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TheVitalGlutes:ConnectingtheGaitCycletoPainandDysfunctionissponsoredbytheSocietyfortheStudyofNativeArtsandSciences,anonprofiteducationalcorporationwhosegoalsaretodevelopaneducationalandcrossculturalperspectivelinkingvariousscientific,social,andartisticfields;tonurtureaholisticviewofarts,sciences,humanities,andhealing;andtopublishanddistributeliteratureontherelationshipofmind,body,andnature.

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v3.1

Contents

CoverTitlePageCopyrightDedicationPrefaceAcknowledgmentsListofAbbreviations

1PuttingtheMaximusBackintoGluteusMaximus2MuscleImbalanceandtheMyofascialSlings3TheGlutesandtheGaitCycle4LegLengthDiscrepancyandOver-Pronation—theEffectontheGlutes5FunctionalAnatomyoftheGluteusMaximus6FunctionalAnatomyoftheGluteusMedius7MuscleEnergyTechniques8TheAntagonisticCause—theVitalIliopsoas,RectusFemoris,andAdductors9GmaxandGmedCausingKneeandAnklePain10GmaxandGmedCausingLumbarSpinePain11DifferentialDiagnosisofWeaknessInhibitionoftheGlutes12GmaxandGmedStabilizationExercises

Appendix:GmaxandGmedStabilizationExerciseSheetBibliographyIndex

Idedicatethisbooktomyfather,JohnAndrewGibbons,

whoIwishwasheretoseewhatIhaveachieved,

andtomymother,MargaretGibbons,

whomIlovedearly.

Preface

Thesuccessofmyfirstbook,MuscleEnergyTechniques:APracticalGuideforPhysical Therapists, inspired me to continue with the dream of writing, and IwantedtowritespecificallyaboutwhatIfeelisoneofthemostneglectedareasinphysical therapy—the“glutes.”The last chapterofmypreviousbook lookedatthefunctionsofthegluteusmaximus(Gmax)andthegluteusmedius(Gmed)andhowtheyaffectedthegaitpatternandsubsequentlycausedpainanddysfunctionelsewhereinthebody.Ialsobrieflydiscussedthefiringpatternsofthespecificmovements of hip extension and hip abduction.However, Iwould now like toelaborateuponthisfascinatingareaandhopefullyinthisbookIwilldojustthat.Ialsowantmyreaderstobeabletodemonstrate,andexplainamongtheirpatientsandcolleaguesindiscussiongroups,thatifaweaknessormisfiringoccurswithintheseparticularfiringsequences,adysfunctionalpatterncandevelopthroughthebody’snaturalcompensatorymechanisms.

InthisbookIwanttotakethereaderonajourney,justasIdidinmyfirstbook.ThefeedbackIhavereceived in response to thatbookhasbeenoverwhelming;peoplehavesaid that theway Ihaveexplained thingshasguided themon theirjourney through the topic. I consider my books (and also my teaching andarticles) tobeabit likejigsawpuzzles:whenyoufirstopen thebox/cover,youhave many pieces to try to fit together to form a picture. After reading onechapteryouwill storesomeinformation inyourbrain,but the“picture”willbesomewhatblurred.Asyoucontinuereadingsuccessivechapters,however,Itrulyhope a sharper picturewill begin to form.Once the book has been read fromcovertocover,youshouldhaveaclearpicture;itmightnotbecrystalclear,buthopefully will be adequate for you to utilize and adapt to your own clinicalsetting.

Iwillexpandonthetheoryofmuscleweaknessandmisfiringinordertodiscussanddemonstratehowandwhytheseissuescausepainanddysfunctioninsomanypatientsandathletes. Ihavealsoaddedcomplementary treatmentprotocols thatwillhelpaphysicaltherapistdealwiththecausesoftheweaknessandmisfiring,ratherthansimplytreatingthesymptoms.Onceallthishasbeenunderstoodand

thecauseshavebeendealtwith, I thenwant thephysical therapist tobeable tocompetentlyadvisetheathlete/patientonthebestformsofglutealcontrolbytheuseofspecificexercises.

