Sports Injuries

Shoulder chiropractor, Dr. Alexander Jimenez examines the latest research into shoulder problems and gives practical advice on achieving balanced upper-body development.

Chronic shoulder injury is a common issue, and not only for athletes. Among the people at large, day-to-day activities such as DIY or gardening can produce chronic pain, as may resistance work at the gym, when weightlifters pile on the weight without paying attention to the demand for balanced strengthening. Adults beyond age 50 are more vulnerable to general to rotator-cuff tears, the incidence increasing with age(1).

One large group, known as 'overhead athletes', are at increased risk of chronic shoulder injuries. The overhead group covers a broad array of sports such as swimming, tennis, cricket, javelin and baseball, all of which include variations on the standard throwing activity where the arm moves over the head (see below).

The throwing movement recruits a large number of muscles and unites a massive assortment of arm motion with high forces or levels at the shoulder joint. All overhead athletes often perform many repetitions of the movement, typically with the dominant arm only, as part of their sports training.

For the shoulder and arm to maneuver efficiently requires coordinated movement of the scapula and humerus, called scapulo-humeral rhythm. By way of instance, arm abduction is accompanied by some upward rotation of the scapula, allowing the deltoid muscle to maintain a good length-tension relationship throughout the whole 180 degrees of abduction.

Scapular and humeral coordination also involves the stabilizing muscles of the scapula working in concert with the rotator-cuff stabilizing muscles of the glenohumeral joint. If the scapula retains its position correctly, the rotator cuff is going to do its job more effectively. Or, to put it another way, active stability is necessary to prevent excessive stress on the shoulder joint.

Get The Balance Right

The importance of rotator-cuff muscle strength in throwing was examined by a researcher from the West Point Army Hospital at the US(2). Scoville et al looked at the strength of ordinary subjects without any shoulder injury symptoms, comparing strength ratios of the end range of lateral and medial rotation. Subjects were assessed on an isokinetic dynamometer (which measures joint strength). Full range of motion (ROM) was defined as 90 degrees of lateral rotation (forearm vertical) to 20 degrees of medial rotation (forearm 20 degrees below the horizontal). The average force produced in the last 30 degrees of each direction was assessed as end ROM.

The group average strength ratios outcomes are as follows:

The concentric lateral rotation to eccentric medial rotation ratio of 1:2.4 indicates the lateral rotators have readily enough strength to decelerate the arm as it moves back into the cock position. The eccentric lateral turning to concentric medial rotation ratio of 1.05:1 suggests that the lateral (external) rotators are capable of decelerating the forward motion, but only just.

The results of Scoville's study suggest that ordinary adults without a shoulder problems possess adequately balanced strength for effective biomechanics of throwing. But it also shows how significant it really is for overhead athletes to keep that equilibrium of muscle strength, otherwise the lateral rotators might not have the ability to manage the more powerful lateral spinning force, compromising the shoulder joint.

Problems often arise when athletes concentrate on their training solely on the prime mover muscles, such as pectorals and deltoids, resulting in a relative weakness of the rotator-cuff and scapular stabilizer muscles. It is common practice now for overhead athletes to pay additional focus on lateral rotator strengthening. The same information will apply to all those that do resistance training: be certain to include exercises for the rotator-cuff and scapular stabilizers in order to create balanced strength in the upper body.

While the Scoville study analyzed rotation strength alone, we have already noted above that throwing combines spinning with flat extension and flexion movements. The rear deltoid muscles should also therefore act eccentrically to decelerate the arm throughout the end range when the pectorals and anterior deltoid are working concentrically. So strengthening applications must also look closely at back shoulder strength, including pulling and rowing movements to equilibrium pressing movements.

Here, again, gym-goers have a tendency to be most unaware of the need for balanced development, typically focusing on the 'mirror muscles' (pectorals, deltoids and biceps) and neglecting the back. The ideal program is going to be one that boosts strength in all muscle groups and also develops a balanced physique, front and back.

What Goes Wrong

Recent research from Kibler and McMullen (3) utilizes the idea of 'scapular dyskinesis': a change in the normal position or motion of the scapula during combined scapulo-humeral moves. They suggest that a wide variety of symptoms reveal exactly the same biomechanical fault, the inhibition or disorganization of activation patterns in scapular stabilizing muscles, resulting in altered scapular function.

This idea is supported by research from a team from Belgium(4). Cools et al investigated the time of trapezius muscle activity during a sudden downward decreasing motion of the arm, comparing the operation of both 39 overhead athletes with shoulder impingement against the of 30 overhead athletes with no impingement. The trapezius operates on the scapula in 3 sections: the lower portion depresses, the centre portion retracts, and the upper portion raises it.

Cools measured the time that the muscles took to change on in all three parts of the trapezius and at the middle deltoid, and discovered significant differences between both groups. Those with impingement showed a delay in muscle activation of the middle and lower trapezius the muscles which are important for preserving good shoulder positioning.

Another study from Cools and his group(5) researched if 19 overhead athletes with impingement symptoms had differences in their scapular muscle power (measured by isokinetic dynamometer) and electromyographic activity on the affected and uninjured sides. They found that the injured side revealed significantly lower peak force during protraction, a significantly lower ratio of protraction to retraction force and significantly lower electromyographic activity in the lower trapezius through retraction.

Collectively these findings support the idea of scapular dyskinesis involving abnormal recruitment timing and strength of the trapezius muscle, specifically the middle and lower portions. These results indicate the importance for harm prevention of good scapular stability in the depression and retraction movements.

Research in Germany highlighted changes in flexibility at the shoulders of overhead athletes(6). Using ultrasound-based measurement, Schmidt-Wiethoff et al found that the dominant arm at a group of pro tennis players had a considerably greater range of external rotation compared to the non-dominant arm, even while their internal rotation showed a substantial deficit relative to the non-dominant arm. Furthermore, the total rotational assortment of motion of the dominant arm was significantly less than that of the non-dominant arm or of a management group. Among the control group (not included in any overhead sports), there were no important differences in flexibility between their own shoulders.

How To Protect Your Shoulders

It would appear in the study that incorrect muscle function (developed through sport-specific demands or injury) is most evident at the lower and middle trapezius and lateral rotator-cuff muscles. From a practical viewpoint this means overhead athletes and people involved with weight training need to spend time on specific strengthening exercises to encourage injury prevention and ensure balanced strength and good posture.

Step 1: Equalize Front & Rear Strength

The beginning point is a balanced program for front and back shoulder muscle growth. Opposing muscle groups have to be trained equally. While exercises for the anterior shoulder and pectorals create power, to train just those muscles will unbalance the shoulder. The better approach is to plan exercise pairs that work opposing muscles (see Table 1). Coaches and therapists must check that equivalent quantities of sets from each column are written into strength programs.

Step 2: Develop Good Pulling Form

It's crucial to do row or pull exercises with proper technique so as to ensure that the middle trapezius, rhomboids and lower trapezius muscles are properly recruited.

As an example, the lat pulldown is a popular exercise for the upper-back and rear-shoulder muscles, involving adduction of the arm. The workout begins with the arms above the head. Throughout the pulldown motion the exerciser must focus on utilizing the lower trapezius muscles to depress the scapula while the massive latissimus dorsi muscles pull on the elbows downwards. And throughout the return motion, it's important to make the lower trapezius muscle 'keep hold' of the scapula as the arms rise with the weight.

This recruiting creates the proper scapulo-humeral rhythm. Without correct use of these lower traps, the lat pulldown is performed in a hunched shoulder position, which promotes poor mechanics.

Exactly the same coaching principle applies to rowing exercises. These involve horizontal expansion of their arm, utilizing the powerful latissimus dorsi muscles, and require concurrent scapular retraction in the middle trapezius and rhomboids. Exercisers should concentrate on retracting the scapula at the same time as the elbow is pulled straight back and maintaining the scapula retracted as the arm goes forward with the weight on the return motion. If the scapula is not stabilized the athlete will perform the practice in round-shouldered (kyphotic) posture, which again leads to bad shoulder joint mechanics.

Measure 3: Isolate The Rotator Cuff

The small but essential muscles of the rotator cuff should be targeted alongside the lower traps to prevent developing weakness or dysfunction. In the following four exercises, look closely at the coaching points.

A club golfer was cured of a nagging consistent shoulder pain. Shoulder injury chiropractor, Dr. Alexander Jimenez evaluates the case study.

Here’s a pertinent quote from the late lamented author of Letter From America, Alistair Cooke: ‘To get an elementary grasp of the game of golf, you must learn, by endless practice, a continuous and subtle series of highly unnatural movements, involving about 64 muscles, that result in a seemingly “natural” swing, taking all of two seconds from beginning to end.’

An avid club golfer with a handicap of 4 and a right-handed stroke asked for assistance with his nagging L shoulder pain that had recently become markedly worse and finally was threatening to stop him playing. He explained he knew he must have asked for help sooner, but he believed it would just go away (one of the most commonly heard statements by treating practitioners!) and it had now been hanging around for about six months in total, despite routine training.

He explained that initially it only used to damage when he caught his chipper from the grass and disrupted his follow-through, but now if he used an iron he'd feel a sharp pain unless he happened to stroke the ball flawlessly. It would also ache when he slept on the side, and after playing a full round it ached for some days. He had tried a million stretches and even appeared quite flexible with specific movements around the shoulder. In addition, for some years he had battled with R low- back pain and anterior hip pain which, when really bad, would render him limping a couple of days after an 18-hole round.

Assessment

Evaluation showed all the signs of rotator-cuff tendinitis (inflammation and microscopic breakdown of tendon), together with accompanying weakness of the muscle itself, leading, over time, to excessive anterior translation of the head of his humerus (extra shearing of the ball in his socket joint) on follow-through. This would likely cause an impingement of his already thickened tendon beneath the rectal acromial arch of the shoulder, giving him the sharp stabs of pain he complained of more lately.

His standing posture gave us the most clear clues as to why this had evolved, without ever needing to video his stroke biomechanics: rounded shoulders and a very noticeable low- rear arch (lumbar lordosis) are classic signs of poor postural control resulting in wrong movement patterns within his stroke. Gradually over time something needed to give often it's the non-dominant arm.

Had he had been middle-aged, we may have X-rayed his shoulder to search for any calcification of his tendon (he'd just turned 30), and only if progress wasn't going well would we believe doing an ultrasound scan to find out the size of scarring and limb breakdown.

Treatment

Rehabilitation could have a month or two if all went according to plan the key unknown factor is how well he'd take on the challenge of holding his shoulders and pelvis differently; this re-education procedure is frequently the most difficult. The general treatment procedure will first entail improving flexibility so that appropriate posture positions can be held most of us get stiffness in a number of our joints because of gravity wrecking our great posture.

Recent improvements in sports physiotherapy have enhanced the speed of the process significantly. Aside from a systematic stretching regime from the patient, we 'release' muscle tightness by deep-tissue massage and trigger-point treatment, heat, a home program of self-pressure massage with a tennis ball, and mobilizing of the tight parts of the capsule of the shoulder with seat-belts. Tightness in the posterior rotator-cuff muscles of this specific patient took a lot of effort to workout, and lat dorsi and pec major/minor were also big players.

Additionally, he had considerable stiffness in his thoracic spine, particularly with L rotation, which was worked loose, as were certain gluteal and hip-flexor muscles.

The Next Two Phases

Secondly, postural muscles needed to be 'turned on', ie recruited correctly, and a schedule of gradual strengthening of their ability to restrain the joints to which they're responsible began. In this instance the crucial ones were the lower and mid trapezius and transversus abdominus muscles we also taped up them sometimes to help him remember to continue using them, until it became more habitual.

Around this time, pain has gotten less and less of a problem along with his postural control was growing nicely. He was able to come back to his coach and start utilizing the positional changes in his stroke, slowly increasing the stroke distance and frequency and all the while maintaining his flexibility with the tennis ball. This third phase, which entails integrating the right posture into the stroke, has to do with the coach, and requires substantial discipline on the part of the athlete to ensure he remains inside the realms of what his brand new system can tolerate without being overloaded. Because he can still overdo it!

All went well, with all the golfer reaching one of his best-ever scores in the Queensland Open Tournament three months later. However, two weeks after that he dived badly in a game of rugby and twisted the exact same L shoulder and ripped the exact same rotator-cuff tendon he'd worked so hard to fix. Back to the chiropractor.

Sports fitness & injury chiropractor, Dr. Alexander Jimenez suggests additional exercises that will assist you avoid shoulder pain.

The functional anatomy of the shoulder an the way the weakness at the rotator cuff and an inability of the scapula to stabilize the shoulder are the significant contributors to shoulder impingement injuries. Three important exercises for strengthening the rotator cuff and approaches to boost scapula stabilization. This article provides more exercise suggestions and provides further practical tips to help athletes prevent shoulder pain.

1. Balance Your Upper-Body Workouts

A good way to prevent shoulder injuries is to ensure that your upper-body strength sessions are more balanced. This means that every push or press exercise must be balanced using a pull or row exercise. Too many athletes and weight trainers focus on creating the 'mirror muscles', the upper trapezius, anterior deltoid and pectorals. As a result, the 'non mirror- muscles', lower trapezius, rhomboids, latissimus dorsi and rear deltoid, are underdeveloped. This also contributes to a muscle imbalance in the shoulder, which results in poor scapular stabilization because the non-mirror muscles are those that function to stabilize the scapula. Moreover, over developed mirror muscles may lead to some round-shouldered position, which wrongly places the scapula up and forward. Redressing this imbalance is quite vital for the prevention and rehabilitation of shoulder impingement injuries.

The following is a good illustration of a balanced upper-body workout which I would recommend.

Note the 1:1 ratio between push/press and pull/row exercises.

For those who are more prone to shoulder pain or are recovering from a shoulder injury, then I would advise changing the ratio to 2:1 in favor of the non-mirror muscles. Remember, it is the push/press exercises which cause the problems, so you need to change your accent before the imbalances have been redressed. Additional pull/row exercises include: bent-over row, single-arm dumbbell rows, single-arm cable pulls, bent-over rear fly, pull-ups (wide or narrow), stiff-arm pull-downs with cable/flexaband.

2. Limit Your Range Of Movement, & Take It Easy

Rehabilitation from a shoulder impingement injury should focus on rotator-cuff strengthening. But it is important to remember that when it comes to re-introducing your own weight-training exercises, you must progress slowly. Frequently this implies avoiding specific ranges of movement where the shoulder joint sub-acromial space is compressed the most. The impingement zone to avoid is between 70 and 120 degrees of shoulder abduction (when you move the arm laterally away from the side of the body).

To start training the non-mirror muscles, start with the seated row, since the shoulder joint is not abducted in this workout. Once the pain is totally gone, then introduce the overhead exercises for example pull-ups and lat pull-downs. You ought to be even more careful when it comes to the mirror-muscle exercises. I'd avoid lateral raises, upright rows and shoulder presses completely for a while. But, incline bench press with arm abducted to 45 degrees are a great place to begin again. Slowly build up to the normal bench-press range as strength improves.

It is also crucial that you don't increase your weights too soon. Bear in mind that the tendons and ligaments need to accommodate to exercise as well as the muscles, and they may take longer to do so. I'd suggest staying in the 12-20 rep scope for a while before pushing up the weights, particularly with the mirror- muscle exercises. While I realize that it is important for many athletes to be powerful at exercises such as the seat and shoulder press, I would advise that you develop gradually to maximum advantage. Reducing your reps by two every 2 weeks is a fantastic guideline. During heavy workouts, ensure that you warm up the shoulder joint and rotator cuff thoroughly prior to lifting.

3. Correct Scapula Positioning When Performing Exercises

The appropriate position for the scapula (shoulder blade) is back and rotated down. Essentially, this means maintaining a great 'military posture', together with shoulders back and chest out. A round- shouldered or hunched posture is to be avoided at all times.To achieve the right position, you need to use your rhomboids, mid and lower trapezius muscles to retract the shoulder and pull the scapula down.

When you do any upper-body weight-training exercise, always get into the habit of starting with good upper-body posture and pinching the shoulder blades together. You need to feel that the scapula is a good platform which keeps the shoulder properly positioned as you do the exercise. As mentioned by Dr Kemp, a fantastic way to learn the correct position is through the seated row exercise by keeping your scapula down and back while you move your arms. Throughout the exercise, you should believe that the rhomboids and trapezius muscles have been statically contracting to maintain the scapula set up, and the latissimus is working to carry out the movement. After you have the feel for maintained scapula stability during the seated row, try to achieve it during all upper-body exercises. What you may find is that exercises such as the press-up or front raise, in which the shoulder may become impinged, won't be painful if you stabilize your scapula correctly. In effect, by using the scapular muscles you can achieve better shoulder mechanisms and avoid injury.

Correct scapular stability is hard to learn and demands a lot of concentration and practice during your training sessions. First you need to understand what the correct position is, and frequently this needs a trainer/physio to guide you. Then, during training sessions, instruction and observation from a trainer can help you reach and maintain the right shoulder position.

4. Sports-Specific Exercises Plyometrics For The Shoulder

Just as rehabilitation training for leg injuries needs a functional progression from simply strength exercises to sports- specific exercises, so does rehab for your shoulder. This means that for the athlete, eg a thrower or tennis player, conventional resistance exercises at the gym might not be enough to allow a full return to competition. Often what is needed to bridge the gap would be plyometric exercises for the shoulder that mimic sports- specific movements. Plyometrics for the shoulder usually involve medicine balls of different weights.

Plyometric exercises have two advantages. First, they're performed fast, and second, they demand stretch-shortening- cycle movement patterns. This means that they are much more sports-specific than traditional resistance exercises. Specifically, plyometric exercises for the rear-shoulder and external rotator muscles are extremely useful since they provide eccentric training for these muscles. This enhances their ability to control the shoulder through the potent concentric actions of the pectorals and anterior deltoid involved in throwing or serving. Thus it's important to ensure that your plyometric workouts are balanced between the prime movers (pectorals, latissimus, anterior deltoid) as well as also the rear-shoulder and upper-back muscles. I would recommend incorporating shoulder plyometrics through general conditioning exercises to prevent injuries and in the later phases of shoulder rehab to guarantee a functional progression back to competition.

Here are two suggestions. The key to both these exercises is that the medicine ball is caught, the impact quickly absorbed (fast eccentric phase) and then thrown back explosively (powerful concentric phase).

For athletes who rely on their shoulders, here are the five major guidelines for maintaining them injury-free. Shoulder chiropractor, Dr. Alexander Jimenez assesses the data.

There is not any joint in the human body as complicated, intriguing, or bothersome as the shoulder. It can leave clinicians scratching their heads, wondering why a problem they've solved several times before is this time so stubborn. And shoulder problems can surely be stubborn! That's why, in every case, prevention is indeed much better than cure. Rarely is a pain which has surfaced a very simple matter of applying some ice -- it is more likely to be the tip of an iceberg!

An athlete's shoulder is either a joint that he/she hasn't given a second thought to, or it's ever-present in their minds -- it is either no problem, or an issue they cannot dismiss. It has been stated that the design elements which compose the shoulder are either close to perfection, or close to disaster! Now, of course, this greatly depends on the sport you're in: cross-country runners are unlikely to possess the shoulder difficulties that javelin throwers or swimmers may encounter. But it is uncommon for athletes using their shoulders as part of the main routine to not take at least a little pain, while others possess a background of a substantial shoulder problem.

This report takes a good look at the big picture of shoulder injury management, and tries to empower and instruct athletes with a few DIY home injury prevention and performance enhancement techniques. It presents, some complex concepts, and is therefore in no way an exhaustive explanation or listing of exercises.

Preliminary Precautions

If you have a shoulder injury and would like to try and treat yourself, please bear in mind:

Treatment, Prevention & Performance Enhancement

The information that follows describes the prevention and treatment for overuse injuries of the shoulder, not the management of traumatic or acute accidents such as glenohumeral dislocation, clavicular fractures, or tears of the labrum ('cartilage').

However, the broader principles of rehabilitating a shoulder that has been surgically repaired, or been stuck in a sling for four weeks, are not any different, although there could be limitations and time constraints imposed by orthopedic surgeons.

The most important principle of shoulder management is: start working on it now. Don't wait until your shoulder starts to hurt!

However, moreover, the preventative steps outlined below are sure to improve performanc they will really improve the way your shoulder operates, and consequently it will be more powerful, more coordinated, and reach farther and last longer befpre fatigue sets in. All the experts say it: injury prevention equals performance enhancement.

Some Simple Anatomy Of The Shoulder Complex

The shoulder joint really comprises four joints -- see If You're able to feel them on your own:

The Rotator-Cuff Muscles

Without learned muscle control, any overhead action, let alone just lifting the arm, could be hopeless -- that the GH joint could dislocate or the HOH would jam under the arch of the acromion. The muscle group we all rely on for this control is your rotator-cuff (RC) muscles -- the infraspinatus, supraspinatus, teres minor, and subscapularis muscles (a body book will reveal where they lie). All of them arise in the scapula and are coordinated together to keep the HOH spinning/rotating as near the centre of the glenoid as possible with movement. The long head of biceps tendon running over the front of the GH joint also has a stability role to perform together with the RC, especially with the throwing action.

The muscles primarily designed to place the scapula for overhead motion are the trapezius (notably lower trapezius), and serratus anterior -- called therefore the 'scapular stabilizers' -- with counter forces being produced by levator scapulae, rhomboids and pec little muscles.

The larger and more powerful muscles that create motions of the arm are the deltoids, latissimus dorsi, and pectoralis major. So whereas the RC muscles organize the proper positioning of their HOH by acting near the centre of the joint (the 'inner core'), then the larger muscles with long lever arms move the arm with speed and force (the 'outer core').

The Five Guidelines: Balance Through Control

Let's sew what might be considered the five most essential ingredients for an athlete whose main weapon is the shoulder:

1. Sports-specific technique.

2. Flexibility.

3. Core stability.

4. Rotator-cuff control.

5. General strength.

The primary objective of these five regions of intervention is, in a word, balance. And the way to achieve it? Control. The higher your levels of functionality, the larger the control required to maintain equilibrium -- just as a Formula 1 car needs much higher levels of balance and control than does a standard road car. A deficit in any one area will ultimately trigger muscle imbalances to grow, which lead to soft-tissue breakdown and after even joint degenerative change. Picture a bike wheel in which one spoke in the wheel has been bent out of shape: a slow warping happens using use which creates an imbalance which further damages other spokes before the whole system comes to a grinding halt.

The more elite the athlete, the more committed he/she needs to be to getting expert help in satisfying and keeping these fundamentals. You'll also save yourself much time and distress should you seek experienced assistance as a preventative measure, rather than only requesting treatment once the issue has surfaced. Having a regular tune up/service can be done in the form of screening, where a sports-experienced physiotherapist can conduct you through a set of tests to find out if some of the areas below are not being adequately dealt with.

1. Sports-Specific Technique

Inadequate performance and shoulder pain very commonly originate in bad habits of technique. Often they're only clearly noticed when muscle fatigue sets in. But a fantastic coach will be able to pick up if this is occurring and recognize it is time for rest and recovery.

As a general rule, technique work ought to be performed after a thorough warm-up (or even as part of a warm-up), even whereas the muscles along with the brain-connections are still fresh and strong. On the flip side, when fatigue sets in can sometimes be a great time to do specific drills that don't load the shoulder, nevertheless will fortify good movement patterns. The only proviso is that one has to be extra diligent to observe when compensation strategies are setting in, and call a halt immediately.

Without wanting to state the obvious, practice is the key! Once you have mastered a new aspect of technique it must be repeated about 10,000 times before it will become an engraved on your mind, in other words, the point where the motion pattern becomes subconscious and feels 'natural'.

There are many methods to discover if your technique is faulty, however one of the greatest is video recording in order to slow down the action and break it into smaller components. The better the technology, the greater the outcome, but for actual worth it comes down to the experience of the person evaluating the picture. Using a mirror is seldom effective because the position of the mind focusing on the mirror may greatly affect the shoulder posture. The two main sources of opinions in this respect are your mentor and a bio-mechanist, and often a sports physiotherapist who has had a great deal of expertise in your sport.

What Faults To Look For

The assortment of overhead motions necessary for every sport gives rise to quite subtle and unique technique flaws. The following are some examples of things to look out for:

Tennis serve/smash: inadequate trunk twisting to open up torso in cocking position, ball toss too close to human anatomy or too far behind body, cutting follow-through short by whipping racquet.

Javelin/water polo/baseball throw: side-arm activity, elbow behind the shoulder through follow-through, inadequate trunk rotation at late cocking stage to open up the torso and at conclusion of follow-through to dissipate forces following release of the object. The nearer the surface of the upper arm may follow the point of the front part of the chest, the less strain there will be about the shoulder joint, and also the longer rotation which may be harnessed from the shoulder, the less the strain on the elbow joint.

Freestyle swimming: insufficient body roll, just ever breathing to one side, catching the water too close to the midline, not keeping the shoulder blade scraped on the back during pull stage, not keeping the elbow high enough during recovery stage (a indication of insufficient flexibility).

2. Flexibility

The objective of flexibility varies for the different muscles around the shoulder. For the major power muscles, it is necessary that flexibility allows freedom of motion for your pelvis, trunk, scapula, and humerus. For your rotator cuff, the critical issue is that the balance of forces centering the mind of humerus, and to a lesser degree, liberty of motion. It's more critical that the internal and external rotators are equally elastic, rather than how flexible they may be.

A warning: to have an excessive amount of flexibility at the expense of control and strength could be dangerous due to the excessive shear forces causing wear and tear in the joint. This is very true of the glenohumeral joint at which the primary source of equilibrium are the rotator-cuff muscles functioning in conjunction with additional soft-tissue structures like the torso, ligaments and cartilage. Too much flexibility at the cost of muscle control puts strains on the soft tissues and causes injuries like rotator-cuff tendinitis and degeneration, labral tears, subluxations and possibly even a dislocation.

