping, couldntextend through hip using gluteus maxiumus due to thigh psoas

Thus they hyperextend at the knee and drive the inferior pole

of the patella into the fat pad creating the inflammatoryresponse (Summer, 1988).



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Musculature Adductors: frontal plane stability

Hip External Rotator: Create Pelvo-femoral

rhythmGemeli, Obturators, Piriformis help to

decelerate femur, If inhibited they become

extremely tight because they are attempting to

stabilize

Often we attempt to stretch these muscle where

a core program would eliminate the origin of

the problem


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Force Couples

Saggital Plane: Psoas and superficial erector

spinae which create and extension force and

shear force int he lumbar spinecounteracted by transverse abdominis, internal

oblique multifidi, transversal spinalis groups,

gluteus maximums

Trend - most athletes the psoas and erector

overdeveloped inhibiting stabilizers

Frontal Plane: Gluteus Medius,


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ipsilateral adductor and

contralateral quadratus lumborum

Example: weak gluteaus medius will causecontralateral LBP, into knee pain on

opposite side


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Force Couples Cont.

Transverse Plane Left Rotation - left

internal oblique, left adductor, right external

oblique and right external rotators of the hipExample: synergistic dominance Weak

transverse abdominis and internal oblique the

same side adductor will become tight and

inhibit gluteus medius causing anterior kneepain, posteior tib tendonitis etc. Down the

kinetic chain.


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Principle of Core Training:

Postural Alignment: Primary Function -

misalignment will produce predictable

stresses, pain, chronic injuries, jointdysfunction

Common Postural Dysfunction


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Common Postural Dysfunction Lower Cross System: Anterior Tilt in most

athletes increase lumbar lordosis tight muscles movement groups muscles erector spinae

superifical psoas, upper rectus, rectus femoris,sartorius, tensor facia latae, adductors

Weaker muscle/inhibited - stabilizing group deepabdominal wall transverse abdominis, internal obliquemultifidus, deep erector spinae biceps femoris gluteausmedius/maximus

muscle that decelerate femur are inhibited

Joint dysfunction illiosacral rotations, S1, L-spine, Tib-fib joint, subtalar joint

Injury patterns: plantar faciiitis, patellar tendonis,posterior tib tendonitis



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Upper Cross System: Rounded Back/ForwardHead

Tight muscles pec major/minor, lat, upper trap,levator, subscap, teres major, sternocleidomastoid,erectus capitus, and scalenes

Weak muscle: rhomboids, middle.lwr trap, teresminor , infraspinatus, posterior deltoid, deep neckflexors

Joint dysfunction: Upper cervical, cervicalthroricis, SC joint problems (which can causerotator cuff problems)


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Pronation Distortion Syndrome: Flat feet

tight muscles: peroneals, lateral gastroc IT

band, PsoasWeak muscles: intrinsic foot muscles,

anterior/post tibialis, VMO, bicep femoris,

piriformis, glut medius

muscles that control pronation are inhibited andweak causing overuse injuries


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Pronation Distortion Syndrome

Joint dysfunction: 1st MTB joint (EX: cause

anterior shoulder pain: stub toe and then

lack normal passive extension, shortenstride, internal rotation of the femur,

causing pain up the core chain into

movements of the extremity). The same

can occur with sprain ankle and lock tibo-

talar joint


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Through the kinetic chain,muscle problems can lead to joint

problems and joint problems canlead to muscle problems.