Ihavenowreachedastagewhere,inalmosteachandeveryoneofthephysicaltherapycoursesIteach(eveninthecaseofthe“ShoulderJointMasterClass”),Iamconstantlybeingaskedabouttheglutesandhowtheycausepaininaspecificarea.Ialwaysdiscussverballyhowthisphenomenoncanhappenandthengoontodemonstratepracticallythecausesandeffects;however,Ihaveneverbeenableto say, “Read such-and-such a book and youwill find the answer.”My aim inwriting now is to meet the need for a book which does give such answers. Iwanted to produce a text that over time will helpmany thousands of physicaltherapists,whethertheyarestudentsinthisareaorhavebeenpracticingphysicaltherapists formany years. I believe that this book can serve as a core text foranyoneinthefieldofphysicaltherapywhowantsabetterunderstandingofhowmaximizing the glutes to achieve optimum functionality will help reduce apatient’spainanddysfunctioninalmosteverypartofthebody!

ManyyearsagoIwroteanarticlecalled“Puttingmaximusbackintothegluteus.”IhavewrittennumerousarticlesovertheyearsbutIconsiderthisparticularoneto be my most important: it has been read by lots of physical therapiststhroughouttheworld,andIhavehadmanycommentsandnumerousemailsfromtherapists(andpatientstoo)aboutthecontent.IenjoyedproducingthearticlesomuchsothatIdecidedtowriteabookonthesubjectoftheglutes,andhencethispracticalguideforphysicaltherapistsonmaximizingtheglutes.

Arevisedversionofthatarticleformsthefirstchapterofthisbook,andIwouldlike to think that reading itwill inspire you andwhet your appetite tokeeponreading. Hopefully you will continue on the journey with me through theremainderofthebook,whichwillgointogreatdepthastowhyglute-relatedpainanddysfunctioncanpresentitselfinyourathletesorpatients.

A three-week holiday in Turkeywas a good time forme to put pen to paper.MuchasI likethesun, it isnotagreat ideaformetospendallmytimeinthesunshine,asIhavehadsomeskincancerissuesinthepast(infactmyfatherdiedofskincancer);sothiswasagreatopportunitytodosomewriting.WhileIwassitting there onemorningwith a coffee, typing onmy laptop,my sonThomascameuptomeandaskedmewhatIwasdoing.HeknewthatIhadwrittenabook

the previous year, and I had mentioned to him that I was thinking of writinganotheronejustontheglutes,butIamnotsureifheunderstoodmeatthetime.IsaidIwasstartingtowritethebookthatIhadmentionedtohimawhileback,buttryingtoexplaintoa12-year-oldabouttheGmaxandGmedwasgoingtobeabitheavy,soItoldhimthatIwaswritingabookaboutthe“bum”muscles.Hesaid,“Dad,youarewritingawholebookjustaboutthebummuscles?”Ireplied“Yes,”towhichmysonthenresponded,“Butthebumisjustbigandabitsquidgy”!

Aswenowbeginour journey, Ihope to inspireyou tocontinuereadingall thechapters so that youwill gain a better understanding of the role of the glutes.Onceyouhavefinishedthebook,youwillthenrealizethatthereismoretothebumthanbeing“justbigandabitsquidgy.”

Acknowledgments

MythankstoJonHutchingsofLotusPublishingforallowingmetheopportunityto continue with my passion for writing—I hope that this book will be assuccessfulasmypreviousbookonmuscleenergytechniques.

IalsowanttothankthemodelsandJackMeeksfromOxfordUniversitySport,aswellas IanTaylor,whospent somuch time takingandediting thephotographsforthisbook.

Iwouldliketopersonallythanksomeonewhoguidedmethroughmyosteopathytraining—amusculoskeletalphysiotherapistbythenameofGordonBosworth.Iconsiderhimtobeoneofthebest,ifnotthebest,physicaltherapistsIhaveevermet.HewasandstillisaninspirationtomeinbecomingthepersonIamtoday.

Ihavetomentionmyson,ThomasRhysGibbons,ashemeanstheworldtome.Hewas12yearsoldatthetimeofwritingthisbookandwithouthimIwouldnothavehadthemotivationordedicationtoachievewhatIhaveaccomplishedinmylifesofar.IhavemanydreamsandaspirationsinmylifeandoneofthemistobeasuccessinanyavenueorgoalthatIpursue.ThatisoneofthereasonsIdowhatI do in my life, as I want to show my son that when you set your heart onachieving something that you might initially consider to be potentiallyunachievable,thenwithcontinuedperseveranceyouwillnoticethatthingsstarttochangeinyourlife,andyourdreameventuallybecomesareality.