Do not start a flexibility program until you've seen a sports physician or physiotherapist if:

Stretching

Stretching to increase flexibility should not be done prior to competition or training, but rather done during 'down' times in the week. This is because of the suppression of the 'stretch reflex' that occurs during sustained passive stretching of muscle tissue (ie repeated holds of 20-30 minutes). If you were to perform rapid forceful movements like throwing straight after such passive stretching, there could be an increased chance of muscle and tendon tears. For flexibility every muscle has to be stretched a few times in 20-30 seconds each, and repeated three to four times per week.

The most important areas for regular flexibility sessions are:

● Infraspinatus/teres minor (posterior rotator cuff and capsule).

● Pectoralis major/minor.

● Latissimus dorsi.

● Biceps/triceps.

● Thoracic spine (between shoulder blades).

● Upper trapezius/scalenes/levator scapulae.

● Gentle nerve extending (oscillations).

The perfect way to understand how to stretch the above areas is to be taught by a sports physiotherapist, sports conditionist or private coach.

It is important not to stretch the ligaments of the shoulder, which in due time may lead to laxity of the joint and potential instability. The most common case I see? Athletes stretching their pec muscles and ending up with their arm supporting them against the wall, but with their shoulder rolled forward, feeling the stretch onto the front of the point of the shoulder.

What is being stretched here are the anterior ligaments ('capsule'), not the muscle, which can be better stretched by pulling the scapula back and twisting from the trunk away from the shoulder (hands still on the wall). One then feels the stretch far more down to the chest area where it ought to be.

Warm-Up Practice & Theory

The shoulder ought to be warmed up thoroughly with gradually increasing movements -- large circles, across-body movements, back twists, shoulder-blade rolls and forward and backward squeezes. The objective of this is to increase blood circulation and temperature, thus increasing the elasticity and 'contribute' from the soft tissues. A streak of short-duration stretches (ie five to ten seconds) of all the major muscle groups should follow and then eventually a session of more sports-specific drills. These are utilized to heat up the brain's connection to the muscle, ie to fortify correct motor patterns, and also to place the right neural reflexes from the muscle.

Massage

One of the most essential features of massage is to decrease the build-up of 'trigger points' -- regions in the muscle which literally grab up due to excessive loading. This might make a muscle imbalance or be the result of one -- either way it must be 'published' via massage. Each of the muscles described above which are necessary to stretch are vulnerable to activate points and may become tight and/or feeble because of them. It is not unusual for a trigger point to develop in the muscle as the initial structure to start breaking down, gradually dragging different muscles, nerves, and the glenohumeral joint down into a cycle of inflammation and pain.

The best way to begin is to get a hard tennis ball to perform your massage with, then try these two ideas:

Pectoralis minor/ major 'release': This is a important muscle to keep loose since if becomes too tight, it binds the scapula forward, leading to the head of the humerus being thrown off centre, especially in overhead positions. Hold on the tennis ball into the soft muscle overlying the chest directly at the front part of the shoulder. Lean towards a door frame and allow the tennis ball to press against it, with the same side arm halfway up the wall, palm facing towards the wall. Look for the tender trigger points, and when you find you, stay with the pressure on to it until it softens and the pain eases.

Rotator cuff 'release': Often accompanying the above condition is tightness and overactivity of the infraspinatus and teres minor, the net impact of that can also be to push the head of the humerus forward from the centre of rotation. Hold a tennis ball into the rear of the shoulder on the scapula, and press the back and side of the scapula onto the wall. The arm that is being worked on should be cradled in the opposite hand. Let it dig deep!

3. Core Stability

Core stability has come to be a whole science in itself in the last decade since all manner of sports professionals have realized just how crucial it is for the inner core of the human body, particularly those joints nearer to the backbone, to be encouraged from the postural muscles designed to achieve that. For your shoulder, the essential areas are the lumbar and cervical spine, and the scapulothoracic joint. If these areas aren't secure, then significant extra loading and strain will be passed on into the shoulder joint.

The stability of the lumbar spine is achieved by the combined effects of transversus abdominis and multifidus acting on the thoracolumbar fascia. Pulling in the lower navel area when tensing the lower-back muscles slightly activates the 'corset'. The cervical spine is stabilized by the upper cervical flexors in conjunction with the lower cervical extensors, to attain a 'tall' neck posture with the eyebrow slight drawn into the neck. Keep in mind that this can be easier for some than others, based on how your system has been trained -- for example, ballet dancers will come across the stable position of the neck comes naturally, rugby players may not. Activating the muscles is the first stage of the learning process; training the position till you are prepared to integrate it into simple movements that are relevant to your sport.

The scapulothoracic joint is the most important 'joint' for the shoulder, because the glenohumeral joint is formed by the glenoid (the socket) of the scapula and the humerus (the ball). The muscles most directly accountable for its stability would be the trapezius muscle (especially its own middle and lower fibres) behaving together with the serratus anterior muscle -- together they act to hold the scapula at a neutral position whether the arm is from the side or over the head. The neutral position is where the glenoid socket is most ideally orientated for the rotator cuff to control the HOH .

Imitate The Action Of The Seal

Bear in mind the earlier picture of a seal with a ball on its nose? The seal is the scapula trying to balance the ball of the humeral head using the rotator-cuff muscles. How amazing it is to think that these high levels of balance are being utilized when we perform overhead activity!

Deficiencies of core stability are always found with chronic shoulder injuries, or after surgery or injury, because pain will inhibit the postural muscles so they cannot do their job correctly.

The way to activate the lower trapezius/serratus anterior muscles would be to sit at a relaxed tall position, arms relaxed across your thighs. Gently pull the inner boundaries of your scapula together and down with the minimum of work, and hold it there for 10 minutes. Do not pull too far back or you may over- activate other muscles which are not meant to be the primary core stability muscles -- it is always a delicate and relaxed activity using a 10-second hold. When you have practiced this for a couple of days as frequently as you can, experiment with 'setting' your scapula into the neutral position with your arms out to the side, along with your arms on your hips, up behind your mind, etc..

Once you have mastered the 'setting', add small movements of your arm when holding the established position, and slowly over a few weeks you can increase the sophistication, speed and loading of your arm. Finally you're doing the setting in precisely the exact same time as you are carrying out the rotator-cuff strength and control exercises explained below.

4. Rotator-Cuff Strength & Control

The rotator-cuff muscles are all determined by the great positioning of the scapula for successful management. If the scapula is angled too far forward or downward, for example, while the tennis player reaches overhead to smash, the RC muscles are biomechanically disadvantaged and may neglect to maintain the HOH centered. The role of the RC muscles therefore is to keep the position of this HOH whereas the prime mover muscles create power.

As you enhance your scapular management, the RC muscles can act more effectively and independently of the scapular control muscles. That's to say that you should have the ability to hold the scapula quite still in the neutral position while you individually move your arm. This ability is known as 'glenohumeral dissociation'.

Thus with each of the exercises following, it's presumed that the scapula is being held as close as possible to neutral:

5. General Muscle Strength

When the foundational issues of technique, flexibility, core stability, and rotator-cuff controller are being executed, we have to take a look at the larger picture of this 'outer core'. What is the rest of your body like -- does it help or hinder the functioning of your shoulder?

In every sport that relies heavily on the shoulder, it is vital to view it as merely one link in a 'kinetic chain' -- all the other connections must also be adequately developed to aid in the growth of rotary torque or the shoulder will be overloaded. There is a 'winding up' and an 'unwinding' which takes place at a quick speed starting from the legs, progressing through the hips, pelvis, lumbar spine, thoracic spine, shoulder, elbow, and wrist. And each must be educated to absorb its fair share. Golf is your classic game to use as a very clear case of this transfer of rotary power -- a succession of wind-ups finally being unwound since the stable base of this hips whips back into the opposite direction.

To this end there is a whole segment that may be written on the value of plyometrics, the exercise science involved in harnessing the eccentric strength of muscles to get increased power. The rotary energy of the human body is greatly strengthened by developing the eccentric contraction power involving the kinetic connections described earlier -- and this is where medicine balls, harnesses, and other strength and conditioning equipment come in.

Avoid This Imbalance

It is clear to most athletes that a gym routine needs to include strengthening function for the deltoids (three heads), latissimus dorsi, pec major, upper trapezius, and the rectus abdominis since they are the prime movers of the shoulder. Frequently what is critically overlooked, however, is the imbalance which could develop between the front part of the shoulder and the back.

In those athletes which are carrying an overuse injury at the shoulder, nine times out of ten they have overdeveloped pecs and lats comparative to their trapezius, rhomboids, posterior deltoids, and posterior rotator cuff. In these scenarios, flexibility must frequently be enhanced, scapular setting must be taught, and also the focus of gym exercises changed in the direction of the back. Seated and vertical row, barbell flies to the back, seat pull, and lat pull-downs with the bar behind the head are all exercises that must take higher priority.

Throughout all gym work it must be stressed that scapular setting along with the activation of core stability muscles to get good posture are vital for injury prevention.

Summary

So there we have it -- that the big picture of injury prevention and performance enhancement for athletes who rely on their own shoulders for playing their sport. Decide today which among these issues you may need some more work on, try some of the house exercises, and possibly seek out expert assistance to maximize the results of your efforts.

Hip chiropractor and trauma specialist, Dr. Alexander Jimenez looks at among the most frequent causes of hip pain -- femoroacetabular impingement (FAI)...

Over the previous 10 years, with the advent of MRI and hip arthroscopy, the reported prevalence of hip labral and acetabular rim pathology has considerably increased(1). Hip pain is a common cause of reduction of training/game time with as much as 15 percent of all AFL injuries reported as hip pain(1).

What's FAI?

FAI happens when the femur impinges on the acetabulum. This happens due to an anatomical variation in either the femur or acetabulum and is present in up to 20% of the population.

FAI is categorized into three main types (see Figure 1):

1) Cam impingement -- this is the most common type of FAI and is most often found in young males(3). It refers to a "bump" most often on the anterior and also superior part of the femoral neck. In a camera lesion, the normally concave head/neck junction of the femur appears flattened or even convex(two) because the hip flexes, adducts and internally rotates this part of the femur then abuts against the acetabulum. Repetitive abutment applies shear stress into the articular cartilage resulting in delamination and labral tears can eventually occur(2). The cause of the anatomical variations on the femoral neck is unknown but a couple of theories have been suggested. Cam lesions could have a genetic inclination and/or they may occur due to over-activity of the epiphyseal plate (because of increased load) during adolescence(2,3). Most probably it is a combination of both of these factors. Ganz (2003) proposed that camera lesions can predispose the athlete to early osteoarthritis of the hip with up to 40 percent of OA hips revealing signs of a camera lesion(2).

2) Pincer impingement -- this refers to over- coverage of the acetabulum with a normal appearing femur. Acetabular abnormalities that may lead to pincer impingement contain a retroverted acetabulum, protrusion acetabula or osteophytic development. This type of impingement is commonly found in middle-aged guys.

3) Mixed presentation of both camera and pincer impingement -- this describes the situation where both cam and pincer impingement exist. It's important to under- stand that all these are anatomical variants and therefore are not in themselves the pathology but they might predispose the athlete to hip pathology both in the long and short term.

How Is FAI Diagnosed?

Subjective Assessment

FAI is most commonly seen in male athletes. They will frequently report a long history of hip stiffness or groin pain. They may report that their hip pain started with a minor trauma but never solved. They often report that their "hip flexors" happen to be tight particularly after prolonged sitting and that they might never sit back. Labral tears must be suspected when the athlete refers to a click or grating, giving way or locking feeling(1).

Objective Assessment

FAI should be suspected in athletes that have limited hip ROM particularly into internal rotation in 90 degrees of hip flexion. This may be quantified in either supine or sitting. These athletes will probably also have a debilitating FADIR and restricted and debilitating FABER(4). Several evaluations are described as diagnostic for a labral lesion; those comprise: FADIR, FABER, impingement provocation test and Fitzgerald test. In Leibold's systematic review they discovered that the current best evidence that a negative finding for these tests gives the clinician good proof that there is not any labral tear present; however, no evaluation has adequate specificity to confidently predict when a labral tear is present(5).

Imaging

Imaging is needed to validate the clinical investigation of FAI. Osseous abnormalities may be seen on x ray (but may be missed). If a bony impingement is suspected then a CT scan has improved precisionnonetheless, you must be aware of the greater radiation dosage associated with CT scanning and a CT scan doesn't specifically diagnose labral or cartilage lesions.

MRI may be utilized to recognize articular cartilage and labral pathologies; however, for imaging the labrum MR arthrography seems to create exceptional results(4).

Treatment

Conservative Therapy

At this stage there is no obvious evidence on when conservative or operative therapy are required. In circumstances where imaging shows minor signs of FAI and no additional significant pathology of the hip, conservative treatment should be trialled.

1) Education

These athletes should avoid exercises and positions which impinge the hip (cool F angle >90deg) ie deep squats, leg press particularly in incline machine along with large step-ups. Some common positions which needs to be prevented are sitting at low seats where knees are higher than hips, sitting cross- legged and position using a hip hitched to a side. These athletes, even if they sleep in their side, must be encouraged to utilize a pillow between their knees and feet to help keep their fashionable from flexion and adduction.

2) Soft tissue work and manual treatment

Soft tissue work through TFL, ITB and adductors can be very beneficial to reduce tone in these muscles. This may be completed in a variety of various ways such as trigger point massage, work, roller and dry needling. Manual therapy methods to restore normal arthrokinematics of the fashionable are also quite useful in decreasing symptoms.

Normally as the hip flexes, the femur glides slightly posterior and conversely since the hip extends the femur should glide slightly anteriorly in the acetabulum.

Considering these arthrokinematics, manual therapy methods which posteriorly slide the femur are very useful in athletes that have inferior posterior glide of the femur during hip flexion (see Figure 2). Approaches that anterior slide the femur may be useful in athletes who lack hip extension. Lateral glides of the femur have also been demonstrated to be rather helpful to reduce symptoms and increase range in athletes with FAI.

3) Exercise Therapy

What Are The Finest Rehabilitation Exercises To Do?

In most instances of hip pain, exercise therapy is vital to ensure long-term effects of therapy. Particular focus should be given to the hip abductor and hip extensor muscles.

The hip abductor synergy includes of glut medius, exceptional glut max and TFL. Frequently in athletes, TFL is overactive and the gluteal part of the abductor synergy is weak. Recently, Selkowitz and colleagues, using EMG, set out to identify that which exercises especially target the gluteal muscles whilst reducing action of this TFL(7). The results of their study identified the five exercises that showed strong stimulation of gluteus medius and superior glut maximal using the least action of TFL (in healthy volunteers).

1) Clam -- activation of glut med and glut maximum was maximized while the pelvis was at a neutral position (vs a reclined position) and the hip was flexed to 60deg(6) (see Figure 3).

2) Side walking with band around thighs in a squatted position was also demonstrated to have minimal TFL action (see Figure 4).

3) Single-leg bridge (see Figure 5).

4) Quadruped hip extension -- short and long lever (see Figures 6 and 7).

In humans the glut max works in 2 ways -- one, it expands and abducts the hip; and secondly it controls flexion of the trunk in walking and standing. If this muscle is weak then it is important that we as clinicians consider including both actions when creating a rehabilitation exercise regiment. A good example of an exercise that targets the component of this glut max that controls back flexion is Romanian deadlifts (see Figure 8).

The above exercises are very great for isolating gluteal stimulation and as the athlete progresses through their rehabilitation further load and multidirectional movement should be integrated into the program. Some examples of exercises which strengthen both the abductor and extensor muscles of the hip include:

1) Split squat with band (see Figure 9);

2) Split squat with rotation (see Figure 10);

3) Wood chop high to low or low to high (see Figures 11 and 12).

The resistance band and pulleys are employed in each of these drills to ease the hip abductor synergy muscles to work.

Operative Treatment

If conservative therapy fails or if a significant bony lesion or labral tear is identified then surgery might be required. The objective of surgery is to not only repair/treat the labral lesion or chondral pathology but also relieve any rectal abutment. Historically this has been done through an open process but most surgeons now are doing these processes through arthroscopy. Chondral pathology might be seen and delaminated components will be trimmed/shaved and chondroplasty, drilling and micro fracturing may be used to help stimulate fibrocartilage regrowth. Labral tears related to FAI occur most commonly on the anterosuperior rim. Where possible these ought to be repaired instead of resected, as eliminating large parts of the labrum alter hip mechanics, which might lead to further damage. To restore the normal anatomy of the femoral head/neck junction if a cam lesion exists, a femoral osteoplasty/ chielectomy should be performed.

Conclusion

Hip pain is a frequent reason for loss of training time in various different sports. This report has outlined the various types of FAI and possible conservative treatment options. Rehabilitation exercises are a critical part of the rehabilitation program of athletes with hip pain and a number of exercises that specifically target the gluteal muscles have also been described.

References
1) Brukner and Khan (2012) Clinical Sports Medicine. 4th edition
2) Kasserjian A, Cerezal L, Llopis E (2006) Femoroacetabular Impingement. Topics of Magnetic Resonance Imaging Vol 17, No5 , 337-345
3) Ganz R, Parvici J, Beck M, Leunig M, Notzli H, Sienbenrock K (2003) Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and related research No 417, 112-120
4) Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Sobelle K (2009) What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthopaedica 80 (3) 314-318
5) Leibold R, Huijbregts P, Jensen R Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review. The Journal of manual and manipulative therapy vol 16 no 2 e24-e41
6) Wilcox E, Burden A (2013) the influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during clam the exercise. Journal of Orthopaedic and Sports Physical therapy Vol 43, No 5 325-332
7) Selkowitz D, Beneck G, Powers C (2013) Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine wire electrodes Vol 43, No 2 54-66

Science chiropractor, Dr. Alexander Jimenez investigates the methods described in treating a tight calf muscle.

Assess The Calf Complex

In the calf complex, the medial sural nerve descends between the two gastrocnemius heads and also at mid-calf level combines with a branch of the peroneal nerve to form the sural nerve(1,2). As we get older, the body's connective tissue gets less pliable. Nerves are naturally surrounded by connective tissues -- sometimes they even run through connective tissues, so with aging the nerves can get trapped, trapped or tethered to surrounding muscle or fascia(3).

This can manifest as a feeling of tightness deep in the calf muscle that never changes, no matter how much the customer stretches the muscles.

Action! Evaluate The Calf

The perfect method to appraise the calf is to palpate the muscle in a relaxed position (see Fig 1. below). Begin with your patient's unaffected calf; palpate (feel) deeply between the gastroc heads supporting the knee and work down the calf into the Achilles tendon. This will give you a sensation of the deep neuro myofascial tissue enclosing the tibial nerve, and what 'normal' feels like in this patient. Beware: it's generally quite uncomfortable to do so because of the sensitive neural structures.

Then feel the affected calf in the exact same way. If there is a difference in the deep center section (eg tightness, pain, lumpiness) and if, when you press, then it replicates their usual 'pain' or 'tightness', it might indicate a nerve tethering problem that needs hands-on intervention.

Assess the nerves of the lower limb by using the slump test (see Fig 2, below) or the straight leg raise test to cross-check your client's neural system and compare sides.

Treat The Neural Calf Complex

Once you've found something asymmetrical, you can treat the problem.

Warning: this therapy could be painful, but in my experience you need to treat very firmly to get results. Warn your patient.

Action! -- Friction The Deep Structures

In the exact same position (see Fig 3, below), ensure finger tips are together and palpating right on the tight, painful area. With firm pressure, friction across the line of the nerve with your finger tips going into the left with both hands and then to the right (firm treatment is essential).

Repeat this along the length of the tibial nerve down the area where the patient has identified a difference in the feel compared to the other side. After you have loosened the neuro-myo-fascial constructions, get your client to walk or jog to see how it feels.

Action! Educate Your Client To Self-Treat

Sitting with knees bent, they should use their thumbs to palpate; ensure they can replicate the sensation you produced with your treatment. This way, your active patient can make chronically tight and painful calves a thing of the past.

Sourced From:

Running might appear the most natural thing in the world, but for many who try, it certainly does not come naturally, nor even easily. The awkward reality is that many people simply shouldn't be running at all if they would like to avoid ongoing injury. Among the rest of us, running styles differ so much that it is fair to say everybody's individual running style will be exceptional -- after all, we all differ slightly in our body position, our lower limb muscle recruitment and our foot placement when striking the floor. El Paso, TX. Chiropractor, Dr. Alexander Jimenez has a look.

For a lucky few, running does appear to come naturally. But most individuals who aspire to run well and injury-free will require work in their technique and overall postural control.

Chiropractors are just as likely as anybody else to be confused by the large amount of analysis available on the biomechanics of running; it's really hard to make sense of information like the subtalar joint axis or level of lumbar rotation whenever you are attempting to figure out what's gone wrong with the wounded client running on a treadmill in front of you.

I have previously written about the method of 'pose running' as one approach which I believe to be highly effective for training individuals to conduct while avoiding injury. This report focuses especially on the technique fault of poor lumbopelvic management, which I think is essential to injury-free running.

Some People Should Not Run

Not all of us are born athletes, and some folks are intrinsically not designed to run. Others will struggle because of a combination of physiology and lifestyle variables. Although the following list is probably not exhaustive, here are some of the main sorts of people that will be more prone than average to running-related injury, and will certainly struggle to sustain any longevity of running form.

Muscular Control Is the Secret

Nicholas Romanov, the leader of this pose running style, characterizes the differences between good and bad running this way:

'A proper technique has particular perception of lightness, brief support, no pressure on muscles, no feeling of loading On your joints... The opposite -- wrong technique -- goes together with muscle strain, loading on your joints, heaviness...' (www.posetech.com)

Over time that I've been involved with conducting athletes, I have come to consider that static stretching is likely Less important and less successful in warding off harm and recovering from it than sufficient muscular strength, endurance and control at crucial sites.

Like I have previously mentioned, the pose method is 1 method that runners can really work on muscular control and postural dynamics in activity-specific positions. Anyone who adheres to this technique should be ready for a great deal of practice in order to learn proper alignment and muscle recruitment.

Pose places plenty of focus on lumbopelvic and eccentric knee muscle management, particularly the way that knee and Hip muscles operate when the mid-foot strikes the floor.

I realized that the need for great lumbopelvic stability partially as a consequence of my own early experiences in practicing pose running. I Discovered I was getting a great deal of calf muscle soreness at the first phases, and really the pose method could lead to jet muscle sprains.

The method requires the runner to lean or 'fall' forwards and pick up their foot off the ground together with the hamstrings. This certainly develops a lot of speed but can place undue strain on the anterior musculature of the joints and leg of the lower back. The eccentric load around the calf will be enormous and often contributes to physical breakdown of this muscle.

The underlying cause of the calf strain, however, is that the pelvic place the runner has embraced so as to lean Forward to gain momentum. It is very easy to over-do the normal inclination to hinge forward from the hips while jogging, which places the shoulders a very long way before the buttocks, also leads the runner to rely in their erector spinae and hamstring muscles to take the strain of the running stride. It is actually not surprising that all these athletes create symptoms within their hamstrings and low backs.

Set your customer on a stepper machine and you'll probably have the ability to see exactly the same muscular imbalances in action. The patient will stick out their bum and push through their quadriceps, not utilizing much hip joint action at all. These people tend to hang on their erector spinae when leaning forwards with regular activities and might benefit from more low abdominal activation.

This understanding has made me to advocate that any running client who presents with calf muscle tears should be Researched for a loss of pelvic control, particularly in the sagittal plane (uncontrolled anterior-posterior motion). While sports support professionals are utilized to the connection between hamstring injuries and inferior pelvic control, in my experience calf tears tend to ship us looking downwards into the over-pronating foot, rather than upward in the over- extending pelvis.

Conclusion

Like any athletic activity, some people make running seem easy, but some have to work at it. The reward for those who do not find running simple initially is that they'll truly appreciate advances in their technique, as It removes pain, effort and risk of injury.

1. Introduction

Stretching is one of those topics in fitness and exercise that is shrouded in mystery and misunderstanding. Most people know that stretching is good for them but concerning exactly what type of moves to do and when? That's where the confusion starts! El Paso, TX. Scientific sports chiropractor Dr. Alexander Jimenez examines the data in part I of a 2 part series.

While stretching is significant and the consequent growth in flexibility may mean the difference between poor operation or injury and establishing up a personal best, the wrong type of stretching at the wrong time may actually reduce the quantity of force your muscles have the ability to generate. Not a good thing...

Many exercisers find the entire process of extending very dull! To a extent this mindset is simple to understand. Most of the exercises we perform are very lively, ramp up your heart rate, make your muscles burn and bring forth lots of sweat. Stretching does not produce that much-sought endorphin rush that we regular exercisers enjoy so much.

Another difficulty that individuals who extend o en experience is a lack of obvious benefits; despite spending extended periods of time stretching. Unlike running or li ing weights, in which the payoff is normally more evident, the benefits of stretching could be slow to manifest, even though this is sometimes as much due to inferior stretching technique, incorrect flexibility program layout and/or doing the incorrect types of stretch.

On the other hand, some exercisers really spend too much time stretching and develop their versatility above and beyond what's healthy or necessary. Stretching, like all kinds of training, should be particular to the activities you are searching for. Excessive or overly-aggressive stretching may be as damaging as not doing enough.

Stretching is just as with any other facet of exercise -- it should be specific to your individual requirements -- your sport, as an instance, or its required range of motion. Those requirements don't just differ from person to person but from muscle to muscle. While you May Need to perform lengthy developmental stretches to your lower body, you may find that you only need quick stretches to maintain the flexibility on your upper body. Your left leg may need more care than your right. It is only by being aware of what your body needs that you could design a bespoke flexibility program that matches your unique requirements and in this e-book you will learn how to evaluate your own flexibility requirements to optimize your stretching program.