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Postural Considerations

Many individuals have well developed

muscle strength and power to perform

specific activities, however few havedeveloped stabilization systems optimally

Optimal alignment of each segment in the

kinetic chain is a cornerstone for allfunctional rehabilitation programs


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Postural Considerations

If one segment in the kinetic chains is out of

alignment, then predictable patterns of

dysfunction will develop in other parts ofthe kinetic chain

A weak core is a fundamental problem o

inefficient movement which leads to

injury

Low Back Pain & Rehabilitations


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Transerve abdominis, multifitus, internal oblique

are inhibited in someone with LBP Decrease in stabilization endurance can perform

the movement until fatigue. OK for 3x20 but oncestart functional movement revert back to previous

positions Increase interdisck pressure and compressive

forces with lack of pelvic stabilization

Think about athletes that lift and then have LBP

cause may not be stabilizing and can perpetuatemuscle imbalances creating hamstring dysfunctionetc.

Address through unstable ball training


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Hiltons Law: any muscle thatcrosses that joint will be

inhibited. With injuries theindividual will have a lot of joint

substitutions and muscle

imbalances

Muscle Imbalances


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An optimal functioning core helps to prevent

the development of muscle imbalancesOptimal core neuromuscular efficiency allows

for the maintenance of the normal:

Length-tension relationships

Force-couple relationships

The path of instantaneous center of rotation

A strong stable core can improve

neuromuscular efficiency throughout the kineticchain by improving dynamic postural control


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Assessment of the Core:

Core strength can be assessed using the

straight leg lowering test

Core power can be assessed using theoverhead medicine ball throw

Core muscle endurance can be assessed

using back extension

Core Stabilization to create


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Core Stabilization to create

program: Sport Demand Analysis

Demands of the individual sport

Demands of the athlete (player vs non-player)Demands of the position/specialty

G id li f C i i


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Guidelines for Core Training:

A comprehensive core stabilization training

program should:

progress from slow to fastsimple to complex

known to unknown

low force to high force

static to dynamic

G id li f T i i


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Guidelines for core Training

Exercises should be safe, challenging, stress

multiple planes, incorporate a multi-sensory

environment, and activity specific Put each athlete in the most challenging

environment they can control.

G id li f T i i


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Guidelines for core Training

Change program often

ROM

Loading (Cable, tubing etc.)Plane of motion

Body position, floor standing, one leg etc..)

speed of movementduration

frequency

Abd i l B i K


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Abdominal Bracing Key

Transverse Abdominis - draw belly-button

into spine Make self skinny)

Pelvis tilts work rectus abdominisavoid anchoring feet so as not to activate hip

flexors or psoas

Full ROM]Exercise profession

Stretch Antagonists between sets to prevent

inhibition (if working abdominal stretch hip

flexors between sets)

E i P i


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Exercise Progression

Stage I: Learning Abdominal Bracing

maintain stability

change duration and frequency Stage II

Educate on daily use

Increase ROM and instability mainly uniplanar,change body position

E i P i


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Exercise Progression

Stage III: instability

Maximize the use of functional activities with

abdominal bracing

Maximize multidirectional patterns and

unstable positions

Maximize frequency and duration changes

Stage IV:

Challenge the individual with high intensity

strength and power

H d

SPINE MUSCLES


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Heads

1.Iliocastalis

LumborumThoracis

Cervicis

2.Longissimus

ThoracisCervicis

Capitis

3.Spinalis

Thoracis

CervicisCapitis

ANATOMYMacro anatomy. Multifidus



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medial of the lumbar paraspinal

muscles. Each muscle consistsof five separate, overlapping

bands that form a triangle as

these bands run caudo laterally

from the midline.

Insertion: spinous process at

caudal tip.

Origin: transverse process at

mamillary process, iliac crest,and sacrum (polysegmental: 2-4

segments below insertion at

spinous process).

Functional Anatomy Lumbo-


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y

pelvic-hip Complex

The LPH complex musculature produces

force, reduces force, and stabilizes the

kinetic chain during functional movements The core functions primarily to maintain

dynamic postural control by keeping the

center of gravity over our base of support

during dynamic movements.

P l i Gi dl


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Pelvic Girdle

29 muscles

attach to the

core (LPHcomplex

unilaterally)


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Documents

Diagnosis & Treatment of Movement Dysfunction Syndroms 1