Posture and Lower Limb

• Function of RC:

  • moves shoulder through range
  • abduction = supraspinatus
  • internal = subscapularis
  • external = teres minor and infraspinatus
• RC strains (young):

  • sudden
  • twinge in shoulder
  • acute overload
  • limitation in function
  • positive STTT
  • graded 1-3
  • responds quickly to rest and rehab
• RC tear (older):

  • gradual
  • pain with overhead activity
  • inability to sleep on shoulder
  • weak RC
  • positive impingement
  • actually an osis
• Shoulder impingemen:

  • primary = acromion shape
  • secondary = weak RC(affects centralization) / weak SS (affects position)
  • humerus pulled too far up and gets pinched under subacromial bursa
  • pain with motion between 70°-120°
• Impingement causing RC tendinitis/osis:

  • diffuse pain over deltoid and around acromion
  • overhead activities increase pain
  • OK below shoulder
  • hard to sleep on it
• Impingement causing RC tendinitis/osis:

  • painful arc
  • OK below 90°
  • weak external rotators with scapula stabilized
  • poor scapulothoracic rhythm
  • poor joint stability
  • anterior humeral head
  • positive Hawkins-Kennedy and Neer tests (test supraspinatus pinch beneath coraco-acromial arch)
• Impingement causing RC tendinitis/osis treatment:

  1. decrease pain
  2. increase ROM
  3. strengthen scapular stabilizers
  4. strengthen RC
  5. reinforce proper movement patterns
• Fowler reduction/relocation test:

  • anterior and posterior pressure on GH joint
  • centralizes humeral head
  • takes pressure off anterior capsule
• Forward head posture:

  • ears in front of plumb line
  • extended upper c-spine
  • flexed lower c-spine
  • protracted scapula
  • forward rounded shoulders
  • tight suboccipital, levator scapulae, trapezius
  • weak anterior flexors
• Forward rounded shoulders:

  • humeral head in front of plumb line
  • internal GH rotation
  • protracted scapula
  • tight pectoralis minor
  • weak rhomboids, trapezius
  • restricted scapular upward rotation and posterior tipping
• Kyphosis:

  • excessive thoracic curve
  • tight pectoralis major and minor
  • weak erector spinae, rhomboids, trapezius
  • protracted scapula
  • forward head posture
  • extended c-spine
• Lordosis:

  • increased lumbar curve
  • increased anterior tilt of pelvis
  • tight hip flexors and lumbar paraspinal
  • weak hamstrings and abdominals
• Swayback:

  • anterior shift of pelvis
  • thoracic shifts posteriorly
  • kyphosis
  • sharp curve at lumbar sacral junction
  • tight hip extensors and lower lumbar extensors
  • weak hip flexors and abdominals
• Flatback:

  • increased posterior tilt of pelvis
  • decreased lumbar lordosis
  • tight hip extensors
  • weak hip flexors
  • poor postural sense
  • stooped forward
• Non-structural scoliosis:

  • no bony deformity
  • can be treated
  • disappears on forward and side flexion
  • due to postural problems (muscle spasm: tight in concave side; weak on convex side)
  • due to leg length discrepancy
  • due to hip contracture
• Structural scoliosis:

  • bony deformity
  • hump appears (>10°)
  • vertebral bodies turn toward convex side
  • due to genetic problems, congenital issues, idiopathic
• Knee alignment:

  Varus:

  • open on lateral side
  • pinched on medial side
  • internal rotation of leg and patella
  • load-bearing axis moves medially

  Valgus:

  • open on medial side
  • pinched in lateral side
  • external rotation of leg and patella
  • load-bearing axis moves laterally
• Q-Angle:

  • axis formed by femur and tibia
  • the greater the angle, the more lateral pull on the patella
  • angle >20° = less stability of patellofemoral joint
  • factor in patellofemoral pain, OA, ITB friction (varus)
• Medical collapse mechanism:

  • hip adduction
  • femoral internal rotation
  • knee valgus
  • changes femur under patella (joint contact area; joint stress.
  • affects Q-Angle
• Knee movement:

  knee flexion/extension:

  • between bottom of femur and top of menisci

  knee rotation:

  • between bottom of menisci and top of tibia
  • for locking
• Screw home mechanism:

  • occurs the last few degrees of extension
  • medial femoral condyle is larger
  • foot planted = femur rotates internally
  • foot fixed = tibia rotates externally
  • locks the joint for stability and patellar alignment
  • to unlock, popliteus contracts and femur rotates externally
• Arches:

  medial longitudinal:

  • attached to spring ligament for support
  • aka: calcaneonavicular ligament
  • reinforced by tibialis posterior

  lateral longitudinal:

  • lower
  • less flexible

  transverse:

  • across tarsal bones
  • protects soft tissue
  • increases foot mobility
• Plantar fascia:

  • originates on medial tubercle of plantar surface of calcaneus
  • divides into 5
  • wraps around MT heads
  • supports foot against downward forces
• Plantar fascia:

  • toes extended
  • plantar fascia shortens (acts like a muscle)
  • toes extend as soon as we lift our heel
  • transfers weight from medial to lateral side
  • shock absorption
• Gait cycle:

  • stance = 60% (heel strike to toe off)
  • swing = 40% (toe off to heel strike)
  • initial contact and early loading = two feet
  • midstance to terminal stance = one foot
• Pronation:

  • phase = impact absorption
  • occurs when foot is loaded
  • allows for shock absorption, terrain changed, equilibrium
  • 3 movements: eversion, dorsiflexion, abduction
  • tibia rotates internally with talus and calcaneus; convert torque
  • unlocks the foot
• Supination:

  • 3 movements: inversion, plantar flexion, adduction
  • mid-tarsal joints are locked
  • stable for toe off
  • achieved via cuboid pulley (fibularis longus)
• Gait cycle:

  • foot = neutral at foot flat
  • knee = neutral at foot flat
  • foot = neutral at heel off
  • knee = neutral at heel off
  • foot = pronated from foot flat to heel off
  • knee = internally rotated from foot flat to heel off
• Running:

  • no simultaneous foot contact
  • open kinetic circuit
  • heel strike; foot = absorber
  • foot = rigid lever at toe off
• Pronation and supination:

  pronation:

  • mobile adaptor
  • lower arches
  • looser joints
  • after heel strike to foot flat

  supination:

  • rigid lever
  • higher arches
  • tighter joints
  • heel strike and foot flat to toe off
• Excessive pronation:

  • at subtalar joint
  • causes tibia to internally rotate
  • delayed resupination
  • affects screw home mechanism because tibia doesn’t externally rotate
  • so femur has to internally rotate to finish extension
  • patellar tracking issue = lateral pull of patella
• Static and dynamic issues:

  1. at the joint with faulty mechanisms
  2. above or below joint (patellofemoral pain, ITB friction, bursitis at hip)
  3. surrounding soft tissue

  • dynamic issues that cause pain due to change in pressure distribution
  • find weakest link in chain
• Bottom line:

  assess:

  • posture
  • alignment
  • functional movements
  • extrinsic factors
• Plantar fasciitis:

  • most common foot condition
  • medial heel pain
  • overuse or excessive loading
  • atypical arches
  • in active people with increase FITT
  • linked to BMI in less active or recently active people
  • collagen disarray
  • no inflammation
  • therefore = osis
• Plantar fasciitis symptoms:

  • gradual
  • stabbing pain in the morning
  • pain improves with walking
• Plantar fasciitis signs:

  • pes planus/cavus
  • decreased dorsiflexion
  • tight gastrocs or soleus
  • poor joint mobility
  • weak tibialis posterior
  • pain on palpation
• Plantar fasciitis findings:

  1. over pronators = hard time arching, slow resupination, twist with propulsion
  2. supinators = decreased shock absorption, lack of pronation, force through fascia
• Gait cycle issues:

  • over pronators have issues getting back to heel off
  • supinators have issues getting back to foot flat
• Heel spurs:

  • present in 80% of plantar fasciitis cases
  • due to repetitive microtrauma
  • related to BMI, age, symptom duration, pain perception
  • may not be related to pain
  • may worsen after symptoms go away
• PF treatment:

  • taping
  • orthotics
  • night splints
  • correct training errors
  • soft tissue release
  • stretching
  • strengthen
  • power and agility