Stretching is not the most exciting of fitness issues but it's among the most essential. Adequate flexibility means your joints are going to be able to function optimally which means less wear and tear on your joints and also a great deal of other benefits you may read about in the next chapter.

Flexibility is one of the physical fitness components that you will overlook the most as you get older. It is only once you lose vital freedom and functional movement capacity which you realize that stretching is essential for long-term wellness and functionality. Like so many things, an ounce of prevention is much far better than a pound of cure so be certain that you make stretching part of your workout routine -- albeit the ideal types of stretching at the right time, obviously!

2. Benefits Of Stretching

Stretching is usually performed to preserve or enhance flexibility. The definition of flexibility is that the selection of motion at a joint or group of joints. Increased flexibility may improve joint mobility, but freedom is actually quite different to flexibility. Joint freedom is more to do with the health of the articular surfaces within a joint and explains the fluidity and ease of movement of constructions like your knees, shoulders and hips. For the purpose of clarity, this e-book will focus on extending and flexibility instead of joint distress.

So why stretch? Why should you invest precious time sitting very still for extended periods of time for those who might feel your training would be more useful if you're beating the sidewalk or hitting the squat rack?

Your muscles are arranged in pairs round joints. In the vast majority of cases, these muscles have opposing actions which affect the identical joint. As an instance, your quadriceps extends your knee while your hamstrings ex your knee. In case your quadriceps become excessively tight, your knee joint can be pulled slightly out of alignment that will increase the stress put on the passive articular membranes and connective tissues inside your knee. Is would raise your chances of suffering short-term discomfort and even long-term injuries.

Why do muscles become tight? Interesting question! Is has a great deal to do with workout specificity. The law of exercise specificity dictates that your body will adapt to the stresses put on it. Is means that in case you perform biceps curls but not straighten your arms at the bottom of the workout, your biceps muscles will react by shortening so that you shed that end selection of motion. Is is called adaptive shortening.

Not many exercises or activities take your muscles throughout their fullest range of motion, which means that many exercises are likely to reduce instead of increase your endurance. Running, cycling, li ing weights etc all are inclined to work out your muscles within a restricted selection of movement and, as a result, your muscles shorten because they conform to these stresses.

So what happens when you choose your muscles beyond the range of motion they've been used to? If you're lucky, a slight muscle tear; however if you are unlucky, a major tear which may require surgery to fix.

To illustrate this point, imagine you are a recreational jogger. When you operate, your stride is short and quick and you run mostly with a at foot-strike. You've trained this way for many years as well as your muscles have adapted to the relatively restricted range of motion.

Then, one day, you're crossing the street and a vehicle approaches you in a dangerously large speed. You lengthen your stride, come up in your toes and endeavor to accelerate from the oncoming car's path. Searing pain dissipates at the back of your thigh and you limp across the road to safety.

What happened? You used your muscles outside of their normal array of movement and pulled a hamstring.

Just like over-stretching a rubber ring can cause it to snap, more than stretching your muscles may lead them to tear.

Would you have injured yourself if your hamstring flexibility was better? E response is "maybe". Why maybe? E thing is, flexible people become injured just like non- adaptive people, and it's very hard to prove that stretching reduces your risk of pulling a muscle (actually some research from sport suggests that too much extending at the wrong time, i.e. prior to sport, may actually increase the risk of muscle strains). Logic suggests that in the event that you increase the operational range of movement of your muscles, then you are much less inclined to overstretch them. Is doesn't, however, assure that you'll remain injury free but if reduce your chances -- but by how far it's impossible to say.

Going back to our pairs of muscles version discussed earlier, muscle length imbalances can also have a negative impact on your posture. Posture is best called the best alignment of joints so that no or little force is set on passive structures such as cartilage or ligaments. Posture is generally connected to the place of your spine and neck but can also be applied to your shoulders, knees and hips.

Poor posture is often caused by two linked factors -- too tight muscles and overly weak muscles. Commonly, if one muscle in a pairing is tight, then its opposite number will be feeble. Is is because of a phenomenon called reciprocal inhibition.

Consider this case: a wannabe bodybuilder performs lots of sets of chest exercises. He does multiple sets of bench press, barbell, dips, press ups and utilizes a pec deck. As a result, his torso gets very powerful but also very tight. His tight chest muscles pull his shoulders forward into what's commonly called a protracted position. As a result of the overactive pecs, the opposing muscles, specifically the middle trapezius, rhomboids and posterior deltoids, become inhibited and weak.

Try as he would, our bodybuilder is unable to overcome the strain in his chest muscles and pull back his shoulders into optimal postural posture because the upper back muscles are inhibited and partly "switched off ". That is reciprocal inhibition.

To correct such a substantial postural imbalance, it might be essential to relax the overactive torso muscles using stretching and possible massage while reawakening and strengthening those inhibited muscles of the upper back.

One last benefit of extending is an increase in operational range of movement that contributes to improved efficacy. Fundamentally, your limbs will be free to move though a wider arc. Is is especially important for sportsmen and sportswomen.

For instance, to be an effective sprinter, then you need to cover the ground as fast as possible. Is requires electricity, a fast leg turnover AND the ability to cover a large distance in each stride. If, because of tight muscles, your stride length is significantly diminished, you won't be able to sprint up to per stride and then will cover the ground less efficiently.

The same holds for a boxer, although the implications are slightly different. Most boxers choose to hit than be struck so a long reach is quite important. A prosperous punch is powerful and fast but, if you're able to stay out of your opponent's reach, you are more inclined to avoid a painful counterpunch. Good flexibility can mean a longer punch and subsequently, permit you to remain out of range of your competitor.

As a final example, envision a climber reaching up to catch a very small handhold while hundreds of feet up a rock face. Fantastic lat, arm and shoulder flexibility may indicate the difference between attaining the hold and continuing upward or missing the hold and having to climb back down.

As you can see, flexibility is a vital part of fitness and can make a big difference between success and failure in both sport and exercise. At the very least, stretching is vital for ensuring that your muscles do not get shorter as a consequence of the actions you are doing. Whether stretching reduces your chances of injury is hard to say but when there is even a slight possibility that a couple of minutes of flexibility training might help save you weeks of rehabilitation and pain, then there is actually no good reason not to stretch.

3. Specifics Of Flexibility... How Flexible Do You Need To Be?

We've established that stretching is a good thing and being flexible is important, but just how flexible if we try to be? Is it crucial to have the ability to contort yourself as a yogi or is a more moderate outcome more desirable?

In regards to flexibility, the bottom line is that you need to be as flexible as you need to be! I know this might sound like any kind of Zen conundrum but that is the truth about extending. Every one of us has different flexibility demands depending on our chosen sports, favored form of training, everyday activity patterns and so forth. What could be sufficient for a single person may be nowhere near flexible enough for another.

What is crucial when training for flexibility is to make sure you prepare your body for the tasks

It is most likely to face. For example, a gymnast or high board diver needs much more versatility than a cyclist. The abilities in gymnastics require a high amount of flexibility in virtually every joint of the body whereas biking uses a much smaller motion and so the flexibility demand is much less. That isn't to state the cyclist doesn't need to stretch -- just that their versatility program will be more aligned to minimizing excessive adaptive shortening and promoting good posture. Conversely, the gymnast will need to come up with a high degree of flexibility for performance reasons. Both athletes will need to elongate but the result goal is extremely different.

Precisely the same is true of sports like sports. For example, high hurdlers need a Massive amount Of hip and hamstring flexibility to get in the right position in the air so they skim over the top of their barriers. But a 10,000-meter-runner employs a much smaller variety of motion than a hurdler and would not bene t from such intense versatility.

In chapter Ve you will find out how to evaluate your own flexibility and see if you come up to the minimum criteria required to make sure your joints are able to work as they need to. Any flexibility in excess of these measures depends on what you're stretching for.

In my personal experience, I've noticed that, in the majority of instances, extreme flexibility is o en demonstrated by People Who have no need for such extended ranges Of motion. Getting adaptable for flexibility's sake is little more than a waste of time and may even be the cause of musculoskeletal problems. Extreme flexibility can lead to joint hyper-mobility that could lead to bony surfaces coming into contact in a manner that they were not supposed to. As an example, very flexible hamstrings could result in hyperextension of the knee joint which may predispose the exerciser to atherosclerosis. E same holds of an overly flexible backbone -- the curse of several gymnasts and dancers.

I suggest you get your endurance levels into a point where you can fulfill the basic standards set out in chapter five and after that, if needed for your chosen game, exceed these by Enough that your flexibility is optimized for maximum performance. Unless there is a extending world championship or you are likely to run o and join the circus for a contortionist, extreme versatility is neither necessary nor desired!

4. Stretching Dos & Don'ts... How To Get The Most From It

Before you knuckle down to some serious stretching, it's crucial that you set a few flexibility rules and guidelines. These bullet points are designed to make your flexibility training as safe and productive as possible so It is going to pay to invest a few Minutes ensuring you understand all the next.

Stretching Dos...

Do ease into your stretches gradually. It takes a couple of seconds for the mechanisms that control your level of stretch to kick in and allow you to stretch safely and deeply. Take 20-30 minutes to facilitate into heavy stretches to minimize your chance of injury.

Do extend often. A once-a-week marathon extending session is not likely to have much of an impact on your endurance. You have to stretch little and o en route to make a noticeable difference.

Do unwind as much as you can. Tensing your face or neck when stretching other parts of your body sends the wrong signals to your stretching mechanisms and will inhibit the degree of stretch you may encounter. Attempt to eliminate all tension from your body when extending and not just the muscle you are working to lengthen.

Do make sure that your muscles are warm before stretching. Cold muscles can easily Be injured by over-enthusiastic stretching. Perform some mild cardio and joint mobility work until you attempt any deep stretches and remember to ease into them gradually. Always increase your body temperature first (jog, cycle for a few minutes or even stretch out a er a spa or shower).

Do consider stretching out of your normal workout time. While stretching after your exercise is convenient and logical, you may be overly tired and your muscles overly excited to relax properly. O en, the best time to stretch is when you are feeling relaxed and calm. A few stretches while seated before the TV at the day can be very relaxing and valuable.

Do chose the proper stretches for the ideal moment. There is a lot of information on this topic in chapter six but as a general guideline; static or static stretches are ideal for your cool down while dynamic stretches are ideal for your hot up.

Do focus on the muscles that need the most attention. If you have an especially tight muscle, try to stretch it three to five times every day to help recover the missing range of motion as quickly as possible.

Stretching Don’ts...

Do not bounce when stretching. Bouncing in a stretched position tells your muscles to tighten up and can be called ballistic stretching. If any type of stretch is going to cause harm it's bouncy ballistic stretches! There is more on ballistic flexibility and the reason to avoid it in chapter six.

Do not neglect hydration. Water is an essential part of your muscle building make-up and being dehydrated can impair flexibility. Ensure you are well hydrated by sipping plenty of water during the day. Aim for at least 2 liters of water per day -- more if you exercise aggressively or live in a hot climate.

Don't hold your breath when extending. Is will create tension elsewhere in the human body and negate some of the benefits of stretching. Breathe slowly and deeply to make certain you keep nice and relaxed. In yoga, practitioners are taught to imagine their breath is being directed to the muscle being stretched -- this can be a helpful image to use if you're finding it difficult to relax.

Do not stretch beyond your comfort point. If your muscles are burning or shaking as you stretch, chances are you have gone too far. Back o and then ease back in the stretch. If you feel your muscles have started to cramp up, cease stretching altogether and try again later.

Do not feel you have to stretch each and every muscle to the same duration. Or even at all! If you have tight muscles subsequently x them together with developmental static stretching but when your muscles are relaxed and the right resting length, some rapid stretches for upkeep or even not stretching them whatsoever is also okay.

5. Flexibility Self-Assessments

You can, of course, only stretch every muscle in your body in a "hell for leather" style and hope you are giving your body what it needs. The difficulty with this approach is the fact that it is more hit and expect than a prescription of proper exercise.

Instead of risk wasting time by performing unnecessary moves, you should assess your present flexibility requirements and design your extending program on these results. Should you come up to or are simply shy of reaching these minimal standards then you probably don't need much more than to ensure you stretch correctly in the end of each exercise. If, however, you're a very long way o those standards, you may wish to consider a couple of committed stretching sessions per day until your flexibility is all up to standard.

Keep in mind, these are minimums that nearly everybody should achieve. If your game demands it, you might have to achieve higher levels of flexibility but that is between you and your coach.

Most of these assessments require a partner who will passively stretch your muscles to Obtain the desired outcome. Make sure they read these instructions carefully to avoid providing you with a false result. Additionally, make sure they're comfortable and capable of handling your limbs safely, as over stretching a muscle, even in a flexibility assessment, could lead to an injury.

Note: this Isn't an exhaustive list of flexibility evaluation exercises but covers the main muscles that most of us have to operate on. If your sport has specific flexibility demands, don't hesitate to add suitable tests in to this battery.

Remember to warm up by spending three to five minutes doing some light cardio and then a few dynamic stretches as discussed in chapter six. Perform each test two or 3 times to make certain you receive the most meaningful outcome and, where appropriate, compare your left limb into your right limb. It isn't sufficient that you get to the mandatory minimum standard for these tests but additionally that both limbs are equally flexible.

Log your results in the chart at the end of the chapter and retest regularly to measure progress.

Note: With the exception of the last two tests, these evaluations are supposed to be PASSIVE. At is to say that you, the subject, do nothing. You have to keep your limbs utterly relaxed and allow your partner to discover the magnitude of your flexibility. Is can be hard but any undue tension will invalidate the outcome of the tests.

Warning! Approach the end-range of each test carefully and don't force limbs into unnatural positions. E tester should feel the tension rise in the muscles being Analyzed and be able to expect the approximate end point for each assessment. Ensure that there's plenty of communication between tester and subject so that the assessments are safe and meaningful. If any bony blocks or crepitus (crunching, Clicking or popping) are felt/heard proceed with caution if at all.

Science based chiropractor, Dr. Alexander Jimenez takes a look at the patho-anatomy of a side strain and outlines clinical tests to assess, treat and determine readiness for return to play for a cricket fast bowler.

Side strains are reported in a number of sports, such as javelin throwers, baseball pitchers, tennis players, golfers and cricketers. This article however will focus on side strains in cricketers. Australian cricket information (according to both national and state gamers) reports that in the 18 cricket seasons up to 2013-2014, side breeds had the second greatest incidence and the third greatest incidence of accidents that led to players lost games(1). More than 90% of the reported unwanted strains (called acute onset lateral back pain and also happen throughout the bowling delivery) at cricketers over the past twenty years have happened in fast bowlers(1).

What Is A Side Strain?

A side strain in cricket happens most commonly when bowling. Fast bowlers will describe that through a single delivery, they believed abrupt onset, sharp lateral trunk pain on the side contralateral to their bowling arm(two). On most occasions the bowler is not able to continue bowling (while this isn't always the case) and also often the player will leave the area. The mechanism of injury is thought to be related to the bowler; their quest to increase ball speed, vigorously pulling the front arm (contralateral side to their bowling arm) down causing a strain (see figure 1).

Age and intensity are also potential risk factors for a negative strain(1). Younger bowlers (under 24years of age) have been demonstrated to be twice as likely to suffer harm as those aged between 25-29 and 3 times more likely than bowlers more than 30 years(1). Side strains also occur more commonly in the first portion of the season and most happen during early season games. This implies that changes in intensity from training to aggressive games may contribute to the likelihood of harm in the first parts of a year. With most recurrences of unwanted strain happening within a year, increases in intensity might also be a risk factor in recurrences(1). Interestingly there seems to be no further increase in risk if a negative strain is reported at a previous season.

Clinical Presentation

The quick bowler will commonly report an acute localized sharp lateral back pain (frequently at the mid axillary line) which occurred during their delivery. They might also clarify pain with breathing, coughing and coughing, and they are sometimes quite uncomfortable moving around particularly rolling over in bed. The pain may radiate slightly into the abdominal area. From this description alone a side strain is highly likely. Some useful clinical evaluations that help to confirm the identification (and track its development) are as follows:

• Palpation -- A player with a side strain will be extremely tender over one or more of the lower four ribs (most commonly at the mid axillary line).
• Lateral flexion assortment of motion (ROM) evaluation ROM (see Figure 2) -- The participant stands side on to a wall with feet pelvis width apart, and the pelvis and the lateral border of one foot up against a wall. The hand closest to wall is placed on their mind. Together with the pelvis remaining connected with the wall, the player is then requested to only laterally flex away (avoiding truck flexion or extension) from the wall so far as they can and the therapist steps how far in the ground their middle finger may reach their leg down. This evaluation in the early stage is often both restricted and painful. The therapist steps both the distance and where the restriction is felt -- such as 'jamming' on ipsilateral side or 'stretch' on contralateral side. These results can then be compared with all the non-injured side and/or previous measures. This evaluation is also used as a monitoring tool during a year to determine 'normal selection and feeling' and may pick early indications of tightness. Post injury, players need to have the ability to return to complete lateral flexion assortment of motion and their normal limitation feeling.

Side Pain Contraction Tests

(Note -- these evaluations are progressive with stage 1 being the easiest and stage 3 the toughest. Once a player is pain-free on a single point, the testing could be improved to the next phase.)

Alternative Contraction Tests

Imaging

Identification of a side strain is generally a clinical diagnosis based on the explanation of positive and injury findings summarized previously. Imaging is however beneficial in deciding the degree of damage and precise structures involved(two). Ultrasound may be used however, MRI is the modality of choice. On MRI, an acute side strain is characterized by high signal on T2 image at the muscular, rib/costal cartilage port, and frequently shows partial or complete rest of the abdominal musculature(two). The internal oblique at its attachment on the 11th rib is the most frequent muscle hurt. But, pathology has also been reported in external oblique, transversus abdominus and abdominal muscular attachments of their 9-12th ribs(1,2). MRI imaging may also show rib or costal cartilage damage, including bone strain, bone avulsion or periosteal stripping(1). With these harms, hematoma may be viewed tracking between the internal and external oblique musculature(1). Figure 10 shows a MRI image of an elite level fast bowler with a tear of the inner muscle as it attaches onto the 11th rib.

Differential Diagnosis

Other possible diagnoses that should be considered when analyzing a bowler with side pain are:

• Costoiliac impingement. This happens as a consequence of a drop in space between the lower ribs and pelvis, and might be due to either a hypertrophied internal/external oblique muscle, rib hypertrophy or a hypersensitive scar from a former side strain.
• Referral from thoracic spine and/or either costotransverse or costovertebral joints.

Table 1 summarizes common clinical findings of each of these pathologies and may be utilized as a guide to help the clinician differentiate.

Treatment

At the first stages, the principal intention is to decrease pain especially if coughing, breathing and sneezing are debilitating. This can be done via the usage of pain-relieving medication in the acute phase. After the player can deep breathe and cough afterward cardiovascular training can commence -- initially with bike or walking and then progressing to running as pain allows.

• Soft tissue work throughout abdominal musculature including obliques, and rectus abdominus.
• Thoracic spine and rib mobilisation.
• Gentle stretching to contralateral side, together with deep-breathing drills to help expand ribs.
• Dry needling.

Strengthening ought to also be started as soon as pain allows. This should commence with isometric exercises, and advancement to impede through-the-range exercises. At length, higher-speed drills and sport-specific drills can help prepare for the intensity of bowling. Some examples of useful exercises for each of those stages are:

A player can start a return to bowling plan when they have:

The duration of time to return to play with this harm varies substantially with reports ranging from one to seventy times(1). Rehabilitation should be directed by a player's symptoms rather than based on scanning results or a predetermined time. In season recurrence rates are high with this injury, and as such, the return to bowling plan requires to a graded return to both intensity and volume.

Table 2 shows an example of graduated return to bowling plan for a player who returned to play at week six. Anecdotally, harms that involve the rib/costal cartilage tend to take longer than those that simply involve muscle. However, further study is needed comparing scan time and results to come back to play until this is confirmed.

Conclusion

Negative breeds are a common and significant injury to cricket fast bowlers as they often require considerable periods of rehabilitation and inability to perform. The clinician should be aware that this harm has a high 'within-season' recurrence rate and a graded return to high-intensity bowling is integral part of the rehab process. Further studies have to determine risk factors and also the relationship between imaging findings and time frames for returning to play.

References
1. J Sci Med Sport. 2017 Mar;20(3):261-266
2. British Sports Med 2004 38 (5): e21

El Paso, TX. Chiropractor, Dr. Alexander Jimenez looks at the role of the proximal tibiofibular joint in the etiology of lateral knee pain.

Pain about the lateral aspect of the knee is usually attributed to ailments such as iliotibial band compression/friction syndrome, lateral meniscus lesions and patellofemoral pain, and the encouraging patella lateral retinaculum. In the absence of those conditions, other less frequent presentations could be sinus plica, fabella syndrome, biceps tendinosis, or popliteus tendinosis.

One of the more unusual kinds of lateral knee pain in the athlete might be the proximal tibiofibular joint (PTFJ) -- either as hypomobility or instability(1-4). This injury occurs in various sports involving twisting forces around the ankle and knee like football, wrestling, softball, gymnastics, long jumping, dancing, judo and skiing. The variety of symptoms it can cause, contain external knee pain (particularly on weight bearing), locking and 'popping' in the knee and also transient nerve symptoms. This makes this harm a significant one to recognize and speech, particularly in large demand athletes.

Anatomy Of The Proximal Tibiofibular Joint (PTFJ)

• Biceps femoris tendon
• Lateral collateral ligament
• The principal capsule and ligament associated with the joint.
• The secondary stabilizers contain:
• Arcuate ligament
• Popliteofibular ligament
• Popliteus muscle and tendon

These soft tissues work together to stabilize the PTFJ. Kinematic studies have suggested that the lateral collateral ligament serves as the major stabilizer of this PTFJ in extension(1,2). Because of the resistance supplied from the lateral collateral ligament, the majority of the joint injuries are thought to occur while the knee is in flexion. This may explain the association between multi-ligamentous knee injuries which occur in flexion and PTFJ disruptions.

The joint is surrounded by a fibrous capsule, which can be further strengthened by notable attachment ligaments which blend in the capsule. Posteriorly, it's a thick single band, which runs in an oblique direction from the head of the fibula to the rear of the lateral tibial plateau. This can be coated with the popliteus tendon. Furthermore, a single feeble band runs from the fibular head into the anterior element of the popliteus tendon. Anteriorly two or three bands run obliquely in the very front of the fibular head to the lateral condyle of the tibia(7).

A synovial membrane -- like that found inside the knee joint -- lines the interior surface of the capsule of the PTFJ. In 10 percent of the populace, this synovial space is continuous with that of the knee joint. The joint is closely connected with the frequent peroneal nerve, moving forwards by the popliteal fossa around the fibula head, and here it is vulnerable to injury. Such an injury to the nerve with injury to the PTFJ may cause foot fall and loss of sensation in parts of the feet and leg.

There are different anatomic variants of the PTFJ which can be classified into three types:

These anatomic variations have to be considered when treating patients with an injury to the PTFJ.

Biomechanics Of The PTFJ

The anatomy of the PTFJ directly relates to its functional stability. It can withstand stresses applied in either a longitudinal or axial manner. Roughly one-sixth of this static load applied in the ankle is transmitted across the fibula into the PTFJ(9,10). Thus, the primary functions of this PTFJ are as follows:

When the knee bends, the fibula moves anteriorly, and with knee expansion the fibula head moves posteriorly. It was found that with the knee bent, the mobility of the proximal fibula increased and the fibular head may be moved approximately 1 cm in both anterior and posterior directions. With the knee extended, the trip of the fibular head was minimal as a result of stabilizing character of the supporting soft tissues(1,2). There's also a slight upward movement of the fibula due to forced expansion of the malleolar mortise during maximal dorsiflexion of the ankle(11).

The shape and orientation of this PTFJ may also influence the way the PTFJ works. In a horizontal PTFJ, both articulating surfaces are both curved and planar, and their place provides some stability against displacement. From the oblique type of joint, the articulating surfaces are far more variable in place, configuration and inclination. Because this kind of joint is not as able to rotate and accommodate torsional stresses than a horizontal joint, it is thought to be more likely to dislocate.

PTFJ Dislocation

Associated peroneal nerve injuries are more likely to be associated with types 2 and 3. The mechanism of injury was described as a surprising inversion and plantar flexion of the foot and ankle, with a simultaneous knee flexion and external rotation of the leg. For this reason, it is commonly related to lateral ankle injuries, and therefore usually related to a traumatic event in the athletic context. Normal mechanisms of injury would be twisting injuries, hard landings or slipping together with the knee flexed under the body.

Sports doctors should also be alert to subluxation of the joint (excessive forward to backward motion of the fibular head, causing symptoms), which is frequently related to ligamentous laxity.

The nature of the traumatic event dictates the manner in which the PTFJ will dislocate. Even though there are four types of dislocation, the usual person in sporting contexts is anterolateral (type 2). This, together with the external rotational torque of the tibia on the foot through twisting of the body, springs the head of the fibula outside cartilage. At this point, a violent contraction of the peroneal nerves, the extensor digitorum longus and the extensor hallucis longus (caused by abrupt inversion and plantar flexion of the foot), pulls the fibula forward.

Signs & Symptoms

Identification of the harm is generally based on clinical history and clinical suspicion. Because of the nature of this presentation, it's often mistaken for a meniscal injury. Common signs and symptoms which may alert a sports medicine practitioner to a PTFJ injury are as follows:

Plain X-ray imaging is generally not helpful, but may show the subtle signs of increased interosseous distance and displacement of the fibula from its regular position. But a CT scan may be needed to verify the diagnosis(16, 17). The main abnormality is lateral displacement on the anteroposterior view, and possibly slight anterior or posterior displacement on the lateral view(18). It has been suggested that computed tomography of the knee could be proper in patients where this diagnosis is suspected, due to the poor analytical value of plain radiology (16). MRI has the benefit of revealing ligament injuries in addition to the dislocation.

Injury Management

Currently, there is not any definitive option for surgical treatment of severe dislocations of this PTFJ. The options are:

The treatment options also change with the pattern of dislocation. The management of type 1 and 2 injuries is reduction by anteroposterior pressure over the fibula head, together with the knee slightly flexed and the ankle everted. There is often an audible and/or palpable movement with rapid improvement in symptoms.

There's insufficient evidence to support or refute the use of immobilization after a decrease of a type 1 or 2 injury, although several previous case reports have recommended immobilization for varying periods together with the knee in extension or minor flexion for 2-3 months(1,2,19,20). It is controversial whether weight bearing ought to be performed after the process(21). It's more difficult to reduce type 3 and 4 accidents, and these can require open reduction and fixation. However attempting a closed reduction initially is an alternative. Several techniques have been described involving fixation and supplementing using a portion of the biceps femoris tendon(22, 23).

PTFJ injury is usually missed, and a number of individuals present with chronic lateral knee pain or joint uncertainty. Unrecognized dislocations often present with peroneal nerve symptoms like pins and needles in the leg or feet, or weakness of foot motions. There is absolutely no function for attempted closed reduction within this circumstance.

Surgical stabilization is needed in around 57 percent of late or recurrent instances because of persistent pain and chronic instability(1,2,24). Normal ligament reconstructions include iliotibial band or the biceps femoris tendon(25, 27-29). Resection of the fibular head is believed to affect knee stability and gait. The decision to eliminate hardware after arthrodesis remains contentious. It has been discovered that PTFJ arthrodesis with early screw removal at three to six months has got good results in athletes(30).

Conclusion

Injuries to the PTFJ are uncommon in the sporting knee. This injury type may manifest as instability and dislocation, or as a hypomobile joint following ankle sprains. Early identification and treatment are essential to enable prompt rehabilitation. Treatment options vary according to the time of injury, nature of injury and associated morbidity. A return to sport is possible after effective treatment.

References
1. J Bone Joint Surg 1974;56-A:145–54.
2. Clin Orthop; 1974. 101:192-197.
3. J Orthop Sports Phys Ther. 1982; 3:129-132.
4. J Orthop Sports Phys Ther. 1995;21:248-257.
5. Emerg Med J. 2003;20(6):563.
6. Knee Surg Sports Traumatol Arthrosc. 2006;14(3):241
7. Arthroplasty Today; 2016. 2(3): 93–96.
8. J Anat. 1952;86(1):1.
9. J Bone Joint Surg Am. 1971;53:507–513.
10. Gegenbaurs Morphol Jahrb. 1971;117(2):211.
11. Moore K.L., Dalley A.F., Agur A.M., Limb L. 6th ed. Lippincott and Williams and Wilkins, Wolters Kluwer India Pvt; New Delhi: 2010. Clinically oriented anatomy; p. 508.
12. Nelaton A. Elemens de Pathologie Chirugicale. Paris, France: Balliere; 1874. p. 292
13. Am J Knee Surg. 1991;4:151–154.
14. J Orthop Trauma. 1992;6:116–119.
15. J Bone Joint Surg Am. 1973;55:177–180.
16. Orthopaedics 1999;22: 255–8
17. Br J Radiol; 1993. 66;108-11.
18. Postgrad Med; 1989;85:153–63.
19. Ann Emerg Med 1992;21:757–9.
20. Am J Sports Med 1985;13:209–15.
21. Cases J. 2009;2:7261.
22. Arch Orthop Trauma Surg 1999;119: 358–9.
23. Int J Clin Practice 2002;56:556–7.
24. J Am Acad Orthop Surg. 2003;11(2):120
25. Arthroscopy. 2001;17(6):668.
26. Clin J Sport Med; 2007. 17(1), 75-77.
27. Knee Surg Sports Traumatol Arthrosc. 1997;5(1):36.
28. J Bone Joint Surg Am. 1986;68(1):126.
29. J Bone Joint Surg Br. 2001;83(8):1176.
30. Knee Surg Sports Traumatol Arthrosc. 2011;19(8):1406.
31. J Orthop Sports Phys Ther. 2006; 36:3-9.
32. Foot Ankle Int. 2000;21:657-664. 23.
33. Foot Ankle Int. 2004; 25:318-321
34. J Orthop Sports Phys Ther. 2002; 32:166-173

A lady in her early 30s recently came to see me complaining of a stone in her shoe. At first I proceeded to check that the sign in the window hadn't changed to say cobbler, instead of physiotherapist! I returned, rather relieved to observe that a waiting room filled with individuals with orthopedic ailments, but confounded with this very strange complaint from Karen the runner. I had to hear more. Chiropractic injury specialist, Dr. Alexander Jimenez examines the case.

Karen went on to detail a three-month history of pain between her second and third metatarsals. It started for no apparent reason. She had been running quite a little down the mountains of northern England, but this was nothing unusual for her and she'd never previously had issues. She could not pinpoint any other changes except one -- she was practicing her bridal dance with Paul, her fiancé. They wanted to dance salsa, also Karen admitted to a particular weakness for high-heeled dance shoes. Right, I thought  possibly there was a loading along with a footwear issue here. By this stage, I was beginning to feel less anxious about the possibility of being expected to resole all of her shoes.

Further questioning revealed that Karen's pain had a burning quality that had first started coming on after about an hour of either running or dance but was now appearing within about 10 minutes of her wearing any kind of shoe that wasn't completely flat. She was not sure, but she felt that it had begun to hurt between her third and forth toes as well. These clues were leading me down the route of considering a nerve (nerve) element for her pain, especially when she clarified a „weird tingling somewhere in my feet . It appeared to be worsening both in intensity, distribution and irritability. She was otherwise in excellent health.

Evaluation proved tricky as Karen's foot wasn't debilitating the morning she came in to visit me and nothing I could do could reproduce her symptoms, much to her dismay and my disappointment. She was my very first appointment of the day. So I asked her to go home, pick up her heels and wear them that day and come back to see me after work, when (hopefully) her symptoms might resurface.

As it was, Karen hobbled in at 6pm. She had decided to make sure her foot hurt by wearing the offending Manolo Blahniks all day and going for a run at lunchtime. Suffice to say, this made my job a lot easier and she received a gold star for being such a dedicated patient!

Evaluation this time revealed that her pain was replicated by doing a heel raise -- a manouver which induced her to keep weight through extended metatarso- phalangeal (MTP) joints. As soon as I palpated the plantar part of her foot at the second and third interdigital spaces (between second to third and third to fourth toes), she jumped with her familiar pain, which now extended into her feet. I was able neither to palpate any unusual lumps nor elicit a click (called Mulder's sign) when I squeezed the metatarsal heads. This can sometimes happen if there's nerve swelling and also a proliferation of scar tissue adjacent to the metatarsal heads.

If the pain had still been hard to localize, I would have considered referring Karen to a sports doctor for them to inject a local anesthetic within the interdigital area to see whether this could relieve her pain, albeit for a brief period. As it was, this measure was not necessary as Karen managed to pinpoint exactly the space between her third and fourth metatarsals, only distal to her fourth MTP joint. She was also experiencing pain at the second interdigital space, although this was less intense.

I was fairly comfortable at this stage with the identification of interdigital neuroma, more commonly called Morton's metatarsalgia. I did want some plain-film X-rays to show me what state the MTP joints were in, however. I asked Karen to avoid running, dance only in flat shoes and to plunge her feet in ice water for 10 to 20 minutes a couple of times every day. And I asked her to see her GP with a view to getting a prescription for some anti- inflammatory medications.

I made her some temporary metatarsal load reliefs from podiatry felt and put these in her shoes. These are meant to distribute the weight-bearing load across all her MTP joints, but not only the irritated ones. She was due to see me in three days, ideally with her X-rays and at less pain. This also gave me three days to refresh my memory on your foot's neural anatomy!

Forefoot Anatomy

Causes Of Interdigital Neuritis

Although often referred to as a neuroma, Morton's metatarsalgia is not usually a true neuroma, but more of a chronic irritation of a nerve, characterized by intra-neural swelling and excessive extra-neural scar tissue formation. A true neuroma is actually a tumor, pathophysiologically different from that which we're dealing with in this example. Some ideas have been put forward regarding the origin of the problem. Some have stated it is the end result of poorly-fitting (usually too small) footwear compressing the interdigital space and all of its contents. Some say it's more to do with faulty biomechanics resulting in degeneration at the MTP joints and chronic synovitis. Others think injury is likely to be the main cause, leading to scarring and thickening of a damaged nerve sheath. Actually, the clinician will often find a combination of these issues.

In Karen's case no joint degeneration showed up on X-ray, but there was a degree of laxity in her third MTP joint, leading to the suspicion of a plantar plate accident at some point in her past. Karen was a former dancer, so this was indeed a possibility. The plan of management we had decided upon appeared to have dampened her pain down significantly. She felt that the anti inflammatory medications were especially helpful, giving additional weight to the theory that the pathology was an active and inflammatory one, most likely kept by loading that the joints in expansion (as seen in high heels and just prior to push-off when running).

Management

Karen was especially keen to pursue conservative (non-surgical) options. The inflammation brought on by loading the loose MTP joint was further distending the joint, rendering it even less stable and more prone to inflammatory processes. Clearly the dual methods of loading and inflammation were perpetuating every other, thus we had to interrupt the cycle.

Karen had to accept this, particularly in the short term, she'd have to take steps to decrease load through the third and second metatarsal joints. We also had to reduce the severe inflammation. Karen carried on together with the anti- inflammatory medications under the advice of her GP for another week and continued to ice her feet. She wore shoes with a wider toe box, allowing her transverse arch be under less strain. I left some metatarsal relief bars out of high-density, low-profile foam, placing these under the insoles of three pairs of her shoes. I put them slightly towards the heel of the metatarsal heads, which prevented the MTP joints in hyperextending.

I also did some manual treatment to ensure Karen' back and forefoot joints were suitably mobile and gave her some intrinsic muscle strengthening exercises. We were able to prevent the need for corticosteroid injections and surgery, although these choices were open to us if the conservative route failed.

Surgery could be aimed at excising built-up scar tissues and is often successful, but only if the underlying biomechanical problems are fixed. I saw Karen twice more over the following three weeks, during which time we could re-introduce her to running. This was initially on the flat after which she was slowly exposed to the increasing toe extension that operating on hills demands. She weaned herself off her meds, but would prophylactically take a few as she returned to dancing salsa. She'd need to take wearing marginally lower heels as a result of her symptoms, but said she'd prefer this compromise to having to hobble around for the remainder of her life with a pebble stuck in the sole of her foot!

Fraser, a promising young Australian Rules football player who had sustained an inversion sprain of the ankle. I saw him soon after the episode and it seemed like the rehabilitation process would be short and straightforward. I was confident enough about this to inform the coaching team that Fraser would shortly return to the training paddock, ready for the upcoming final series. As it turned out, I was wrong. Injury specialist, Dr. Alexander Jimenez assesses the case further.

A couple of weeks passed; Fraser's ankle selection of motion returned and he managed to finish stationary balance exercises and strengthening exercises. However he couldn't hop on the bad leg or operate without ankle pain. I began to think that this rehabilitation cycle might become a little extended.

He was then sent to see a sports doctor to seek further explanation as to why the injury was taking so long to heal. The sports doctor thought that the young footballer should adopt a "wait and see strategy," sitting outside the rest of the season and starting to train again in the brief off-season. This advice did not go down well either with the athlete himself, or the coaching team.

Six weeks after, when I next saw Fraser, he still could not jump on the leg pain-free, so was still unable to do any running. He had rehabilitated his ankle as far as he could, but just could not get past this step. He still had swelling over the ATFL, but had full range of motion with no laxity in any of the supporting ligaments.

It was then that I tried a different treatment technique, a posterior glide of the fibula in the lateral malleolus. I recorded the fibula in a posterior direction, and Fraser managed to jump pain-free for the very first time in 19 weeks. It was a miracle.

Or maybe not: Brian Mulligan, the mythical New Zealand physio, has provided the physiotherapy profession with numerous guide techniques to help fix joint immobilities and subluxations. This is but one of the invaluable therapy methods he prescribes (1).

I saw Fraser again 10 days later and he had been up to conducting 1.5km without pain; he was also positive that he would complete his rehabilitation before pre-season training.

The fascinating thing about all this is that I'd already attempted Mulligan's posterior glide two months earlier, with no effect -- no decrease in pain nor increase in function. Why did tape and the manual gliding of the fibula belatedly help, and why had it not assisted at a previous stage?

The answer can be found in the anatomy of the anterior ankle. Irritation in the lower edge of the inferior tibio-fibular ligament and the very front of the anterior talo-fibular fascia can thicken these ligaments, setting up a series of knock-on effects. The irritated and thickened tissue becomes vulnerable to getting pinched between the tibia and talus as the foot is dorsiflexed. The ligaments may also begin to rub on the joint capsule of the ankle, which can inflame the synovial lining of the capsule, causing synovitis. Finally, the inflamed ligaments can form too much scar tissue along the front and side of the ankle joint, creating a small mass of tissue called a meniscoid lesion. Dorsiflexing the ankle can trap the tissue between the edge of the ankle joint, causing pain, popping, and a feeling that the ankle will give way and not support body weight.

However, my first effort at this therapy, had, I think, been too early, once the area was probably still overly inflamed to reply positively. Only when the structures had all calmed down was it possible to proceed in the rehabilitation.

When treating acute ankle sprains, caregivers are educated to encourage the client to regain ankle dorsiflexion as soon as possible, because study shows that the earlier the person regains this motion, the earlier they will be back to normal function. In years past I have awakened many customers pain by making them do repeated dorsiflexion exercises, or simply by mobilizing the anterior ankle joints.

Now I'm being much more competitive about pushing my clients to recover this dorsiflexion, as sometimes this can clearly result in more irritation -- slowing rather than speeding recovery. There was not anything unusual about Fraser's ankle injury concerning the origin -- it was only a great deal of damage to a very sensitive portion of the ankle joint.

I feel the moral of this brief story is that the therapist needs to add up all the information offered by the patient and treat them without using a pre-determined recipe. Think anatomically, picture what has happened to the tissues and don't be afraid to revise your strategy as you proceed; this will direct you to better treatment choices and the patient will recover quicker.

References
1. Brian Mulligan. Manual therapy –”NAGS”, “SNAGS”, ”MWMS” etc. (5th ed) 1995. Wellington. Plane View Press.

A 33-year old finance manager with severe knee pain and a knee injury that had already been examined by a surgical specialist. On the case notes, the surgeon had scribbled a differential diagnosis list. In the top was meniscal injury, and in the bottom were the words "lunge lesion." Science chiropractor, Dr. Alexander Jimenez investigates and discovers a little about this unusual injury.

"Lunge lesion" describes an isolated injury to the femoral trochlear groove -- a single surface of the patellofemoral joint. It was first described in 1978(1). Seen infrequently, it may happen in active young patients involved in recreational sports.

My client recalled a social game of badminton where he'd lunged forward quite deeply on to his right foot in an attempt to reach the shuttlecock for a net-shot. He described a deep ache in his knee and lack of ability to push back through his front foot to endure. He could not play on. During the upcoming few days that he developed swelling and pain, and detected "creaking in his knee when he flexed it. His symptoms hadn't resolved after two weeks of rest.

Plain radiographs (x-ray) of the knee were ordinary and an MRI scan failed to identify any pathology. It confirmed that his ACL, PCL and collateral ligaments were all intact, and it showed up nothing indicative of meniscal tear. A small field of bone bruising was observable beneath the trochlea. The non-specific findings of this MRI further dampened my patient's mood.

His symptoms had been slow to improve, so the decision was made to proceed into a diagnostic arthroscopy, which, despite great improvements in MRI technology, remains the "gold standard investigation of intra-articular pathology from the knee. The arthroscopic findings were normal, except for one thing: an isolated split running lengthways across the femoral trochlear groove (see Figure 1, below). The under-surface of the patella was unaffected. The cartilage edges were stable and no loose flaps were identified which required debridement (tidying up). This reassured my client that he did really have an injury that explained his pain, and it provided information for us to invent a rehabilitation program for him.

The reason behind a lunge lesion injury is usually a rapid deceleration of the flexed knee using co-contraction of the quads and hamstrings(2), though other less common mechanisms like a direct blow to the patella are postulated. This injury classically takes place through a lunging motion of this type that happens in squash, tennis and netball(3). And, because functionally, it is the trochlea that acts to stabilize the patella between 30 and 100 degrees of flexion(4), loading of the joint in this way causes substantial shearing and compressive forces at the bottom of the groove. If the load is high enough, then a fissuring of the intercondylar cartilage can occur, resulting in painful crepitus (creaking) and catching when the knee is bent (envision the wedge shaped patellar- articulating surface dividing the cartilage of the groove).

Despite the injury to the trochlea froma a lunge lesion, the patellar surface remains uninjured. Various hypotheses have been proposed to explain why. One is that the articular cartilage of the patella is heavier and much more malleable than the cartilage of the trochlea. Another suggests that the encompassing soft-tissue supports of those highly mobile patella are somehow able to dissipate load better than the trochlea(5).

Treatment

A guessed lunge lesion doesn't always need arthroscopic debridement. Initial therapy should be the standard practice of rest, ice and elevation, progressing to mild passive and on to active knee mobility exercises. Passive mobilizations of the patellofemoral joint can be initiated after the acute phase (typically four to seven days post injury), as pain allows. Progression of practice back to running and cutting maneuvers will be decided by the customer's tolerance of these actions. Persistent or worsening swelling and pain without improvement within a few weeks would imply that further investigation and possible arthroscopic debridement is essential. The significant determinant of effective lunge functionality is volatile strength of the closed kinetic chain of the lower limb, but at the sports science laboratory, body mass, stamina and leg length has all been found to affect performance(6). So the "return to game" phase of rehabilitation must tackle all four factors. Strengthening the prime movers of the knee with functional activities and progressive loading should be the mainstay of therapy. This area of the program should include eccentric loading of the knee.

It's also very important to help the client regain correct motor patterns once the acute phase is over. An extensive evaluation of biomechanics may identify deficits or imbalances that could be adjusted with orthotics and/or construction techniques.

My patient progressed well and returned to his usual level of function. Unfortunately I am no longer connected with him, so it's not possible to create any longer-term evaluation of the natural history in this case. However, I would expect an injury to the load bearing surface of the patello femoral joint to heal slowly, with a higher likelihood of the individual developing patello femoral joint symptoms at some point in the future.

References
1. Cross MJ “The painful kneeÐ. Australian Patient Management: 11-21, August 1978.
2. Cross MJ, Morgan, DG. “The “Lunge” LesionÐ presented at The Third Congress of Knee and Orthopaedic Sports Medicine Section of WPOA, Sydney, 8-11 September 1993.
3. Cross MJ, Morgan-Jones RL “Knee syndromes and arthroscopic knee procedures. www.kneeclinic.com.au/papers/
ArthProcedures.htm (Access date: 9/12/2004).
4. Heegaard J, Leyvraz PF et al “Influence of soft structures on patellar three-dimensional trackingÐ. Clinical Orthopaedics and Related Research. 1994;299:235-243.
5. Morgan-Jones RL, Cross MJ, Morgan, DG “Isolated articular cartilage lesions of the femoral trochleaÐ. www.kneeclinic.com.au/papers/FemoralTrochleaLesions.html (Access date: 2/3/08).
6. Cronin J, McNair PJ, Marshall RN “Lunge performance and its determinantsÐ. Journal of Sports Sciences, 2003, 21, 49–57.

Two surgeons discuss the diagnosis and treatment of acromioclavicular injuries in athletes. El Paso, TX. Chiropractor, Dr. Alexander Jimenez follows the discussion.

Acromioclavicular (AC) joint injuries most often occur in athletic young adults involved in collision sports, throwing sports, along with overhead activities like upper-extremity strength training. They account for 3% of all shoulder injuries and 40% of shoulder sports injuries. Athletes in their second and third decade of life are more often affected(1), and men are injured more commonly than women (5:1 to 10:1)(1,2).

Acromioclavicular dislocation was known as early as 400 BC by Hippocrates(3). He cautioned against mistaking it for glenohumeral (shoulder joint) dislocation and advocated treating with a compressive bandage in an attempt to hold the distal (outer) end of the clavicle in a diminished position. Almost 600 decades later Galen (129 AD) recognized his own acromioclavicular dislocation, which he sustained while wrestling(3). He left the tight bandage holding the clavicle down as it was too uneasy. In today's era this injury is better known, but its treatment remains a source of fantastic controversy.

Anatomy

The acromioclavicular joint combines the collarbone to the shoulder blade and therefore links the arm to the axial skeleton. The articular surfaces are originally hyaline cartilage, which affects to fibrocartilage toward the end of adolescence. The average joint size is 9mm by 19mm(4). The acromioclavicular joint contains an intra-articular, fibrocartilaginous disc which may be complete or partial (meniscoid). This helps absorb forces in compression. There is marked variability in the plane of the joint.

Stabilizers

There is little inherent bony stability in the AC joint. Stability is provided by the dynamic stabilizers -- namely, the anterior deltoid muscle arising from the clavicle and the trapezius muscle arising from the acromion.

Additionally, there are ligamentous stabilizers. The AC ligaments are divided into four -- superior, inferior, anterior and posterior. The superior is most powerful and blends with muscles. The acromioclavicular ligaments contribute around two- thirds of the constraining force to superior and posterior displacement; however, with greater displacement the coracoclavicular ligaments contribute the major share of the resistance. The coracoclavicular ligament consists of the conoid and trapezoid. The conoid ligament is fan-shaped and resists forwards motion of the scapula, while the more powerful trapezoid ligament is level and resists backward movement. The coracoclavicular ligament helps bunch scapular and glenohumeral (shoulder joint) motion and the interspace averages 1.3 cm.

Mechanism Of Injury

The athlete who sustains an acromioclavicular injury commonly reports either one of two mechanisms of harm: direct or indirect.

Direct force: This is when the athlete falls onto the point of the shoulder, with the arm usually at the side and adducted. The force drives the acromion downwards and medially. Nielsen(5) found that 70 percent of acromioclavicular joint injuries are caused by an direct injury.

Indirect force: This is when the athlete falls onto an outstretched arm. The pressure is transmitted via the humeral head into the acromion, therefore the acromioclavicular ligament is disrupted and the coracoclavicular ligament is stretched.

On Examination

The athlete presents soon after the severe injury with his arm splinted to his side. The patient may state that the arm feels better using superiorly directed support on the arm. Most motions are limited secondary to pain near the top of the shoulder; the degree varies with the grade of sprain. The hallmark finding is localized swelling and tenderness over the acromioclavicular joint.

In dislocations, the outer part of the collarbone will appear superiorly displaced using a noticeable step deformity (in fact, it is the shoulder which sags beneath the clavicle). Occasionally, the deformity may only be apparent later, if first muscle spasm reduces acromioclavicular separation. Forced cross-body adduction (yanking the affected arm across the opposite shoulder) provokes discomfort. The clavicle can frequently be moved relative to the acromion.

Acromioclavicular Visualisation

The typical joint width measures 1-3mm. It's regarded as abnormal if it is more than 7mm in men, and 6mm in women. Routine anteroposterior views of the shoulder reveal the glenohumeral jointnonetheless, that the acromioclavicular joint is over penetrated and so dark to interpret. Reduced exposure enhances visualization.

The individual stands with both arms hanging unsupported, both acromioclavicular joints on one film. Weighted viewpoints (stress X-rays) are obtained with 10-15 lb weights not held but suspended from the individual's wrists. They help differentiate type II-III injuries, but are of little clinical significance and therefore are no longer recommended in our practice.

Classification Of AC Separation

The importance of identifying the injury kind can't be over emphasized because the treatment and prognosis hinge on an accurate diagnosis. The injuries are graded on the basis of that ligaments are injured and how badly they're torn.

Allman (6) classified acromioclavicular sprains as grades I, II and III, representing respectively, no involvement, partial tearing, and total disruption of the coracoclavicular ligaments. More recently, Rockwood (1) has further classified the more severe injuries as standard III-VI.

The injuries are classified into six categories:

Treatment

The treatment of acromioclavicular joint injuries varies based on the seriousness or grade of the injury.

Initial treatment: These can be quite painful injuries. Ice packs, anti-inflammatories plus a sling are utilized to immobilize the shoulder and then take the weight of the arm. As pain starts to subside, it is important to start moving the fingers, wrist and elbow to prevent shoulder stiffness. Next, it's important to begin shoulder motion in order to stop shoulder stiffness.

Un-displaced injuries only require rest, ice, and then a slow return to activity over two to six weeks. Major dislocations require surgical stabilization in athletes if their dominant arm is involved, and if they participate in upper-limb sports

What's more, the patients treated non-operatively returned to full activity (work or athletics) earlier than surgically treated groups(10, 11). The exceptions to this recommendation include people who perform repetitive, heavy lifting, people who operate with their arms above 90 degrees, and thin patients who have prominent lateral ends of the clavicles. These patients may benefit from surgical repair(12).

Any discussion about the management of acute injuries to the AC joint must deal with which of the many methods of surgical therapy described is the best for their situation, but whether surgery should be considered at all. Surgery is generally avoided in athletes participating in contact sports since they will often re-injure the shoulder later on.

Surgery

Surgical repair can be divided into anatomical or non- anatomical, or historically into four types:

For the individual with a chronic AC joint dislocation or subluxation that remains painful after three to six months of closed treatment and rehabilitation, surgery is indicated to improve functioning and comfort.

Postoperatively, the arm is supported in a sling for up to six weeks. Following the first two weeks, the patient is permitted to use the arm for daily activities at waist level. After six weeks, the sling or orthosis is discontinued, overhead actions are allowed, formal passive stretching is instituted, and light stretching using elastic straps is initiated. Stretching and strengthening are begun slowly and gradually. The athlete shouldn't return to their sport without restriction until full strength and range of motion has been recovered. This usually occurs four to six months following operation.

Conclusion

AC joint injuries are an important source of pain at the shoulder area and have to be assessed carefully. The management of these injuries is nonoperative in the majority of cases. Type I and II injuries are treated symptomatically. The present trend in uncomplicated type III injuries are a non operative strategy. In the event the athlete develops following problems, a delayed reconstruction might be undertaken. In athletes involved in heavy lifting or prolonged overhead activities, surgery may be considered acutely. Type IV-VI injuries are generally treated operatively.

No matter what kind of treatment is chosen, the ultimate purpose is to restore painless function to the wounded AC joint so as to reunite the athlete safely and as quickly as possible back to their sport. It is possible in the vast majority of acromioclavicular joint injuries.

References

Reza Jenabzadeh and Fares Haddad

1. Rockwood CA Jr, Williams GR, Young CD. Injuries of the Acromioclavicular Joint. In CA Rockwood Jr, et al (eds), Fractures in Adults. Philadelphia: Lippincott-Raven, 1996; 1341-1431.

2. Dias JJ, Greg PJ. Acromioclavicular Joint Injuries in Sport: Recommendations for Treatment. Sports Medicine 1991; 11: 125-32.
3. Adams FL. The Genuine Works of Hippocrates (Vols 1,2). New York, William Wood 1886.
4. Bosworth BM. Complete Acromioclavicular Dislocation. N Eng J Med 2 41: 221-225,1949.
5. Nielsen WB. Injury to the Acromioclavicular Joint. J Bone Joint Surg 1963; 45B:434-9.
6. Allman FL Jr. Fractures and Ligamentous Injuries of the Clavicle and its Articulation. J Bone Joint Surg Am 1967;
49:774- 784.
7. Powers JA, Bach PJ: Acromioclavicular Separations: Closed or Open Treatment? Clin Orthop 1974; 104 (Oct): 213-223
8. Cox JS: Current Methods of Treatment of Acromioclavicular Joint Dislocations. Orthopaedics 1992; 15(9): 1041-1044
9. Clarke HD, Mc Cann PD: Acromioclavicular Joint Injuries. Orthop Clin North Am 2000; 31(2): 177-187
10. Press J, Zuckerman JD, Gallagher M, et al: Treatment of Grade III Acromioclavicular Separations: Operative versus
Nonoperative Management. Bull Hosp Jt Dis 1997;56(2):77-83
11. Galpin RD, Hawkins RJ, Grainger RW: A Comparative Analysis of Operative versus Nonoperative Treatment of Grade III Acromioclavicular Separations. Clin Orthop 1985; 193 (Mar): 150-155
12. Larsen E, Bjerg-Nielsen A, Christensen P: Conservative or Surgical Treatment of AC Dislocation: A Prospective, Controlled, Randomized Study. J Bone Joint Surg Am 1986;68(4):552-555
13. Bosworth BM. Complete Acromioclavicular Dislocation. N Engl. J. Med. 241: 221-225,1949.

An orthopedic surgeon explains why shoulders go wrong and what can be done to repair them. Shoulder chiropractor, Dr. Alexander Jimenez gets into the discussion.

The shoulder joint is frequently injured in the throwing athlete since it has a greater range of movement than any other joint in the body, and because its stability is dependent upon complete muscles and ligaments rather than supporting bone structures.

Phases Of Throwing

The five phases of throwing are wind-up, cocking, acceleration, deceleration and follow-through. The forces generated during those phases are significant and the subsequent pressures generated around the shoulder joint make it more likely to severe and chronic inflammatory conditions and injuries. A poor throwing technique will exacerbate the possibility of chronic inflammatory shoulder conditions.

A fantastic throwing technique requires the athlete to use his body weight as well as the big muscle groups of the legs, back and trunk to generate kinetic energy across the shoulder in the path of the thrown object. After the object is thrown, then the retained energy in the throwing arm has to be dissipated back to the large muscles which then absorb it. Poor mechanics throughout the wind-up and cocking stages require the shoulder muscles to generate extra energy to propel the object being thrown. This also contributes to exhaustion of the shoulder muscles, and can ultimately result in injuries.

When the object is thrown, a poor follow-through will lead to excess energy being retained in the delicate tissues of the shoulder, rather than returning to be consumed by the large muscles described previously, causing local tissue damage. Dynamic electromyographic analysis has substantiated a lot of the theory(2,3,4).

Simple Anatomy & Biomechanics

The shoulder (glenohumeral) joint is a ball (the humeral head) and socket (the glenoid fossa of the scapula) joint that's supported by the glenohumeral ligaments and labrum. The glenohumeral ligaments (inferior, middle and superior) are different capsular thickenings that restrict excessive rotation and translation of the humeral head. From the overhead throwing athlete, the more inferior glenohumeral ligament is the key anterior stabilizer when the arm is abducted beyond 90 degrees and externally rotated. The labrum is a thickening surrounding the glenoid which functions to deepen the glenoid cavity (the socket).

The shoulder is stabilized by both static and dynamic restraints. Static restraints include the articular anatomy, the labrum, the glenohumeral ligaments as well as also the negative pressure inside the joint. Dynamic restraints incorporate joint compression and also the steering effect of the rotator-cuff muscles (the very important small muscles around the shoulder).

The rotator-cuff muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. The subscapularis is an internal rotator of the glenohumeral joint, whereas the infraspinatus and teres minor muscles are outside rotators. The rotator cuff as a whole functions to center the humeral head in the glenoid for stability and to allow maximal leverage during shoulder movements.

Shoulder Injuries In The Throwing Athlete

One of those dynamic or static restraint mechanisms could possibly be ruined by the throwing actions of this athlete, and there's a considerable overlap of injuries. Furthermore, an untreated or unrecognized injury may progress to additional injuries within the shoulder.

Common acute overuse injuries include rotator-cuff tendinitis and biceps tendinitis. Common chronic accidents include impingement syndrome, rotator-cuff tears, glenoid- labrum tears and shoulder instability.

The athlete will usually complain of anterior shoulder pain that is worst when trying to increase the speed or power of their throw.

Primary Instability & Secondary Impingement

Most athletes with anterior shoulder pain have favorable impingement signs and before a couple of years ago it was considered that they all had primary impingement. They subsequently underwent anterior acromioplasty (removal of the anterior part of the acromion process -- the acromion is a bony plate which juts up from the shoulder blade to supply a sort of protective roof over the shoulder joint) using rotator-cuff repair as necessary and the results of surgery proved to be inconsistent(5). It's currently known that symptomatic throwing athletes frequently have a primary instability of the shoulder with secondary impingement(6,7). Anterior acromioplasty with excision of the coracoacromial ligament in these people may actually raise shoulder instability and magnify symptoms.

Anterior instability can develop after a high-energy injury but in the throwing athlete it starts as an overuse injury. Chronic overuse can stretch the static stabilizers of the shoulder, resulting in instability. The scapular and rotator-cuff muscles act out of synchrony with each other placing an increased strain on the rotator cuff to maintain the head of the humerus at the center of the glenoid. As the rotator-cuff muscles weaken, the head subluxes anteriorly (moves forward) when the arm is abducted and externally rotated. This lateral subluxation causes a secondary impingement (compressing against) of the rotator cuff on the acromion and the coracoacromial ligaments, causing pain.

Clinical Examination

Active and passive array of motion, shoulder strength and regions of tenderness ought to be elicited. Most athletes with shoulder pain have favorable impingement signs. Pain during forward flexion while the examiner stabilizes the scapula is the principal impingement sign. Pain during active abduction of this internally rotated arm is your secondary impingement sign.

Examination of shoulder stability is significant and also the signals may be subtle. The apprehension test may be utilized to detect anterior instability and entails abduction of the shoulder to approximately 90 degrees followed by external rotation. As the outside rotation is increased, the athlete with anterior instability will feel as though the shoulder will 'pop out' or sublux forward. He/she will attempt to guard against further external rotation and eventually become very apprehensive.

The movement evaluation is done in a similar manner with the patient lying supine (on his/her back) and applying lateral pressure into the posterior aspect of the humeral head when abducting and externally rotating the arm. When there's anterior instability, this may be painful, but by employing a posteriorly directed force into the humeral head, the pain will ease because the humeral head is put in the anatomic position.

The existence of posterior capsular stimulation may be modulated by the presence of decreased internal rotation of the shoulder.

Imaging

Recent studies suggest that MRI is superior to ultrasound and CT scanning in assessing shoulder pain caused by rotator-cuff tears, subacromial impingement and osteoarthritis of the glenohumeral and acromioclavicular joints(8,9,10). Ultrasound evaluation in the hands of a good musculoskeletal radiologist is much cheaper, however, and allows dynamic evaluation. With a good history and evaluation, however, such imaging might not be required from the great majority of instances.

Plain radiographs should be taken to exclude bony pathology such as fractures, calcific tendinitis, metastatic disease and osteoarthritis. Axillary views may demonstrate signs of instability, namely spurring or erosion of the anterior glenoid or even a Hill-Sachs lesion (osteochondral depression on the anterior humeral head brought on by impaction of the dislocated humeral head on the glenoid rim).

Other Diagnostic Tools

Selective local anesthetic shots can help pinpoint the painful area in the shoulder.

Diagnostic arthroscopy allows excellent visualization of the glenohumeral joint and the subacromial space with little soft- tissue destruction and brief rehab period. Whilst the individual is anesthetised, the existence, level and management of this shoulder instability might be evaluated(11). Of course, it is likely to proceed to fix or fix many of the pathological conditions in the shoulder arthroscopically.

Non-Operative Treatment

The mainstay of initial treatment for primary instability and secondary impingement is non-operative(12). A huge analysis of non-operative management for subacromial impingement syndrome demonstrated that non steroidal anti inflammatory drugs with specific rehabilitation programs gave sufficient results in 67% from 616 patients and that just 28% needed a subacromial decompression(13). There ought to be a period of 'comparative remainder' where overhead activity is avoided(14).

An individualized chiropractic program should then be initiated. Stretching of tight muscle groups whilst avoiding stretching the anterior muscles and capsule in a patient with anterior instability should be followed by strengthening exercises for the scapular rotators and rotator-cuff muscles. This should last for six to 12 months under supervision. If now it's still not possible due to pain, a surgical procedure to address the problem with the anterior capsule and labrum should be sought. Athletes with recorded rotator-cuff tears, labral lesions or loose bodies should have these lesions repaired or debrided.

Operative Treatment

The athlete with chronic shoulder instability whose ligaments are excruciating, resulting in capsular laxity, must have a surgical alteration to the ligament tension in order to restore ligament equilibrium if non-operative measures have failed. Such processes are termed capsulorrhaphies or capsular changes (that they efficiently demand a tightening of the capsule to stop unwanted movement). The adjustment is made medially, inferiorly or laterally in the capsule(15,16). Other processes are described but are contentious as they work by limiting the selection of motion so that the end-range laxity isn't challenged. That is obviously not ideal for the athlete. Recent work has been printed on laser-assisted capsulorrhaphy(17) andthermal-assisted capsular shrinkage (18) --that the jury is still out on those techniques.

Primary or secondary impingement could be surgically treated by open or arthroscopic acromioplasty. Care has to be taken to avoid elimination of the lateral acromion, to stop deltoid detachment and to eliminate just enough bone. The aim is that by removing the source of mechanical abrasion of the supraspinatus tendon of the rotator cuff, progression of impingement to partial and full thickness tears will probably be ceased. But, inadequate vasculature, tendon nutrition, established fibrosis and makeup changes in the tendon imply that the practice of degenerative disease and cuff tearing continues despite relief of painful symptoms(19).

The anticipated outcome after acromioplasty for impingement syndrome, whether performed within an open or arthroscopic procedure, is comparable(20). Roughly 80% of individuals will experience sufficient pain relief(21,22). There are, however, a lack of some standardized tests, so an accurate comparison between studies is not actually possible.

Post-operative rehabilitation originally requires the recovery of a pain-free passive array of motion and then the growth of active strength. The results of surgery frequently seem poor for the first three months but tend to improve over the first year.

The principal benefits of arthroscopic surgery include the shorter hospital stay, less anesthetic morbidity and reaching rehabilitation landmarks quicker(23). Sadly, some studies suggest poorer results where patients have been involved in compensation claims(24).

Referred neck pain pathology should always be excluded. Repetitive pressure may also injure the acromioclavicular and sternoclavicular joints. Finally, bear in mind the less common causes of shoulder pain in the throwing athlete. These include quadrilateral space syndrome, suprascapular nerve entrapment, axillary artery occlusion, axillary vein thrombosis, lateral capsule laxity and glenoid spurs. These investigations lie in the domain of the professional shoulder surgeon.

References
1. Review of Sports Medicine and Arthroscopy, Philadelphia, pp123, 1995
2. Annals of Cases on Information Technology, Vol 70(20, pp220-226, 1998
3. Journal of Shoulder & Elbow Surgery, Vol 7(6), pp610-615, 1998
4. American Journal of Sports Medicine, Vol 12(3), pp218-220, 1984
5. Clinical Orthop & Related Research, Vol 198, pp134-140,1985
6. Knee Surgery, Sports Traumatology, Arthroscopy, Vol 1(2), pp97-99, 1993
7. Journal of Orthopaedic & Sports Physical Therapy, Vol 18(2), pp427-43, 1993
8. Manual Therapy Vol 4(1), pp11-18, 1999
9. Radiographics, Vol 17(3), pp657-673, 1997
10. European Journal of Radiology, Vol 35(2), pp126-135, 2000
11. American Journal of Sports Medicine, Vol 18(5),pp480-483,1990
12. Medicine & Science in Sports & Exercise, Vol 30(4), pp18-25, 1985
13. Journal of Bone and Joint Surgery, Vol 79(5), pp732-737, 1997

14. Clinics in Sports Medicine, Vol 8(4), pp657-689, 1989
15. Acta Orthop Scand, Vol 68(5), pp447-450, 1997
16. American Journal of Sports Medicine, Vol 22(5), pp578-584, 1994
17. Arthroscopy, Vol 17(1), pp25-30, 2001
18. Instructional Course Lectures, Vol 50, pp17-21, 2001
19. Journal of Bone and Joint Surgery, Vol 80(5), pp813-816, 1998
20. Arthroscopy, Vol 11(3), pp301-306, 1995
21. American Journal of Sports Medicine, Vol 18(3), pp235-244, 1990
22. Arthroscopy, Vol 14(4), pp382-388, 1998
23. Arthroscopy, Vol 10(3), pp248-254, 1994
24. Journal of Bone and Joint Surgery, Vol 70(5), pp795-797, 1988

Dr. Alexander Jimenez, shoulder injury specialist and sports injuries explains how overhead athletes may prevent chronic shoulder pain.

Does your shoulder ache after overhead activity? Is it getting worse and now restricting that action? Has a span of rest apparently resolved the issue just for the pain to recur when you return to the game? Chronic shoulder pain is unfortunately an all-too-common consequence of repetitive 'overhead activity', such as serving and smashing in tennis, freestyle or butterfly swimming, bowling in cricket, javelin, or baseball throwing and above-shoulder weight-training exercises. Chronic pain in the 'overhead' athlete is normally the consequence of damage to the rotator-cuff muscles of the shoulder (a group of four, small, deeply located, strap-like muscles). This article will look at how such repetitive damage is caused and how the athlete could have the ability to prevent it happening in the first place.

Structure Of The Shoulder

The shoulder joint complex is in fact made up by four joints: the glenohumeral joint (the ‘ball-and socket’ joint between the upper arm or humerus and the shoulder blade or scapula, which most non-experts consider to be the shoulder joint), the acromioclavicular joint (the joint between the lateral end of the collar bone or clavicle and the scapula), the sternoclavicular joint (the joint between the medial end of the clavicle and the breast bone or sternum) and the scapulothoracic joint (the ‘virtual’ joint between the undersurface of the scapula and the chest wall). Problems at any of these four joints may result in ineffective function of the shoulder-joint complex and consequently pain.

There is more movement possible in the shoulder joint than at any other joint in the human body. Over 1,600 places in 3- dimensional space can be assumed from the shoulder. The price to be paid for this extreme selection of movement is an inherent lack of stability.

To attain peak performance during overhead activity, there has to be optimum balance between mobility and stability. It is well-known that swimmers who over-stretch their shoulders in an effort to boost the range of their stroke, without improving their functional stability, are at heightened risk of injury to the rotator cuff.Tennis players and throwing athletes, actions which are essentially asymmetrical, often develop greater shoulder external rotation in their dominant shoulder and this is often associated with functional instability. Shoulder-injury prevention strategies need to concentrate on improving shoulder stability.

Impingement & The Rotator Cuff

The bony anatomy of the glenohumeral joint includes a large chunk (the head of the humerus) and also small socket (the glenoid of the scapula) together with all the muscles of the rotator cuff and scapular rotating (stabilizing) muscles acting as the most important dynamic stabilizers of this joint. The muscles of the rotator cuff envelop the glenohumeral joint itself, and include the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Supraspinatus abducts the arm (moves it laterally away from the face of the body), infraspinatus and teres minor externally rotate the shoulder, and subscapularis is chiefly an inner portion of the shoulder. Sitting above the cuff is that the coracoacromial arch, composed of the coracoid and acromion bony processes of the scapula and a ligament connecting the two processes. Since the arm is abducted away from the human body or flexed (brought forward), 'impingement' or squeezing of the rotator cuff involving the head of the humerus below along with the coracoacromial arch above can happen. The healthy, conditioned rotator cuff functions effectively as an integrated component to stabilize and depress the head of the humerus, opposing the activity of the big deltoid muscle and thus preventing impingement.

Any overhead activity that includes the arm being taken regularly enough from below the shoulder level to over shoulder level has the capacity to damage the rotator cuff. With recurrent impingement, a badly ventilated cuff may get damaged, along with a cycle of cuff damage, diminished function, additional impingement and worsening cuff harm is initiated.

This form of primary impingement is most commonly found in weight coaches who overemphasize the development of the 'prime moving muscles' (pectoralis major, latissimus dorsi and deltoid) in the expense of their rotator cuff. It looks increasingly prevalent in athletes as they reach their thirties. Primary impingement is preventable and, even if the cuff is suitably conditioned, exercises like behind-the-neck press, incline bench press and also prolonged front laterals, won't lead to pain.

Secondary impingement refers to impingement secondary to underlying glenohumeral instability, when the rotator cuff is fatigued by its own attempts to maintain the humerus centered on the glenoid and thus allows the head of the humerus to ride up, reducing the subacromial space. This is possibly the most common mechanism of cuff injury found in younger athletes, especially those with increased joint laxity, and is observed frequently in swimmers and throwers. The principal difficulty here is instability and, unless that is treated, pain will probably be ongoing and progressive.

Scapular Stability

A strong and healthy rotator cuff is essential to the overhead athlete. In recent decades, the function of the scapula-stabilizing muscles in positioning the glenohumeral joint for optimum rotator-cuff work has been increasingly highlighted. Coordinated action of the set of muscles is needed to supply a stable base for pain-free overhead activity. The excessively simplistic 'ball and socket' model of the shoulder joint has been superseded by a model similar to the acting seal that could balance a ball on its nose. The seal equates into the scapula, and constant little adjustments by the seal (scapula) are required to avoid the ball dropping off its nose (glenoid). Overhead athletes must be able to effectively control the position of their scapula for optimum cuff function.

Injury Prevention Plans

Most cuff injuries can be prevented relatively simply. The crucial point is not to overwork the rotator cuff by increasing shoulder work too quickly. Keeping increases in workload to less than 10 percent per week will significantly reduce the risk of injury.

The key balance between stability and variety of shoulder movement has already been emphasized. Athletes with access to sports medicine support will benefit from an official evaluation of dynamic shoulder function. This should encompass an extensive overview of static and dynamic anatomy, range of movement at all four joints of the shoulder joint complex, muscle strength and balance (particularly of the rotator cuff and scapular stabilizers) and an assessment of inherent glenohumeral stability in all three planes. Significant abnormalities detected should be addressed and fixed. Such screening is becoming more and more regular for the more elite overhead athlete and validated evaluation and treatment protocols have been defined.

Strategy should be evaluated by the trainer and appropriate technical changes incorporated into the rehab program.

The Function Of The Kinetic Chain

More importantly, the use of force generation by other body parts has been assessed. For instance, the power generated by the shoulder at the tennis serve was preceded by power generated by the legs, trunk and back. The muscular mass of this shoulder is comparatively modest, and if insufficient power is generated by the previous connections in the kinetic chain the shoulder has to perform 'catch-up' and generate power rather than acting as a power regulator. Improving the server's leg activity, spinal strength and trunk rotation during the function will reduce the prevalence of rotator-cuff injury. Such biomechanical evaluation is difficult however, in skilled hands, is a crucial and effective component in injury prevention.

How Can An Athlete Prevent Injury?

Though shoulder rehab protocols after injury need to deal with subtle muscle imbalances and joint restrictions, and so require oversight, isolated rotator-cuff strengthening exercises can be very effective as part of a pre-participation conditioning program and can be performed using the next three simple exercises. The key is to strengthen the inner ozone (subscapularis), external rotators (infraspinatus and teres minor) and abductor (supraspinatus) muscles of the shoulder. This is most easily and safely performed using the varying resistance of a cliniband -- a length of flat rubber available from large chemists in varying resistances. You'll need about two meters; begin with the lowest resistance and workout!

To strengthen the right scapularis muscle, begin by holding your right arm from the side of your body with your elbow bent/ flexed at 90 degrees (the forearm will be at right angles to the upper arm and the line of the forearm points forward). Attach or loop one end of this cliniband above a door handle to the right of your own body and hold the other on your right hand. Internally rotate your humerus against the resistance of this cliniband (seen from above, the forearm moves in anti-clockwise direction towards the left) while maintaining your elbow bent at 90 degrees and at the side of your body. Let your forearm return to its starting place by the pull of the cliniband in a controlled manner.

The external rotators are strengthened from the opposite actions. From the same starting place but using the cliniband looped over a door handle to a left, externally rotate your right humerus from the immunity of the cliniband (viewed from above, the forearm moves in a clockwise direction to the right) while the elbow is again retained to the side of your system in 90 degrees. The forearm is again allowed to come back to the beginning position in a controlled fashion. Single sets include a minute of either internal or external rotation exercises and can be replicated three to five times a day. The cliniband needs to follow you around during the day! To strengthen the internal and external rotators of the left shoulder demands similar but mirror-image maneuvers.

Supraspinatus conditioning requires abduction work and initially should be carried out under shoulder level. The beginning position is quite different from the previous two exercises. To strengthen your proper supraspinatus, put one end of this cliniband beneath your left foot and then extend (keep straight) your right elbow. Hold the other end of the band on your hand and then internally rotate your right arm so that your right thumb points towards the floor and the back of your right hand faces forwards. Then, keeping your elbow extended, move your right arm away from your body (keeping the elbow straight) against resistance to just below shoulder level, and then let it go back to the beginning place in a controlled manner. An easy refinement is to unite pure abduction with just a little flexion so that you bring the arm forwards as you move it away from your side.

Pinch Your Scapulae Together

Pain shouldn't be felt through any of the three exercises. Three- to-five minute sets over the course of a day will generate a conditioning effect. By shortening the length of the band you will have the ability to progressively increase resistance. There are a massive number of variants on the exercises clarified that attain similar conditioning gains, and I make no claims for the superiority of their chosen three. But they have functioned well in my medical practice and infrequently cause unanticipated issues. Similar exercises could be performed using the pulley systems found in most gyms and with further adaptations can be done with free weights. Maintaining scapular retraction (the scapulae are 'pinched together' towards the middle of your spine and 'pushed down') while carrying out these exercises enables you to develop your scapular stabilizing muscles at the same time.

Strengthening the scapular stabilizers without specialist supervision is more difficult, but there is benefit from integrating wall leans (standing push-ups against a wall), knee push-ups and regular push-ups in any conditioning program. Seated rowing will strengthen the latissimus dorsi and should be undertaken while trying to keep scapular retraction.

Simple twisting movements, performed correctly, can develop significant core power. Core chiropractor, Dr. Alexander Jimenez explores body care slings.

Core stability training has come in several of guises over the years, according to whatever modality occurs to be the style of the moment. Most Swiss ball programs, Pilates and other core workouts deliver useful benefits in the physical preparation and injury management. They offer you a whole lot of variety -- and there are some things you can do to a Swiss ball or Pilates Reformer which you simply cannot do on any other apparatus.

As the flow of new fads in equipment and training styles reveals no sign of slowing, it's helpful to return to fundamentals and gain a little education about how the low back (lumbo-sacral backbone) and its encouraging muscle system work. This article introduces some important research done lately that helps us gain a much clearer practical understanding of how the lower back and pelvis work, and therefore what types of training are most likely to have a positive impact on core stability and strength. This research introduces the anatomical concept of 'myofascial slings'.

Myofascial Slings

The idea of myofascial slings comes out of the work done by Andre Vleeming as well as many others on sacro-iliac joint (SIJ) stability. Unlike what rheumatologists will inform say, the sacro-iliac joints -- which link the fused section of the lower spine (the sacrum) to the pelvic/hip bones on each side -- do have to move during regular daily activities such as walking and running.

It's both necessary and desirable that the sacro-iliac joints proceed, since they will need to act as shock absorbers between the lower limbs and spine, and also as a way of providing proprioceptive (body positioning awareness) feedback to get co- ordinated movement and control between the back and lower limbs.

Since the SIJ is capable of movement, that movement has to be properly controlled, much like any of the body's joints. Some hands comes through the pure architecture of the low back and pelvis, but more is possible by employing the surrounding muscle, ligament and connective tissue system (myofascial slings) to provide compression on the joints. This is important since we can help influence the effectiveness of the compression through exercise and retraining following injury. The 3 muscle systems or 'slings' that help to stabilize the pelvic girdle are known as:

• The posterior oblique sling;
• The anterior oblique sling; and
• The posterior longitudinal sling.

Key Training Principles

1. Stay Upright

Maintain the compression load vertical: as most athletic endeavors and functional daily activities are done upright, the majority of the 'core' training function also needs to be performed upright. It is likewise very important to stand, rather than sit, so that you have the ability to transmit load through the legs. Ground reaction force if standing is transferred up the upper leg bone (femur), into the hip along with the pelvic bones. This is fulfilled by the downward force of gravity acting on the trunk. This lets the SIJ to be held stable by using its natural structure when standing, as the sacrum sits nicely into the corresponding surface of the pelvis/hip in this position.

Additional the shock-absorbing intervertebral discs of the lower (lumbar) spine favor the compression power that standing provides, rather than shear (sliding) force or tensile (pulling) force. Most damaging shear force occurs when the vertebrae slide against each other and shear the adjoining intervertebral disc -- as occurs when the body is horizontal (the position used for several Swiss ball exercises). Tensile force occurs when the lumbar spine is bent forwards or backward (flexed or extended).

2. Work In Neutral

Keep the spine in neutral. The most frequent way to harm intervertebral discs would be to get the spine flexed, as you do when bent over. In this position the pressure within the disc increases significantly; with additional compression this place can cause discs to bulge. So it's important to keep the spine away from full flexion and extension positions, to avoid repeated micro injury to disks, vertebrae and ligaments.

3. Learn To Contract Stomach Muscles

Maintain the upper abdominals (rectus abdominis) at static contraction. Many elite athletic endeavors require that the abdominals work statically (isometrically). This permits the stomach muscle to present a stable anchor for the potent side trunk (oblique) muscles to generate force. The rectus anchors the obliques via lateral tendons and this layout allows power to be transferred across to the oblique muscles.

Training The Myofascial Slings

With close attention to good strategy, the easy twisting exercise in the diagram (see below) is a good way of training the myofascial slings. The key principles are as follows:

Programming

Note: one full repetition of this exercise involves rotating from X degrees backward trunk rotation to X degrees forward trunk rotation, and then returning to the backward start point.

Beginners

• Use a single band.
• Move through a small range of rotation 10 degrees to10 degrees each direction (total arc of 20 degrees).
• Perform 3 sets of 10 reps each direction (band at left, then band at right).

Sourced From:

Chris Mallac

Chiropractor, Dr. Alexander Jimenez examines the ankle sprain treatment options presented in this case.

The treatment plan I outline below has been utilized in professional sports for years but hasn't entered into mainstream injury management protocols. I suspect the reason is simple: it is very uncomfortable! Nonetheless, it works: I have seen athletes on crutches after sustaining diagnosed Grade 2 2+ ankle sprains who could walk without crutches with only a minimal limp following their first session of this treatment, and who had been back training after three to four days (obviously with a great deal of tape support).

Readers will probably be familiar with what occurs after an ankle sprain: internal bleeding, inflammatory processes, pain and swelling. The brain also gets involved, producing muscle inhibition and a decrease in proprioception, which usually compels the injured athlete to limp in an effort to reduce pain.

By numbing the toe and tricking the brain into allowing the ankle to move through a normal range of motion without pain, I believe we can minimize the detrimental effects of ankle sprains.

25-Minute Cryo-Kinetic Ice Bath

By icing the ankle in an ice tub, just following the protocol outlined below, I think you will be able to:

Precaution!

Perform this regime every two to three hours for the first two days following the injury. In professional sports, injured athletes may also set their alarms and ice a few days, late at night and early morning (eg, 12pm and 3am) to minimize swelling and optimize recovery speed. For your averagely active individual who also has a day job, I'd get them to perform this program as soon as possible following the accident and after that, for the initial two to three days, once a day towards the end of the day once they're back from work and have settled down to the evening. I have even had success using this technique on chronic swollen ankles that was sprained four to six weeks previously. After one to two sessions in the bucket, the swelling was minimal and the range of movement improved dramatically.

Caution!

There are a few basic principles which the patient should be informed of:

Chiropractic injury specialist, Dr. Alexander Jimenez examines a preventive injury approach based on the very best of what's known.

In sports medicine, there's not any tougher challenge than hamstrings -- often our most commonly seen injury, as well as uncomfortably significant re-injury rates. With a growing amount of research in this area(6), this is a good time to bring the literature together and invent an evidence-based method of preventing hamstring injury and recurrence.

Risk Factors

The logic of identifying risk factors is to modify these so as to decrease injury levels. We will need to know not just which factors are risky, but just how they influence harm.

Modifiable Factor 1): The Hamstrings

Powerful recent evidence implicates strength shortages as a pre-disposing factor for hamstring injury. The imbalances usually analyzed are: hamstring to quad (H:Q); eccentric to concentric (E:C); and side to side (S:S). By comparison, the demand for hamstring flexibility is much less apparent in the signs.

Since 2008 a number of isokinetic strength studies, such as a very large one, have shown isokinetic strength shortages to be predictive of hamstring injury. Back in Hong Kong, athletes using a diminished H:Q had 17 times increased risk of hamstring injury (8) and in elite Japanese sprinters S:S weakness has been correlated with hamstring injury(two).

One of 462 Belgian soccer players, the injury rate was considerably higher among gamers with isokinetic power imbalances, compared to those without(6).

Past injury is an integral factor (see below), and a study may help us to understand why. It reports that optimum length (ie, the best muscle length for active stress) has been found to be briefer in formerly injured muscles. Reduced/shorter 'optimal span' could perhaps predispose the hamstring to injury during eccentric loading in its outer variety (ie, once the muscle is nearing full stretch)(16).

The role of hamstring flexibility remains unclear: one study (Aussie Rules) revealed that sit-and-reach evaluation results didn't correlate with cerebral muscle injury(11). In a bigger Belgian soccer study, nevertheless, those injured had previously had considerably bad hamstring flexibility(17).

Modifiable Factor 2): Other Structures

One of Aussie rules players, too little flexibility in quadriceps(18) and hip flexors(19) has been predictive of hamstring injury. The same studies investigated restricted ankle dorsiflexion and concluded that this could have some relevance(19). I discuss this below.

Weak gluteals are implicated due to their job as concentric hip extensors. It has been proven that sprinters with S:S fatigue in concentric hip expansion were more prone to hamstring injury on the weak side(two). Equally all pelvic muscles help to maintain pelvic stability and hence reduce injury threat(41).

Non-Modifiable Risk Factors

Although the following factors are unalterable, it makes great sense to consider these when targeting particular players for preventive programs, especially in the event that you don't have access to expensive and time consuming isokinetic testing.

Two studies found the best risk factor for a previous posterior thigh injury (12) or a past history of hamstring injury (19). This goes some way to describing recurrence rates touching 40% in 1 study(3).

Some studies confirm that age is a factor, with older players at elevated risk(12,19,18,1). Players of black cultural origin(1) and Aboriginal descent(12) have been demonstrated to be more than averagely vulnerable.

If, for instance, you're responsible for a black 29-year-old participant with a hamstring injury background, you'll have both rationale and evidence to direct your use of a preventive program with that individual.

Mechanism Of Injury

To examine more precisely the mechanism of harm, we must consider the part of the hamstring muscle. Injury generally occurs in a sprinting scenario. Quick active extension of the knee requires the hamstrings to act eccentrically to decelerate the late swing-phase; but then they have instantly to change to concentric loading during early stance phase, where they behave as hip extensors(20). This stage sets the hamstrings in their outer range, in the very moment they have to make the greatest effort. Fig 1 (below) helps illustrate how these risk factors interact.

The eccentric action of the sprint creates very high intrinsic forces at the hamstring muscles(8). If at any stage the load exceeds the mechanical limit tolerated from the muscular unit, this will cause collapse(6) -- probably to be the result of excessive fibre stretch during a lengthening contraction(15). And the faster the exercise speed, the higher the eccentric torque created (22). Therefore it appears that hamstrings are hurt during eccentric contraction at the late swing phase of sprinting(48).

Most injuries include the biceps femoris muscle(1,47). This might be because at sprints of 80 percent to 100% of high speed, summit lengths are significantly longer and occur later than in another hamstring muscles(23). In this last period of gait, a high-force stretch-shortening cycle happens, and the hamstring unit relies on its non-contractile component to absorb, then generate force(22,24).

We can now start to learn the way the reduced isokinetic strength profile could cause hamstring overload and injury.

Hamstring flexibility becomes an issue if you regard that harm happens in late swing/early posture stage, once the muscle is lengthened. Logically, a short muscle must invest additional time in its outer range (ie, slightly lengthened under pressure) so as to come up with a typical powerful stride length. This places the lengthened hamstring under more stress and might explain why short hamstrings can be prone to trauma(17). In the exact same way that 'optimum length' (the muscle's optimal length for active tension) is found to be shorter in previously injured muscles (see above), this decreased length could also predispose the hamstring to injury in the exact situation(16).

The Fatigue Factor

And here is something you may discover surprising: there's a strong rationale and a few evidential back-up to imply that both general aerobic and particular hamstring endurance operate are strongly implicated in injury.

Hamstring injuries are most frequent during rivalry(1), even when effort should be at its highest. It is well known that in football a significant increase in injury is observed toward the end of each half(1). This may well be explained by the reduction in bizarre hamstring torque generation and operational power ratio -- caused by fatigue -- which players tend to suffer from at the conclusion of football halves. The angle of peak torque generation increases significantly (ie, the best length gets shorter) as every half goes on(42). Other factors include:

• Muscle elasticity (which buffers the muscle fibers) reduces with length(48)
• Fatigued muscles consume less energy before they fail(26)
• Hamstrings fatigue comparatively faster than their antagonist, which will affect the H:Q ratio adversely(27).

Place this lot together in plain English and also you get a hamstring muscle that, as exercise duration raises, is weakening relative to its antagonist, and getting unable to create and absorb as much pressure in its own exposed selection. We know that sprint times slow and stride lengths shorten as exhaustion sets in(43). Therefore any athlete lacking endurance will put their hamstring at a compromised position. To now demand high rates and stride lengths can only risk injury.

It's A Multi-Factorial Thing

Fatigue is not likely to be the sole factor in play. Here are some other prime contributors to injury:

Hip flexor length is as important as hamstring length(48). The two rectus femoris and hip flexors can anteriorly rotate the pelvis. In late-stance stage, brief contralateral (opposite side) hip flexors will rotate the anus relatively anteriorly; and in late-swing phase the ipsilateral (same-side) leg will need to stride somewhat further to generate a normal powerful stride length. This will place the hamstring further into its vulnerable outer range.

Similarly, a lack of dorsiflexion in the contralateral ankle during mid- to late-stance phase may limit a normal stride length -- again, causing the ipsilateral leg to over-stride. I've seen this in a young player with no history of hamstring injury who returned to play after a significant ankle injury, which had left him having significantly reduced dorsiflexion. On his return, this player, once worried (two matches in four days, as needs must), proceeded to severely rip his contralateral hamstring.

The glutes play a twofold function. Primarily, neuromuscular control of the pelvis may permit the hamstrings to operate at safe spans(41). As posterior rotators of their pelvis, contralateral gluts control (ie, limit) anterior rotation in late stance phase, thereby helping to normalize ipsilateral stride length.

Secondly, the glutes can act as synergists to the concentrically behaving hamstrings during early stance phase. It's been shown that concentric hip extensor weakness could induce a player to hamstring injury (two). So it can be that more powerful and more effective glutes will float the hamstrings at this point.

Abdominal muscles are rarely mentioned from the hamstring injury literature, but no doubt that they play a part. As controls of pelvic rotation (combined with glutes), they could reduce anterior pelvic tilt and the negative effect of tight hip flexors and low back muscles.

In summary, whatever regulates anterior pelvic rotation will help normalize stride length in late swing phase, which shields the hamstrings by maintaining them functioning inside a positive range (41). And conversely, any compromise or compensation to attain, 'normal strong stride length' will place the hamstrings at a mechanical disadvantage, raising the probability of damage.

Interventions

Prevention is also, as always, the best medicine. And the key to an effective intervention would be to direct it to the right athletes, which means screening. There's both strong rationale and evidence to guide the screening procedure, which will in turn, guide your prescription. The time you save in not needing to train inappropriate players can then be spent with the 'at risk' players. Hamstring strength will be the mainstay of a prevention program.

One out of both match athletes will have significant isokinetic strength shortages(6). I talk below where to 'set the bar' for isokinetic screening, a 'poor man's' algorithm/rationale for strengthening, and the rationale for exercise selection.

Setting The Bar For Isokinetic Testing

How do you determine that athletes require a preventive intervention? Reports give a fairly confusing variety of outcomes. Most predictive studies indicate that a conventional (concentric: concentric) H:Q ratio of over 0.6 predicts injury. Actual figures include 0.6 , 0.61, 0.55, 0.47 and 0.57 or 0.55 (8,11,35,36,6).

Logically, the operational H:Q ratio (bizarre hams: concentric quads) should best reflect injury risk, provided that it examines the ability of the eccentrically acting hamstrings to decelerate the concentrically acting quadriceps in late swing phase(8), where trauma typically happens(48). It appears that if cut-off is put at 0.98 (biodex), athletes under this are 'in danger'(8,6). The Croisier study (level of evidence 1) also showed that using only the 0.6 conventional ratio can miss as many as 30 percent of imbalances. Croisier also showed that a functional ratio higher than 1.40 eliminated risk of trauma, so get your athlete on the weights!

The Croisier study used an imbalance of higher than 5% (between the 2 sides), though it accounts 10% and 20 percent being used in different research studies. 1 key point is that the further steps you use, the less chance of missing an in danger athlete. Consequently, if you place your cut-offs as follows...

• Conventional ratio 0.6
• Functional ratio 0.98
• Side-to-side gap 5%

...you need to catch your at-risk athletes. Two cautionary notes: optimal isokinetic ratios differ between sports, so every individual game might have to set its own cut-off points(29). And keep in mind that the modest but real danger of injury involved with isokinetic testing(30,6).

Poor Man's Assumption Algorithm

Without isokinetic testing, you could be able to reason (evidence-based) or make some assumptions about who to include in preventative strengthening applications, following the algorithm in Fig 2.

Testing Effectiveness

A study of English rugby players found that Nordic hamstring exercises reduced the incidence and severity of hamstring injuries(5). Two more research in football successfully utilized the same exercise to greatly reduce hamstring injuries in contrast to controls(3,34).

It appears that measuring the efficacy of the program does more than just demonstrate progress -- it may actually play a substantial part in consolidating advancement. Back in 2008 Croisier et al showed that by adjusting imbalances (as quantified by successive sessions of isokinetic testing) that they could decrease injury levels to people of players with no imbalances. However, if the isokinetic testing sessions were omitted, and the players were therefore unable to get objective feedback about attaining 'normalization' in their rehab attempts, their subsequent reductions in re-injury rates were not statistically significant.

These favorable studies simply looked at strength parameters. Is it possible that by fixing other particular individual risk factors, as mentioned above, we can yield even more beneficial effects?

Rehabilitate The Injury

Even the very best prevention approaches can't altogether banish hamstring injuries. With recurrence levels being so high(3,1,2,5), successful rehabilitation is an integral part of a prevention program. In most athletes with a history of injury, even when matched, the injured hamstring is still poorer(40,38)and 'optimal span' is shorter(16). So, again, it comes down to strengthening.

Thus, in 26 previously injured athletes, 18 were found to possess a power deficit; those 17 who successfully bolstered the hamstrings to rigorous parameters prevented any further injury during the next season(40).

Evidence of effective rehab also lends weight to the argument that hamstring span(17) and also poor spinal management(2,41,48) are risk factors. Athletes who did more stretching were discovered to have shorter rehabilitation times(39); apps that focused on improving neuromuscular control of the lumbopelvic region were more effective than conventional rehab alone (41).

Alongside rehabilitation, it needs to be ensured that the athlete is back to decent levels of fitness. As there are no consensus guidelines for this(45), it is useful to refer to this athlete's previous aerobic and rate testing scores. Early exhaustion arising from bad aerobic fitness can compromise hamstring muscle functioning(42,43) and place the hamstrings at a physiological disadvantage. Not only should an athlete test ordinary for speed, but as injuries occur at top speed (21), They should have trained at full speed to gain this specific training impact. Lastly, if at all possible, hamstrings should be tested isokinetically to make sure that sensible strength parameters have been reached(38).

The timing of return to competition must be the collectively agreed decision of all parties involved. When analyzing the risk/benefit profile of a recurrence, you want to think beyond simply the likelihood of a repeat accident. In a study of Aussie Rules players, participant performance upon return to game from hamstring injury (as assessed by the team coach) has been substantially reduced(44). It is very important that an athlete reach complete normal function when they should be expected to work well in competition.

And Another Thing...

We haven't yet mentioned the lumbar spine, sacroiliac joint, or adverse neural tension (ANT) as preceding and potentially predisposing a player to hamstring injury. A history of lumbar spine injury doesn't correlate to hamstring injury risk(12). After the concept, however, that anything which interrupts standard powerful stride length increases injury risk, a rigid or rotated pelvis (SIJ lumbar spine) or ANT leading to lack of flexibility in late-swing stage could be responsible.

Equally, any source of pain or aggravation of neural interfaces (by way of instance nerve roots, neural foramen, piriformis) that raised hamstring muscle tone would again set the hamstrings in a mechanical disadvantage. According to this understanding, one of our athletes went to Germany, where they had been exposed to 43 injections, therefore I for one hope the rationale holds good. With this luxury (and possibly even with it), the best expectation would be to improve lumbopelvic control, not only to safeguard the lumbar spine structures but also to unload the hamstrings.

Conclusion

Following this tour around the pelvis, to describe hamstring injury as multi-factorial seems understated. All players should undergo the identical screening and identification processes. But all prevention/rehab interventions need to be tailored to the patient so they target appropriate risk factors.

Sources:

1. Woods C, Hawkins R et al. The F.A. medical research program: an audit of injuries in professional football – analysis
of hamstring injuries. Br J Sports Med 2004;38 (1): 36-41.
2. Sugiura Y, Saito T et al. Strength deficits identified with concentric action of the hip extensors and eccentric action
of the hamstrings predispose to hamstring injury in elite sprinters. J Orthop Sports Phys Ther 2008;38:457–64.
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Part II

6. Types Of Stretching

The reason that flexibility and stretching are confusing issues is partially because there are so many diverse kinds of stretching and exercisers are just at a loss about what type of moves to do and when. With this in mind, this chapter is devoted to setting the record straight so that you understand what kind of stretching is best for your personal circumstances.

Don't feel you've got to perform them all -- that's definitely not what is intended. Rather, read the descriptions and then use the methods that are specific for your training and workout goals. Use the right sort of extending at the ideal time and you're much more likely to find benefits from your flexibility training.

Static Stretches - Active Vs. Passive

Static stretches are the most identifiable form of flexibility training and also what most people today think about when you mention extending. For several decades, static stretching was how we all stretched -- before, during and a er exercise.

Ere are two major types of static stretches -- active and passive. A passive stretch uses an outside object or power to take you in stretch, for example employing a door frame or partner to elongate your pecs. In a busy stretch, you are using your muscles to maneuver you into a stretched position, e.g. clasping your hands behind your back and pushing your elbows to the rear to stretch your torso.

It really doesn't matter too much if you perform passive or active static stretches as the result is the same. It's worth noting, however, that if you are likely to hold a stretch for an extended time period, passive stretches are o en more comfy. Using the above cases, holding a doorway chest stretch for 60 seconds or more will be much simpler and much more comfortable than holding the hands clasped behind the back at a chest stretch for the exact same period.

1. Static Maintenance

In case your flexibility is already great and you simply want to be certain you don't lose it, for example after a work out to o set adaptive shortening, maintenance stretching is right for you. A maintenance stretch is not meant to enhance your flexibility and, as such, is not held for very long.

Maintenance stretches are normally held for between 10 and 15 seconds with no attempt to move deeper than is initially comfortable.

Commonly used as a member of a cool down, static stretches help reduce muscle strain and return your muscles for their pre-exercise length. However, the downside, static stretches have a tendency to cause your heartbeat to drop and reduce muscle contractility which may lead to a reduction in force production possible. In other words, static stretching can make you temporally weaker. For all these reasons, static stretches are normally omitted from setups.

2. Static Developmental

If you would like to enhance your flexibility, developmental static stretching is a good choice. Developmental stretches are held for between 30 to 60 minutes or longer and, as the name suggests, you should attempt to increase the thickness of this stretch as time passes.

If you stretch a muscle, you reach the natural end point of your muscle's elasticity -- known as the point of bind, or POB for short.

Should you stay in the POB for 15 minutes or so, you may feel your muscles relax slightly and you should then have the ability to move into a deeper stretch. Is happens more readily for those who a) unwind and b) do not hold your breath. Continue extending the POB as many days as possible till you get to your true conclusion of scope. Once you are there, continue for a further 15 to 30 minutes to actually maximize your flexibility training.

To recap:

• Move into POB and hold for 10-15 seconds
• As you feel your muscles relax, move a little deeper to new POB
• Keep your body relaxed and breath steadily
• Repeat steps one to three a couple more times before you reach your true flexibility limitation
• Hold this final place for 15 to 30 minutes
• Slowly ease out of this stretch

As you may see, developmental static stretching can be rather time consuming thus is best reserved for muscles that are really tight. Developmental stretching is best used as part of the cool down or, even if you're serious about improving your flexibility, during committed stretching sessions a er a light warm-up.

Just like all types of stretching, don't force either variety of static stretch. If you feel any burning or shaking immediately back off and use a less extreme POB.

An Exception To The Rule

While static stretches are normally reserved for cool downs, tactical use of a select number of static stretches can be used at a warm-up under specific circumstances.

As an example, when you've got tight chest muscles you might find it rather difficult to pull a barbell into your sternum when performing barbell bent over rows. In this instance, stretching the pecs before performing an upper/mid-back exercise could be beneficial.

Another example: if you've got tight hip flexors, then you may discover that, when squatting, you have a propensity to lean too much forwards which could put an inordinate quantity of stress in your lower spine. Statically extending your hip flexors may help eliminate this issue.

Finally, and again using the squat as an example, if you find your heels lift off the ground when squatting, this may suggest tight calf muscles. Stretching your calves before and between sets of squats may stop this potentially dangerous problem.

3. Dynamic

Where static stretches are generally best used in down the cool, dynamic stretches are much better suited to warming up. Dynamic stretches are stretches performed on the move and into the uninitiated do not actually look like stretches at all!

The beauty of dynamic moves is that they prepare your body for the activities you're going to perform without allowing you to get cold or diminishing the contractility of your own muscles. They also offer an excellent chance to rehearse the motions you are about to perform on your upcoming workout.

Dynamic stretches are also quite time efficient and it is possible to have a synergistic impact on most of your major muscles in as few as three exercises although chances are you're going to want to perform more like five or six so that you feel properly warmed up. You'll discover a lot of dynamic stretches in the stretching library in chapter seven.

Dynamic stretching uses a happening called reciprocal inhibition -- the exact same thing mentioned back in chapter two. Fundamentally, when one muscle contracts, its opposite number, called the antagonist, should unwind and this allows you to stretch it. For instance, if you bend your elbow, your knee contract and your triceps, located on the back of your upper arm, then should unwind and receive a gentle stretch as your arm reaches full flexion. Is is the very essence of dynamic stretching.

By performing specific movements like leg swings, overhead reaches and standing waist spins, you stretch none but two muscles -- you, as you move in one way, which muscle's antagonist as possible return. Is two-for-one stretch is what makes dynamic stretching so time-effective.

Unlike stationary stretching, dynamic stretching does little for the resting length of your muscles. It simply takes your muscles into the POB so that they are adequately prepared for your coming workout.

When performing dynamic stretches, it is very important you increase your assortment of movement slowly over a collection of 10 to 20 repetitions. Start o by being really careful and conservative and then increase the range of movement as you believe that you're prepared.

Also, be sure that every stretch is done rhythmically and with controller. Do not ing your limbs around with complete abandon! Each motion should take a couple of moments to finish and at no point should you feel as though you're bouncing out of the end point of the stretch. Decide on a steady tempo and stick to it for the duration of your set.

Make sure you don't do so many repetitions that your dynamic stretches turn into a test of muscle endurance! Is is particularly true of exercises such as lunges and squats -- Both good examples of dynamic moves for the more advanced exerciser. Do as many reps as you need to feel comfortable but no more. Save your energy for your workout!

Precede your dynamic moves using a couple of minutes of cardio to ensure your joints and muscles are warm and nice though, again, only do as much as you want to prepare your body to the coming workout.

4. Ballistic

Ballistic stretching is a lot like dynamic stretching, just faster and more volatile. Is increase in motion velocity includes a heightened probability of harm which is why ballistic stretching isn't suggested for beginners or those who don't actually need it.

In sports such as kickboxing, sprinting, gymnastics and even fencing, motions are performed a) very quickly and b) via a large selection of movement -- that the very definition of ballistic. Is way that participants in such and similar sports may consist of ballistic stretching as part of the training. Not to do so would invite harm when they practice their preferred sport.

For the rest of us, where rapid and large movements aren't the norm, the chance of ballistic stretching far outweighs any possible benefits. Dynamic stretches are fine for the majority of even the most ardent exercisers and provide many of the advantages related to ballistic stretching without the dangers.

If you're a sportsman or women who needs to add ballistic stretching in your training, be sure that you always warm up thoroughly before commencing. Increase the range of movement slowly to prepare your muscles to what's to come, start o with dynamic stretches and then, ultimately, advancement to ballistic moves (and even then advance your speed). Exercise some control at the end range of movement to minimize the risk of injury and make sure the motion is coming out of the ideal part of your body -- i.e. do not round your back when doing high front leads as the strain is being taken o your hamstrings and also being placed in your delicate passive lower back ligaments and discs.

Ballistic stretching bottom line? Only satisfactorily prepared sportsmen and sportswomen should utilize this advanced kind of flexibility training and then with caution.

5. PNF

PNF, short for proprioceptive neuromuscular facilitation, is an effective form of extending that may result in very rapid improvements in flexibility -- almost instantaneous. While the advancements that result from PNF are very rapid and noticeable, they're not permanent so PNF is not a one-shot x for inferior flexibility. But if you need some immediate gratification from your stretching, PNF is for you! PNF functions on the grounds that once a muscle was contracted, it goes to a place- contraction relaxed condition and is much more amenable to being stretched.

Basically, by using PNF, you "trick" your muscles into relaxing more quickly than they would normally so you can progress the point of bind or POB into a greater degree and in significantly less time.

PNF stretches are best done with a knowledgeable training partner since they may be complicated to do independently but, saying that, many can be performed alone if you're ready to think a little outside the box and also utilize external props like webbing straps to achieve the desired results.

Because PNF stretching takes time, it is generally best left for your cool-down and reserved for those muscles that are really tight. PNF is also a great form of stretching to add in standalone flexibility sessions at which time is less of a problem.

It is vital that there's good communication between the 'stretch-er' and 'stretch-ee' because overenthusiastic limb misuse could lead to serious injury. If in doubt or if you feel any discomfort, back o immediately.

6. CRAC

Standing for Contract Relax Antagonist Contract, CRAC is a variation of PNF and for all intents and purposes, synonymous. Using exactly the same contract/relax happening as PNF to encourage a deeper stretch, CRAC adds an extra component to progress the POB farther and potentially faster.

As you know, when one muscle contracts, its opposite number must relax to allow motion. CRAC utilizes this mechanism to allow you to move to a deeper post- contraction stretch. CRAC is also an efficient way to develop isometric power and is a helpful strengthening instrument o en used in post-injury rehabilitation. (Isometric contractions are the most powerful of all muscular contractions and result in no Motion as a single muscle group operates against the other.)

To illustrate how you can do PNF and CRAC moves independently, this stretching Example uses the doorway chest stretch, which is a excellent way to fix a round- shoulder position while, strengthening the muscles of the mid-upper spine (center trapezius and rhomboids)

● Position yourself in an open doorway. Raise your arms and rest your elbows and forearms against the vertical sides. Your elbows should be roughly level with your shoulders.

● Adopt a staggered stance for stability.

● Keeping your elbows and forearms pressed against the door frame, lean your body between your arms until you feel a stretch across your chest.

● Hold this position for 10-15 seconds until you feel your pecs relax.

● Contract your chest muscles by pressing your elbows and forearms forcefully against the door frame. Do not allow your arms to move. Use between 30-50% of your maximal perceived strength and hold the contraction for 10 to 15 seconds.

● Relax your chest and then use your upper back muscles to pull your elbows further back to increase the stretch in your chest. Lean forwards again so that your arms are resting on the door frame.

● Repeat steps four to six a couple more times until you fail to see any noticeable increases in the range of movement.

Like PNF, CRAC is a fairly lengthy process so is best retained to your tighter muscles and utilized in your cool-down or standalone flexibility sessions. It is quite effective for developing your flexibility but, if performed too aggressively or with a spouse who lacks the necessary experience, could lead to injury. While mild distress is acceptable and may even be desired, pain isn't, so make sure you back o if you're feeling anything untoward.

7. Library Of Stretches By Muscle Group

There are literally hundreds of ways to stretch - some very simple and some really convoluted. The primary point to keep in mind when assessing the worth of every stretch is that, to be effective, you must pull off the ends of the muscle away from each other and do this in a way that puts minimal stress on your joints along with the remainder of the body. By applying these standards, the great number of moves which are possible can easily be whittled down to 50 or so stretches.

In this section, you'll find instructions on how best to perform Various great stretches for every one of your major muscle groups. Ere are inactive stretches, dynamic stretches and, where relevant, some which can be performed using PNF and/or CRAC protocol.

Out of your personal flexibility evaluation, you must now know what areas of your body are tight and what regions are normal concerning flexibility. Pick developmental static stretches or PNF/CRAC on the tight muscles and utilize maintenance static stretches to your muscles that are more flexible. Perform these stretches as part of your cool down or through standalone flexibility sessions. Remember, however, to maintain dynamic stretches to your setups.

If, when performing any of these exercises, then you fail to sense much of a stretch a) test that your limbs are aligned correctly, b) try another stretch for the same muscle and then c) don't worry! It might well be that you're adequately flexible in the muscle in question and then you do not feel a lot of stretch.

As mentioned before, all stretches should be preceded by a few minutes of mild cardio to increase core temperature and enhance blood ow though your muscles.

Gastrocnemius

Is is the larger/upper calf muscle and can be among the most powerful by dimension muscles at the body. As they are so powerful, the gastrocnemius can take a fair bit to stretch, however if it Becomes tight can have an adverse effect on knee health. Its basic function is to stretch your ankle.

Prone cobra

●  Lie on your front with your hands under your shoulders

Pectoralis Major

Standing upper trap stretch

●  Stand with your feet hip-width apart and your knees slightly bent

Overly tight forearms can result in hand, wrist and elbow pain. If you hands naturally gravitate to a clenched position when you relax, chances are you have tight forearms. If you spend a lot of time typing, make sure you stretch these muscles o en to avoid developing a repetitive strain injury (RSI) or carpal tunnel syndrome.

Sourced From:

In the first of a two-part article, scientific injury chiropractor, Dr. Alexander Jimenez explains the anatomy and biomechanics of the medial knee ligaments, the consequences of injury, and how these injuries are identified and graded.

The shallow lateral collateral ligament (s-MCL) is among the most commonly injured structures in the knee, in both contact sports and sports that involve sharp cutting and direction changes. It might also be associated with more serious injuries to the medial knee including deep lateral collateral ligaments (d-MCL) and posterior oblique ligament(1-6).

The vast majority of MCL tears are isolated. These injuries occur predominantly in young individuals participating in sports activities, together with the mechanism of harm between valgus knee loading, external rotation, or a combination of these. These are common in sports as skiing, ice hockey, rugby and football, all of which involve motions requiring knee flexion and valgus loading and potential of direct contact to the outside of the knee(7-9).

The treatment of medial-sided knee injuries has moved away from competitive surgical remedies to largely non-operative management. Surgery is generally reserved for chronic MCL lack that has neglected non-operative therapy, or more acute and intricate injuries. The vast majority of athletes who sustain an MCL injury will reach their pre-injury action level with non-operative treatment.

Anatomy

The iconic anatomy reference point for understanding that the lateral knee joint stabilizers comes from Stan James in Iowa State University, who performed a very thorough dissection study about the lateral knee joint at the 1970s(10). The medial knee was divided into dynamic and static stabilizers:

Superficial Medial Collateral Ligament

LaPrade et al 2007 have made the most comprehensive examination to date on the s-MCL(18). They claim the s-MCL is the most significant structure of this medial part of the knee (see figure 1). It's one rectal attachment and 2 tibial attachments(18). The femoral attachment is oval in shape and, on the average, 3.2mm proximal and 4.8millimeter lateral to the medial epicondyle.

Since the s-MCL classes distally, it has two tibial attachments. The proximal tibial attachment is mainly a soft tissue attachment onto and over the conclusion of the anterior arm of the semimembranosus tendon, and lies a mean of 12.2mm distal to the tibial joint line(18). The distal tibial attachment of this s-MCL is broad and is straight to bone with an average of 61.2mm distal to the tibial joint point; it's located just lateral to the posteromedial crest of the tibia(18). The two distinct tibial attachments are reported to lead to two distinct functioning branches of their s-MCL(19).

A more recent study by Liu et al discovered that the s-MCL was triangular in form and the proximal and distal components were composed of parallel fibers. By comparison, the middle area of the s-MCL consists of parallel and oblique fibers, along with the middle portion was 1.7 times wider than the proximal/distal components(20). It's would be interesting to note if the 'oblique' fibers in this study refer to the posterior oblique ligament, which is discussed further below, and numerous authors have made this identical point(13, 14, 21,22).

Deep Medial Collateral Ligament

Deep into the s-MCL is that the d-MCL, which is comprised of this thickened medial aspect of the joint capsule. It is divided into meniscofemoral (MFL) and meniscotibial (MTL) parts (figure 1) and can be firmly attached to the medial meniscus at the joint line(20)

The bigger, but thinner MFL has a slightly curved convex attachment 12.6 mm distal and profound into the femoral attachment of this s-MCL. The MFL is about three times more than the MTL(20). The MTL attaches just distal to the edge of the articular cartilage of the medial tibial plateau, 3.2 mm distal to the lateral joint line,and9.0mmproximaltotheproximal tibial attachment of the s-MCL(18), also is 1.7 times wider than the MFL(20). It has also been reported that that the MFL attaches deep into the s-MCL, and the MTL attaches just distal to the tibial articular surface(25, 27). The d-MCL might play an important part to anchor the peripheral parts of the lateral meniscus in the medial side of the knee(20).

Relevant Biomechanics

The s-MCL is the primary restraint to valgus laxity of the knee and at 25 degrees flexion it provides 78 percent of the valgus controlling force(1,2,28-30). At this angle of flexion, the posterior oblique ligament gets lax and does not provide valgus support. In total extension, the ACL, posteromedial corner and semimembranosus bring about valgus restraint and the s-MCL only provides 57% of the controlling force(1,2). In general, an isolated s-MCL tear contributes to valgus laxity in flexion, whereas additional injury to the secondary valgus restraints (posterior oblique ligament or ACL) contributes to greater laxity in extension.

It has always been assumed that both different tibial portions of the s-MCL had comparable functions. But less than a decade ago it was ascertained via biomechanical studies that there are differences between the two divisions of the distal s-MCL in terms of their answers to applied loads (19). The two divisions of the ligament actually be conjoined but distinct structures. Therefore, any operative repair of this s-MCL must restore the different functions of the divisions by reattaching both tibial attachments, in an effort to reproduce the total function of the s-MCL.

The posterior thoracic fascia acts as a stabilizer of the two inner rotation and valgus movement at between 0 and 30 degrees of knee flexion(1-4,19,31-35). With the tibia internally rotated at 0 degrees flexion, the loads on the anterior oblique ligament are considerably greater than those on either branch of their s-MCL, which can be tauter in external rotation(19). Furthermore, the load reaction involving the anterior oblique ligament and s-MCL is reciprocal since the knee approaches 90 degrees flexion.

Also of interest is the fact that if d-MCL and s-MCL are surgically cut, significant gains in force are advocated by the posterior oblique ligament under valgus loads at 0, 20 and 30 degrees of knee flexion(36). As a result, the posterior oblique ligament in complete knees experiences tensile load using valgus forces, particularly near knee extension(19,36), and it also has a secondary function in supplying valgus stability of the knee(13,14,31,36).

The operation of the d-MCL (both the MTL and MFL) is poorly understood in comparison to the s-MCL. Its specific role is to function as a secondary stabilizer of the knee to valgus load(35,36). Valgus stabilization is offered by the MFL part at all tested flexion angles. The MTL portion stabilizes mostly at 60 degrees of knee flexion. The d-MCL provides restraint against external rotation torque in knees flexed between 30 and 90 degrees(36).

In studies, It's Been found that the maximum load to failure to the three structures were as follows(36):

• s-MCL -- 534 Newtons
• d-MCL -- 194 Newtons
• Posterior oblique ligament -- 425 Newtons

Controversy also exists as to where the weakest part of the complex is and the way this correlates with real injury in athletes. To outline however:

Injury Classification

The time-honored type of grading ligament injuries is derived from the American Medical Association Standard Nomenclature of Athletic Injuries (see figure 2)(41). Inside this naming method:

It's important to perform valgus stress testing in 0 degrees of flexion, which is different from in full extension. In full extension (almost hyperextension), there's recruitment of ACL function that may hide the laxity of the entire medial-sided injury. There is a high prevalence of associated ligamentous injuries with ACL injuries in grade III cases using this classification method.

Clinical Assessment

History

The traditional mechanism of trauma reported is a sudden touch or non-contact valgus force to the knee with swelling and pain along the medial aspect of the knee. They may feel a tearing feeling with acute pain or in acute cases of rupture could hear a pop up. Those with low grade medial knee injuries involving either the s-MCL, posterior oblique ligament or d-MCL may try to continue competing. However, they often described a side-to-side feeling of uncertainty, particularly when doing pruning and cutting maneuvers.

Clinical Evaluation

The key features that may be found clinically are(18):

Stress Testing

With the patient lying supine, the assessor grasps the ankle with one hand and places another hand on the outside of the thigh above the knee. A gentle outward force is put on the ankle. This can be achieved at full extension, 0 degrees flexion and 30 degrees flexion:

Imaging

Plain film X-rays are often unnecessary unless the clinician would like to appraise the degree of gapping of the medial joint line under imaging. In 1 study, a load applied by a clinician into a knee with a simulated isolated tier III s-MCL injury increased medial joint gapping, compared with that in the intact knee, by 1.7 and 3.2mm at 0 and 20 degrees of flexion, respectively(45). A complete lateral knee trauma, with sectioning of this s-MCL and d-MCL and the anterior oblique ligament, increased gapping by 6.5 and 9.8mm at 0 and 20 degrees of flexion respectively, below the clinician-applied load (45).

Magnetic resonance imaging (MRI) is more commonly used to assess the involved structures in patients with injuries to the medial side of the knee (see figure 3). T2-weighted MRI is the gold standard for diagnosing both partial and complete tears of this s-MCL. MRI has an accuracy of 87 percent for the assessment of MCL accidents(46).

Aspects Of Healing

Studies of the variables involved with the healing of this s-MCL in animals have shown that the healing is location dependent and immobilization dependent:

Conclusion

MCL injuries are a common occurrence in sports which require sharp cutting and changing directions, and in contact sports.

The anatomy of the medial side of the knee is pretty intricate and composed of the static stabilizers such as the s-MCL, d-MCL, posterior oblique ligament and the posteromedial capsule. It is encouraged by the energetic stabilizers, the muscles. Injuries to the inside of the knee predominately demand the s-MCL. This is ideally tested with a 30-degree valgus stress test and could be confirmed on MRI. Direction of grade 1-2, and most grade 3 injuries involves brace immobilization and conservative direction. Surgery is reserved for severe and complicated ligament disruptions or even in the case of chronic valgus instability. Part two of the report will discuss in detail the conservative progression following injury to the s-MCL.

References
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2. J Bone Joint Surg Am. 1988;70:88-97
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4. J Bone Joint Surg Am. 1994;76:1328-44
5. Iowa Orthop J. 2006;26:77-90
6. Rheumatology (Oxford). 2006;45:595-9
7. Am J Sports Med. 1995;23: 597-600
8. Am J Sports Med. 1988;16:392-6
9. Am J Sports Med. 2000;28(5 Suppl):S51-7
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15. Orthop Rev. 1989;18:947-52
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17. Clin Orthop Relat Res. 1990;256:174-7
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Chiropractic injury expert, Dr. Alexander Jimenez looks at the human anatomy and biomechanics of the tibialis posterior, & outlines suitable examination protocols as well as the treatment and management alternatives for dysfunction.

The tibialis posterior tendon (TPT) is a major player in the best performance of foot biomechanics, especially since it provides stability to the lateral longitudinal arch (MLA)(1). Dysfunction not only poses as pain on the inside of the lower leg and ankle, but can also be a primary cause of horizontal feet in the event of tendon rupture -- or vice versa, with inherently flat feet causing tendon overload(two). Many health professionals are yet to fully appreciate the significance of the tibialis posterior tendon and its significant role in injury incidence, which makes it important to raise recognition of this condition(3).

Dysfunction Incidence

Lots of risk factors are identified in the incidence of tibialis posterior tendonitis dysfunction. Excess weight is a variable, with heavy middle-aged women being diagnosed in 10% of instances(2). Other aspects including pes planus (flat feet), steroid injections around the tendon, hypertension, diabetes and rheumatoid arthritis(3).

Triathletes often present with this injury because of the persistent loading across both disciplines(4). The demands on this tendon from running are apparent; with poor biomechanics, it is easy to see how the tendon can become overloaded and breakdown occurs. In swimming, the requirements are not so obvious.

But, putting the ankle in plantar flexed position (by simply pointing the feet from freestyle swimming) raises the muscle shortening on the calf complex. Additional to this is the repetitive pushing off the wall at pool swimming. Also as poor foot biomechanics, some of the more frequent factors can lead to tendon overload such as raising training volume/load fast, hill reps, erroneous fitting footwear(4).

During a triathlon consequently, the calf muscle shortening in the swim and the high force production during the bike ride are joined when penetrating the run, which means the run begins with the calf muscles having already been loaded greatly, causing additional fatigue. Thus effective training with good recovery protocols is essential for preventing this sort of injury in triathletes.

Anatomy & Biomechanics

The tibialis posterior (also known as the anterior tibial tendon) originates in the posterior surface of the tibia on the external component, with a muscular attachment to the medial surface of the fibula, and the interosseous membrane between the tibia and fibula(2). It paths through the deep posterior compartment of the lower leg, together with the more dominant calf musculature of the gastrocnemius and soleus, and goes behind the lateral malleolus of the ankle. It is at this stage (just behind the medial malleolus) that the blood supply is diminished(2).

At the distal attachment, then the tibialis posterior divides into three sections with the major section attaching to the navicular tuberosity (bony prominence) on the inside of the foot(2). The plantar segment attaches to the second, third and fourth metatarsals, second and third cuneiforms, and the cuboid bone. The third section referred to as the recurrent portion attaches to the sustentaculum tali of the calcaneus (see figures 1 and 2).

On account of the anatomical landmarks of the tibialis posterior, it's the primary ankle inverter, and also functions to maintain dynamic equilibrium of the MLA of their foot in addition to assisting another calf muscles with plantar flexion(5 feet). Due to its attachment sites at the navicular, calcaneal and cuneiform bones, it's evident how the tibialis posterior plays a significant role in bettering the MLA to raise the rigidity of the back and mid foot during stance. Consequently, this offers an opportunity for the gastrocnemius to function with greater efficacy(2).

Pathophysiology

A substantial period of time in an air cast boot or pot might lead to weakness of this tendon and a reduced height of the MLA. A complete rupture of the tendon in the foot attachment does not have to occur to get a flat foot deformity to occur. Therefore, a rehabilitation program must include strengthening exercises of the foot inverters. Whether this strength work is not carried out then the tibialis posterior tendon can become vulnerable and repeated micro trauma can cause the tendinosis to occur.

As the tendon degenerates it is substituted with fibrotic tissue, and this frequently occurs in areas with inadequate blood flow in areas like supporting the lateral malleolus(2). Bubra and colleagues have stated that because of the rear foot valgus affects, a contracture can occur of the achilles tendon resulting in changes into the forces applied at the back foot(2). These modifications in applied forces can lead to pain because of the touch of the fibula and the lateral calcaneum. A further biomechanical factor linked to changes in the back foot is that the contracture of the peroneus brevis, which causes a mechanical force exerted to the opposing tibialis posterior tendon.

Evaluation

It's critical to formulate a thorough examination protocol when you suspect tibialis posterior tendinosis may be a potential. The first thing to check to get is any swelling behind the medial malleolus of the ankle (figure 3), and when combined with changes in foot shape, has been proven to have 100% accuracy for tibialis posterior tendon dysfunction diagnosis(3).

A progression is to ask the patient to raise up on one leg; a patient with tibialis posterior tendinosis won't be able to do this. The single-leg elevator is one of the major functional tests used for this particular condition. If function is ordinary, a person should be able to finish ten repetitions, pain free.

The ability of the muscle-tendon unit can be analyzed by resisting from a dorsiflexed/ everted position into plantarflexion- inversion, which follows the actions the muscle actively eases(3).

An X-ray taken of the two lower limbs is utilized to observe the individual in standing. The radiographs are best taken in the front and also the outside of the ankle to best view for the presence or lack of degenerative changes in the subtalar and talocrural joints. Even though a radiologist may further request an MRI scan or ultrasound scan, researchers at the Royal National Orthopedic Hospital, UK, have contended that clinical evaluations for tibialis posterior thoracic pain are adequate for forming a diagnosis(3).

Treatment & Management

Tendon degeneration can be simplified into four different phases (Table 1), and the proper therapy at each phase will therefore largely be dependent on the stage of injury. Stages three and four are less commonly observed in athletes, however, at the same time, it is important to acknowledge the progression tendon degeneration can take.

But, stage three is closely associated with irreversible subtalar joint degeneration with irreversible tendon changes. Stage four was added to include degenerative changes within the ankle joint in addition to the constructions involved in phase three. It is important to develop the strength of the tendon in a practical capacity once the swelling has eased and a heel raise can be performed. A simple exercise with a tennis ball between the heels (see figure 5) helps to improve rearfoot eversion and activation of the tibialis posterior.

Summary

A variety of conditions exist as risk factors in the occurrence of tibialis posterior tendon disorder, and these should be regarded as part of the examination. It is important to apply emphasis on the successful rehabilitation of ankle injuries either acutely, or after surgery, to make sure that prior injury does not cause tendon dysfunction later on. Successful screening should take place among an athletic squad to make sure that nobody is present with abnormal foot biomechanics that may cause tendon degeneration.

References
1. Blasimann – J Foot and Ankle Res, 2015, 8, 37
2. Bubra – J Family Med Prim Care, 2015, Jan, 4, 1, 26-29
3. Kohls-Gatzoulis – BMJ, 2004, 329, 1328–1333

There's so much more to stretching than just extending. Chiropractic sports injury specialist, Dr. Alexander Jimenez compares, contrasts & debunks.

Stretching is now a science. A developing understanding of the physiology of stretching means sports support professionals finally have a enormous variety of methods to use with clients for training, injury prevention and rehabilitation. This report provides an summary of some of the most popular types of extending, their benefits and drawbacks, in order to help therapists and trainers pick the most important forms for their clients. I have used the description of a hamstring muscle stretch in every instance to illustrate the various techniques.

Active Stretching (Static)

Popularized in the 1980s by Bob Anderson(1), an active stretch is one in which the client performs the stretch unaided. There's little if any motion as the controlled stretch position is maintained for approximately 30 seconds, then occasionally repeated. Inherent into the practice of yoga, physiologically this Kind of stretch has been termed 'a form of visoelastic myofascial release'(two). Put simply, muscles and their associated fascia begin to lengthen slowly in response to a gentle and constant load.

In therapeutic terms this physiological response is a real property of fascia and muscle known as 'creep'. The fact that the load applied is continuous and gentle is key to the efficacy of active stretching.

Many people wrongly believe that active static stretching can aid warm-ups and cool-downs, reduce DOMS, reduce injury, and enhance athletic performance. There is not much evidence to support these beliefs (3).

How To Do It

A static active hamstring stretch might be done by lying supine, clasping the hands behind an extended knee and flexing at the hip to produce the stretch. Hold the position stable for approx 30 minutes prior to releasing and optionally repeating.

Advantages

• Client can carry out the stretch themselves in the home or after exercise to maintain joint range.
• Gives the athlete control over their own rehab or flexibility routine.
• Useful if the athlete doesn't have access to a trainer or therapist.
• Can be done nearly anywhere and in any time.
• No equipment is necessary.
• Is comparatively simple.
• Strengthens agonistic muscles (see below).
• Is known to enhance range of movement.
• Is allegedly safe.
• Could possibly be utilised in early-stage rehabilitation.

Disadvantages

• Inexperienced clients may embrace an incorrect position and fail to stretch the intended muscle.
• The athlete may not maintain the stretch place for long enough.
• The technique demands strength in the agonistic muscles, which may be troublesome for inactive customers or those with muscle atrophy (although arguably it is also great for them -- view key benefits below).
•  It is boring.
• Most sporting movements are ballistic in nature, so for many athletes there may be little practical bene t from raising static flexibility.

Key Benefits

• Useful in a clinical setting where flexibility has been limited by weakness at the agonist muscles being used to bring about the stretch (as an Example, a sportsperson needing to Obtain knee extension after knee surgery or a hamstring injury where maintenance of quadriceps strength is as important as hamstring rehabilitation).
•  Coupled with controlled breathing, it might be helpful within a comfort program.

Passive Stretching

While an athlete can do passive stretches unaided, by utilizing a piece of gear, the expression is commonly utilized to indicate that another person is needed to help bring about the stretch. This individual is often another team participant, the trainer or a therapist. No muscles are contracted as a way to bring about the stretch.

How To Do It

A passive hamstring stretch might be done lying in supine, using a towel hooked around the thigh to help to bring the hip to flexion in order to extend the hamstring muscles without deliberate contraction of quadriceps. Instead in supine, a coach uses the straight leg raise position to extend the client's hamstring.

Advantages

• Makes stretching less effortful, since the client relaxes into a position that makes it possible for the trainer to facilitate the stretch.
•  When done as a member of a group action, can make stretching more enjoyable, facilitate concern for fellow staff members and enhance feelings of advancement.
•  Is relatively easy to do.
•  Can be performed almost anywhere.
• No equipment is needed.

Disadvantages

• Unless gear is used, a stretching partner is necessary.
• There's a danger of the athlete being overstretched by an inexperienced partner.
• The athlete must trust their partner.

Key Benefits

• Passive spouse stretching is a great option when flexibility is limited by the elasticity of this muscle/s to be stretched.
• Also useful therapeutically when the agonist is too weak to result in a successful active stretch.

Active (Ballistic) Stretching

The stretched muscles serve as a kind of spring to assist the athlete bounce repeatedly and rhythmically in and out of the stretch place, in effect producing several tiny moves. Muscles are not allowed to stay in the extended position even for a few seconds. Instead, the athlete uses momentum to stretch into and beyond their end of scope position with the intent of raising range of movement (ROM) with subsequent movements.

The degree to which ROM is expected to improve with each stretch is not given in research, nor is there a recommended number or variety of stretches required for every targeted muscle (contrast this with AIS below).

Ballistic stretching can significantly raise tendon elasticity(4), a more useful finnding given that tendon elasticity seems crucial to the discharge of stored energy employed in several sports.

Nick Grantham(5) has previously pointed out the similarities between ballistic stretching and the more recent variant of dynamic stretching where controlled leg and arm movements are used to help take the limb into the constraints of the associated joint variety. He notes that in the latter circumstance, movements are gentle and controlled, whereas in ballistic stretching they are forceful and less controlled.

Plyometrics is another form of ballistic training. It utilizes the elastic recoil of this muscle-tendon unit following a surprising stretch of the muscle to enhance muscle strength and is thus helpful in explosive sports. As an instance, after a leap, the muscle-tendon device of the ankle plantar flexors is stretched as the plantar flexors (gastrocnemius and soleus) are eccentrically contracting to help slow the entire body once the feet hit the ground and the ankle begins to dorsi flex. As Sean Fyfe describes(6): '...this stretch-upon-impact can lead to the muscle building larger elastic force in response to the stretch.'

From a security point of view, ballistic stretching is controversial on the grounds that it does not permit sufficient time for tissue adaptation and carries a relatively high risk of harm if poorly implemented. A sudden stretch may stimulate the stretch re ex, muscles contract, muscle strain increases and cells become more challenging to stretch, beating the object of the activity. However, advocates of plyometric training argue that, properly regulated, it plays an important part in late stage rehabilitation, as plyometric movements (running, jumping and throwing) occur widely in sport (6).

How To Do It

A ballistic hamstring stretch may be done standing, bent in the trunk. With straight legs. Make small bounces up and down, trying to touch your toes (this also affects spinal extensors, not just hamstrings).

Advantages

• Reportedly useful for sports with a ballistic component, such as kick boxing.
• Helps build lively versatility, so can be used to increase training specificity.
• Performed after static stretching, it seems to contribute to greater flexibility.
• Clients may do it in your home or following exercise.
• Gives an athlete management over their own flexibility routine.
• Might be done almost anytime, anyplace.
• Does not need any equipment.
• Is relatively easy.

Disadvantages

• Critics think the ballistic movement is more likely to damage muscles, since there isn't sufficient time for creep to occur in soft tissues.
• Can't be used in early-stage rehab.
• The sudden stretch stimulates the stretch re ex, increasing muscle tone and making it harder to extend the muscle.
• Shouldn't therefore be relied on in order to attain developmental flexibility or permanent lengthening of cells, as fast/high-force extending tends to increase muscular stiffness.
• If tissues are stretched too quickly in 1 movement, they may tear, leading to soreness and limited ROM.
• Because of a scarcity of investigation (ethically it is hard to test potentially damaging kinds of stretching), it is not clear what effect ballistic stretching has on range of motion.

Variation

A version of active/ballistic stretching known as busy isolated stretch (AIS) involves stretching one isolated muscle at a time by repeatedly hammering the opposite muscle for only 2 seconds, up to ten times. For each contract/relax, the resistant stage is surpassed by 1-4°. Alter (3), in his literature review of AIS, found 10 almost equal variants on this kind of extending, each using a different title, and differing only on the matter of this 2-second protocol.

AIS (also referred to as the Mattes Method after its developer, Aaron L Mattes) seems to differ in ballistic stretching in 2 ways: it's formulaic in its protocol, and in ballistic stretching the stretch isn't held but simply 'bounced' out of.

PNF Stretching

Developed in the 1940s as a physical therapy to help rehabilitate victims of migraines, there are many forms of proprioceptive neuromuscular facilitation (PNF), all of which use effective muscle contractions.

Probably the most recognizable is the 'single airplane' PNF technique, where an athlete's muscle is accepted several times to a stage of immunity and the athlete restricts the muscle isometrically (often using a coaching partner or therapist as resistance), even before the muscle is then stretched either actively by the client or passively from the spouse. One of the most exhaustive and well-known books on the topic is by McAtee and Charland (7).

The Way To Do It

To carry out a PNF hamstring stretch, in supine the hamstrings are taken into mild stretch. The athlete then isometrically contracts the hamstrings, while the partner provides resistance. There's no consensus on how long to maintain or how powerfully to contract the stretching muscle. Generally PNF contractions are more powerful than those used in MET (see below). Following an agreed period, eg, 6 to ten seconds, the athlete relaxes the hamstrings and the muscle is actively or passively eased to a lengthened position, where the stretch is replicated.

Advantages

• More pleasurable and less boring than straightforward static stretching.

• Improves range of motion.

• Advocates claim many other benefits including improved strength, improved joint stability, improved co-ordination, improved endurance, improved blood circulation.

Disadvantages

• Normally requires a partner.
• Since there are many variants, athlete and spouse / therapist / trainer have to be clear about which protocol they are using.
• There could be more stress in the muscle being stretched than happens in active stretching, raising the potential danger of this technique.
• Done incorrectly, may cause harm, eg, from over- extending by a zealous partner.
• May not be suitable for hypertensive clients, since there's a possibility of the valsalva phenomenon occurring during isometric contraction (customer holds their breath after deep motivation, increasing systolic pressure).
  Key Benefits
• Good for highly motivated people and to aid team- building, in which staff members are encouraged to stretch each other.
• Specific forms may be useful therapeutically where active movement isn't feasible because of pain or weakness, or ROM severely restricted.

Variation

PNF can also involve spiral diagonal patterns of motion, on the premise that muscles have a tendency to spiral around bones; this form of stretch intends to maximize natural motion patterns.

MET Stretching

Muscle energy technique (MET) originated from the late 1950s/early 1960s as an osteopathic technique, by the work of individuals like TJ Ruddy and Fred Mitchell Snr. The main differences between MET and PNF lie inside their roots, coming as they do from two distinct disciplines. This gives rise to different terminology, which can be widespread anyhow within the subject of extending -- helping to add to the confusion.

In technical terms, the force of contraction exerted by a client utilizing MET is reduced in contrast to PNF. The use of submaximal contractions has been shown to be equally as beneficial since maximal contractions at enhancing hamstring flexibility in areas not able to reach 70° of hip flexion, and might therefore be safer in early-stage rehabilitation of cartilage and muscle injuries(8).

There are many variations and applications of MET(two). At its simplest, the therapist requires a client's muscle into a point of mild tension, in which the customer contracts it isometrically (up to 20 percent of their force), whereas the therapist provides resistance.

The muscle can be lengthened either following regeneration, when the client relaxes (called post-isometric relaxation extending, PIR); or during contraction (an isolytic contraction, where the muscle is having to contract eccentrically). In this second kind of MET, rather than fitting the force of the client's contraction, the therapist accomplishes it, raising ROM in the associated joint, thereby stretching the contracting muscle.

MET is gentle and may be used without the stretching component. The very low-level contractions involved in the procedure may be helpful in early stage rehabilitation, to help grow or maintain muscle strength when tissues are in the initial stages of repair.

How To Do It

To carry out a MET hamstring stretch in supine, the client actively exes the hip to its maximum with knee bends, then extends the knee until they reach a point of mild stretch/restriction (therapists can refer to this as the 'point of glancing' or ' first barrier'). The therapist maintains that this position while the athlete tries to ex the knee by contracting the hamstrings, using up to 20 percent of their force, making an isometric contraction resisted by the therapist for 7-10 minutes. The client relaxes and on exhalation, the therapist gently extends the knee to the new barrier position. This place is held for 10-30 minutes and the procedure repeated.

Advantages

• Stretches soft and muscle tissue.
• Strengthens muscle.
• Relaxes muscle.
• Helps regain correct muscle functioning.
• Enhances local circulation.
• Helps to de-activate trigger points.
• Contrary to PNF, among the goals of MET is combined mobilization.
• Advocates claim there are no contraindications.

Disadvantages

• There are many distinct kinds of the technique and coaching is needed to understand how and when to utilize them.

Key Benefits

MET is used to deal with many patterns of muscle dysfunction. Chaitow (2) explains in detail the use of eight variants on the basic MET technique and when they might be implemented.

Soft Tissue Release Stretching

Utilized by physiotherapists, this entails 'locking' a passively shortened muscle close to, or on its own origin prior to stretching the muscle. By forming a false source, the stretch could be applied specifically to areas of brotic tissue.

Advantages

• Stress and stretch are believed to ease a lengthening of soft tissues and an increase in range of motion (9).
• Certain stretches may be performed either actively or passively.
• Comparatively easy to use.
• Performed knowingly, the only equipment needed is a tennis ball.
• Can readily be incorporated into a massage series, so can be helpful where massage is indicated as part of a rehab or care program.
• Helps de-activate activate points.

Disadvantages

• Therapists will need to learn the method, which can take many forms.
• Cannot be used on all customers (eg, people who bruise easily and have fragile skin).
• May result in soreness, very similar to DOMS.

Key Benefits

• Useful where a client can't take a joint through a full range because of injury, or with hypermobile clients where starting a stretch at the end point may not be desirable.
• Valuable for targeting areas of fibrotic tissue in muscles which might otherwise not be stretched with gross active stretching.

Conclusion

This summary isn't meant to be comprehensive -- there is not any space here, for example, to cover techniques like tractioning, neural mobilization and non-traditional kinds of extending. All kinds of stretching can be utilized within a sports-specific endurance regular; it's all up to this support professional to comprehend the repertoire available to help optimize the benefits to their client.

References
1. Anderson B (1981) Stretching.
2. Chaitow L (2001) Muscle Energy Techniques. Churchill Livingstone.
3. Talter, Michael J (2004) Science of Flexibility. Human Kinetics.
4. Witvrouw E, Mahieu N, Roosen P and McNair P (2007) The role of stretching in tendon injuries, Br J Sports Med 41: 224-226.
5. Grantham, Nick (2008) Dynamic flexibility, Sports Injury Bulletin 77, March.
6. Fyfe S (2007) Why you should put plyometric into rehab, Sports Injury Bulletin 71 July/Aug.
7. McAtee E and J Charland (1999) Facilitated Stretching. Human Kinetics.
8. Feland JB and Marin HN (2004) Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching, Br J Sports Med 38 e18.
9. Sanderson M (2002) Soft Tissue Release.

This case study has one of those treatment results that makes you believe you've made a massive difference to somebody's life. Scientific injury specialist, Dr. Alexander Jimenez investigates the case research.

This patient, Mel, loves mountain running. Much of her week revolves round instruction, getting ready for the long term in the weekend, and finally the large competition. I first analyzed her about six weeks out from a race called the Kokoda Challenge, a 96km team race. She was fighting with just two complaints. The first, and lesser, was repeated ankle sprains on both legs; the second has been chronic iliotibial band (ITB) problems, again on both sides. Though these are clearly two distinct issues, they are not entirely separate, as we will see.

Mel was always running on uneven, rocky ground and would roll her ankles several times during training and competition run. On assessment, she demonstrated laxity on both ankles from the anterior talofibular ligament (ATFL, the most commonly strained ligament of the ankle). There was no joint effusion or pain, just increased plantar flexion and inversion and increased joint movement on the ATFL anterior pull test.

Her proprioception was, to put it mildly, terrible. When balancing on one foot, then she'd eliminate balance immediately upon closing her eyes. She was not able to balance on the ball of her foot on one leg, and could not grip balance on one leg when utilizing any balance device such as a wobble board or Bosu ball.

The immediate goal was to stop her rolling her ankles, to prevent long-term joint damage and, importantly, to lower the risk of a serious acute ankle injury -- a risk that is clearly inherent in the nature of her chosen sport. The answer was straightforward: we needed to retrain Mel's proprioception.

And now to Mel's ITB problems. She'd suffered from lateral knee pain for approximately a year. She had fought through the pain in training; it'd come on after distinct distances, but would usually start when she had been going downhill.

Since she had had this problem for quite a very long time and past remedy hadn't been successful, an MRI was indicated; this revealed irritation of this under-surface of the ITB and some quite mild bony inflammation at the lateral femoral condyle. In consultation with all the sports physician, we determined that a cortisone shot would be appropriate. This would permit Mel to carry on doing some running and create a window for a few rehab work. Mel, however, wasn't keen on the concept of an injection and preferred to attempt rehab alone first.

Upon evaluation, she'd just moderate tensor fascia latae, hip flexor and ITB tightness, which we handled with soft tissue massage, trigger points and extending. But these measures didn't actually target the underlying difficulty. Mel managed to continue doing and running her rehab but with the continuing deficit within her range of motion. Back in 1994 Bullock-Saxton, Janda et al (1) revealed that the substantial difference in patterns of muscular activation around the hip in normal subjects in comparison to people who had previously suffered a serious ankle sprain. They revealed that activation of gluteus maximus was postponed on the previously injured side which changes happened in the neighborhood perception of vibration on both the injured and non-insured sides.

On testing, Mel's gluteus maximus activation was very poor. In more than hip extension, it had been nearly non-existent and she fought with another hip expansion- dominant exercise.

And she was finding single-leg stance exercises hard not only because of her lack of proprioception but also because of poor gluteus medius function, evident in isolated hip abduction in side lying, and single-leg posture exercises.

To sum up, Mel, who had been attempting to compete in endurance mountain races, had:

Her running gait represented this great deal perfectly. She conducted with a lengthy stride length. Her heels strike occurred way out before her hip (rather than beneath it), constantly putting gluteus maximus into a lengthened position. This was making it more challenging for the muscle to contract and extend the hip. So Mel was pulling herself along with her hip flexors and rotating her pelvis with a rather forceful hip extension so that she could propel her body forwards at heel strike.

Due to her long stride length, she crossed her midline by a massive level, ramping up the demand on her already weak gluteus medius. It wasn't surprising that in stance stage her pelvis exhibited considerable lateral tilt.

It's worth mentioning that elite runners also often drift across the midline, since they, also, run with a long stride length. The difference is that their greater stride length comes from their strong propulsion through each stride; heel-strike remains firmly beneath the hip.

Not only does a running gait such as Mel's lead to harm, but it is also very inefficient. Because her posture stage was very lengthy, any elastic energy saved from the initial ground contact was lost, causing her to have to work harder to transfer energy with every stride.

That is the reason elite runners tend not to have a heel-toe working routine: they are moving so efficiently that a heel-toe pattern could cause them to spend too long on the floor and therefore lose too much energy. A key aim of all runners -- out of track to marathon -- ought to be to reduce ground contact time, so as to boost efficiency and hence speed.

Rehab

Mel did not want to quit running, despite pleas, because running was more than just exercise for her. Much like many people, it was her solitude and anxiety relief. We had to prioritize proprioception, to attempt to improve this until she suffered a severe ankle injury.

We began with low-level workouts, for example:

Other high-level exercises contained:

• balancing on a wobble board while catching and throwing a ball

• single-leg knee bends on the Bosu ball.

There are just two major goals with proprioceptive training. Firstly, to improve the role of the proprioceptive system with increasingly more difficult activities and secondly (especially essential in Mel's situation, as she had been running long distances on uneven ground), to increase the endurance of their neuromuscular system.

We started her on non invasive activation drills because of her gluteus maximus and gluteus medius. For the glute maximum, she needed to lie prone and practice squeezing left and right glutes together and then isolating each side.

This progressed to prone hip extension, focusing on isolating glute max contraction while maintaining neutral pelvis and spine. Mel also did single-leg bridge exercises, again concentrating initially on squeezing the glute maximum and then extending the hip, but not arching the lumbar spine. We encouraged her to concentrate on feeling like she had been tripping her gluteus maximus in walking and specifically on staircase.

For gluteus medius activation, we utilized clams (side-lying with hips flexed to 30°, heels together and lifting top knee apart without the pelvis shifting; see Fig 1, below) and side-lying hip abduction with a straight leg.

Once Mel had finished these, she improved to standing drills, starting with squats. First we utilized double-leg squatting to boost gluteus maximus power bilaterally, then single-leg squats to add an emphasis on gluteus medius, so as to stabilize the pelvis and knee.

We later introduced the technically demanding Romanian deadlifts (RDLs). These, I believe, are the ideal method for athletes to reinforce the gluteus maximus. Mel finally progressed to single-leg RDLs, an extremely ambitious exercise, which definitely must be worked up to.

Gluteus medius endurance bilaterally was worked on with "crab walk". This involves looping a flexband round the ankles in standing, assuming a semi-squat and widening the stance, then taking little sideways shuffling steps with one foot, then the other, while keeping up the strain on the ring. This impacts the gluteus medius muscles; it can be progressed by increasing the amount of steps or utilizing a more powerful group.

Not Any Old Exercises...

We tailored all of the strengthening exercises to suit Mel's specific sporting needs. She needed to possess exceptional endurance in all those critical muscles we were targeting if she had been going to keep an efficient gait through an occasion. Her program was so designed to signify this, with lower weights but higher repetitions (beginning at 15), and even more than the standard three sets. All these additional repetitions had the additional advantage of assisting her more quickly hard- wire the beneficial motor patterns.

It also meant she had to work very hard indeed on her rehab. Especially during the late-stage rehab, the sessions were very arduous. But then, she wasn't trying to perform what could be considered normal for a 43-year-old girl. One bonus was that since the subsequent sessions were so tough, she had to take adequate recovery period, which restricted her into a maximum of 3 sessions weekly. Mel became technically very capable and powerful; she proceeds to perform her exercises frequently as maintenance.

Running Form

The running procedure re-education was quite simple. We focused on shortening Mel's stride and getting her to feel as though her heel strike was back beneath her body rather than straying over the midline. Next, she had to feel as though she immediately propelled her entire body over her foot, to make a decline in her ground contact time. We also cued her to feel her gluteus maximus contracting as she extended her hip. As she had good body awareness, this worked well for her. I also invited her to connect up the feeling she had been getting in the gym rehabilitation work together with how her gluteals were functioning in her running.

But she wanted to try anyhow. As anticipated, she did not make it and her knees were an issue. But at least she'd ceased rolling her legs. She also began running again, with all the pain improving and still no rolling of their ankles. Mel had a favourite 18km training loop she liked to do regularly and she began running that pain-free -- that she had not been able to do for 12 weeks. Actually, she came to physio after one weekend hugely excited because she'd conquered her personal best by 10 minutes on her 18km training loop.

But the real test was yet to come: a 50km mountain run. This happened around three months after the Kokoda event. Mel ran powerful and pain-free. She was pumped.

Reference
1. Bullock-Saxton J, Janda V et al. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med 1994; 15: 330-334

Legend has it that every year the body department staff at one of the United States' top universities lay down bets on how long it will take before the new medical students discover the "freshman's nervel" when the time comes to dissect the lower limbs of cadavers. Science based chiropractor Dr. Alexander Jimenez takes a look.

The clinical tutors take great joy in hearing the enthusiastic exultations of medical students as they pare back the gastrocnemius muscle of the calf to be presented with what appears a nerve- like arrangement. "Wow, look at this, I just discovered the tibial nerve!"

After allowing time for backslapping and high fives one of the students, the tutor slides over to the dissection table to point out that what they have just found is not actually the tibial nerve but the tendon of the plantaris muscle. The slender plantaris is the topic of the subsequent case study, outlining the rather debilitating injury known as "plantaris tendon rupture".

Mr B's Bumpy Ride

Mr B, a 45-year-old recreational cyclist, introduced to physiotherapy one week after he felt his calf tear while skiing. He was a long-term Warfarin user ever since, a few years before, he had had a surgical C5/6 combination that had resulted in some horrible blood clots. His last clot had been more than 12 months previously.

After being escorted down the slope on the rear of the snowmobile, he removed his boot and noticed swelling in the medial calf. This would not be an unexpected occurrence in somebody on Warfarin. The next day he was tender on the medial side of the popliteal fossa (back of the knee) and then down the calf.

Upon evaluation a week after, Mr B had a tight swollen calf and was not able to walk without a limp. He could not walk down stairs, push off in walk or twist on a fixed foot. Stretching the gastrocnemius was debilitating.

We immediately suspected a garden variety muscle strain of the gastrocnemius and proceeded to treat him with mild soft-tissue flush massage, direct trigger- point therapy, heat and motion therapy, compression and mild isometric calf exercises, which we progressed to single-leg calf increases as pain allowed over a number of days.

After nine days, Mr B has been walking pain- free and managed to perform 3 x 15 one-leg calf increases without pain. He had been discharged from physio with directions to continue calf raises for four weeks, and also to progress his return to biking from wind trainer to flat streets to hills over the same period of time.

Twelve days after we had discharged him, Mr B had been gardening and, while on a slope, his foot slipped. He was forced into rapid dorsiflexion and knee extension again. He felt immediate pain and has been unable to weight-bear. Back at the practice, he revealed significant calf swelling and tenderness at the posterior knee. Concerned that we were looking at something more menacing than a simple calf strain, we delivered him for a diagnostic ultrasound.

The ultrasound clarified the plantaris tendon as being "blind ending" from the calf, suggestive of plantaris rupture. There was a massive hematoma in the gastroc/soleus fascia. No extra gastrocnemius or soleal tear was discovered.

We explained to Mr B this rather unexpected pathology. He had been handled the same way as previously, but we focused on lots of friction massage to his torn plantaris tendon and also a far slower and more conservative return to rehabilitation and cycling; we also threw in certain single-leg proprioception exercises for good measure.

He returned to cycling three months later with no further problems.

Anatomy

The muscle is most likely too small to perform any real part in plantarflexion of the ankle, the job done by soleus and gastroc. It's been indicated that the muscle and its tendon once controlled big-toe flexion in the days when people climbed trees. But apes don't possess this muscle, so that argument doesn't hold.

Moore and Dalley suggest, however, that the muscle has a high percentage of muscle spindles (2): glands in the muscle that are highly sensitive to extend. It therefore seems possible to me that perhaps this muscle building functions just a proprioceptive role, a hypothesis shared with Menton in his very interesting argument about plantaris being a "sensory muscle (3)".

This point has merit once we consider we're the only animals that stand upright on two feet. In standing with the knees extended, this muscle will always be shooting and fine-tuning our standing posture, helping us to maintain equilibrium.

However when injured it may result in ongoing pain and disability, and potentially thwart the development of a serious athlete hoping to return to a running-type sport.

Injury

Rupture of the plantaris muscle/tendon has often been referred to as "tennis leg", because of its tendency to rip in middle- aged tennis players. In fact, they frequently describe the sensation as one of being struck in the calf with a tennis ball. It is an accident nearly entirely continued by the athlete over 40, being nearly unheard of in younger athletes. But a case study does exist emphasizing this injury in a professional footballer (4). Injury to this muscle/tendon must always be guessed in athletes presenting with severe medial calf pain, irrespective of age.

The plantaris tendon can rupture when vigorously contracted, especially if the ankle is dorsiflexed and the knee extended. Imagine a tennis player lunging to get a ground stroke and needing to push off forcefully while down low to the floor.

Although the muscle is quite small and the tendon very thin, the pain can be very intense and is felt at the medial gastrocnemius; immediate swelling and haematoma cause this area. It's easy to mistake a plantaris tendon rupture for a gastrocnemius muscle rupture.

On the positive side, plantaris tendon ruptures usually recover much faster than gastrocnemius tears. Because of this, MRI or ultrasound imaging may be desired in order to determine the damaged structure. This will enable the clinician to make a better judgement about how long that the rehabilitation is likely to take and how the prognosis appears longer term.

What's more, ruptures of the myotendinous junction of the plantaris are often thought to be more severe than simple ruptures or tears of the tendon proper. The pain in this instance will be much more severe and the muscle will retract upwards into the popliteal space, often between the popliteus tendon and the lateral gastroc head. The resultant hematoma is frequently also more severe and functionally more debilitating. Ruptures of the plantaris muscle are often seen in conjunction with anterior cruciate ligament (ACL) ruptures (1). This also suggests that the injury mechanism for a plantaris muscle equilibrium can actually be like the mechanism for ACL rupture.

Treatment

There is a lack of scientific evidence on conservative versus surgical procedures in plantaris muscle or tendon rupture. Much of the philosophical literature implies that the injury should be handled along the very same lines as another muscle injury, bearing in mind that its small size must allow the muscle to fix quickly.

Ice treatment when maintaining the muscle elongated helps to regenerate the muscular tissue faster and to a more functional and aligned matrix. This can be done by icing the calf with a straight knee; the ankle is slowly dorsiflexed and plantar flexed. The muscle should be kept compressed when not iced.

Active release techniques, soft tissue massage, trigger point therapy etc can be used to help enhance calf muscle tone and speed the elimination of the hematoma.

Progressive strengthening can then start as pain permits. This can start as a simple isometric calf hold exercise on a step and then later progress to complete eccentric calf loading as pain and function improve.

References
1. Helms et al (1995) Plantaris Muscle Injury: Evaluation with MRI imaging. Radiology. 195 (1) p. 201-203
2. Moore KL, Dalley AF (2006, Philadelphia) Clinically Orientated Anatomy. Lippincott, Williams and Wilkins
3. Menton DN (2000) The Plantaris and the Question of Vestigial Muscles in Man, Technical Journal 14 (2): p. 50–53
4. Bradshaw et al (2005) Traumatic Achilles Paratendinopathy Complicated By Plantaris Tendon Rupture And Subsequent Post-surgical Complications. Medicine and Science in Sports and Exercise: May 2005 37 (5) p. S281