Iwouldliketothinkthat,intimestocome,mysonwilllookbackatthebooksIhave written, and which have been personally dedicated to him, and feel thatsincehisdadhasaccomplishedsomethingsinhislifeeventhoughittookhimawhiletogetstarted,hewilleasilybeabletodothesame.Youjustneedagoalinyour life, and to add some passion to the equation, and then anything—and Imeananything—canbeachieved.Iamhopingthatmysuccessanddeterminationwillinspireandmotivatehimtodowellinhisownlife.

Thanks too tomysister,AmandaWilliams,andher family. I trulyhopeforallthesuccessthatyou,andyourgorgeouschildren,JamesandVictoria(whoIhave

seengrowingupovertheyearsandareaspiringtobeamazingteenagers),deserve—andlongmayitlast!

And,finally,abigthankyoutomyfiancée,DeniseThomas,whohasstuckwithmeovertheyearsandregularlyputsupwithmygrumpytantrumdays.Youhaveunfailinglyencouragedandguidedmeover the last fewyears,andalsoallowedme the freedom to pursuemy dreams.Without you this bookwould not havebeenpossible.

JohnGibbons

ListofAbbreviationsACJ acromioclavicularjointAHC anteriorhorncellAROM activerangeofmotionASIS anteriorsuperioriliacspineATFL anteriortalofibularligamentCFL calcaneofibularligamentCKC closedkineticchainCOG centerofgravityDDD degenerativediscdiseaseEMG electromyographyGTO GolgitendonorganILA inferiorlateralangleITB iliotibialbandITBFS iliotibialbandfrictionsyndromeLLD leglengthdiscrepancyMCL medialcollateralligamentMET muscleenergytechniqueMRI magneticresonanceimagingMVIC maximalvoluntaryisometriccontractionOA osteoarthritisOKC openkineticchainPD pelvicdropPFPS patellofemoralpainsyndromePHC posteriorhorncellPIR post-isometricrelaxationPLS posteriorlongitudinalslingPRE progressiveresistanceexercisePROM passiverangeofmotionPSIS posteriorsuperioriliacspine

PSIS posteriorsuperioriliacspineQL quadratuslumborumRI reciprocalinhibitionROM rangeofmotionSCJ sternoclavicularjointSCM sternocleidomastoidSIJ sacroiliacjointSTJ subtalarjointTFL tensorfasciaelataeTLF thoracolumbarfasciaTMJ temporomandibularjointTVA transversusabdominisVM vastusmedialisVMO vastusmedialisobliqueWP wallpressWS wallsquat

Physical therapists arewhat I calldetectives: they possess some clues (patient’shistory and symptoms), but they then have to take the patient through aneliminationprocess(viaaphysicalassessment)tohopefullyfindoutandidentifythe actual underlying causeof the symptoms.Thepurposeof this chapter is tobrieflyexplainaboutapatientwhopresentedwithpainintheleftshoulderarea,andtodemonstratethatthepossiblecauseoftheproblemcanoriginateinanareathatonemightnotconsiderinviewofthepatient’spresentingsymptoms.

ThischapterhopefullydemonstrateswhatDr.IdaRolfstates—“Whereyouthinkthepainis,theproblemisnot.”IwanttoillustratethisstatementfromDr.RolfwithacasestudytakenfrommyownphysicaltherapyclinicattheUniversityofOxford.As I becomemore experienced, not only in lecturing physical therapycoursesbutalsoasapracticingsportsosteopathinmyownclinic,Iamconvincedthatmany issueswhich patients and athletes presentwith are purely symptomsrather thanactualcauses.Thiswasoneof themaindrivingforces that inspiredmetowritethearticle“Puttingmaximusbackintothegluteus”(Gibbons2009),onwhichthischapterisbased,andthathasnaturallyledtothewritingofawholebookonthesubject.

ThecasestudybelowisjustasmallsnippetoftheinformationthatIprovideinthisbook.Theinformationcontainedwithin thestudyis takenfromarealcasestudypatientwhocametomyclinicforaconsultation.

CaseStudy

Thepatientinquestionwasawomanof34andaphysicaltrainerfortheRoyalAirForce.Shepresented to theclinicwithpainnear thesuperioraspectofherleftscapula(figure1.1).Thepainwouldcomeonfourmilesintoarun,forcingher to stop because it was so intense. The discomfort would then subside, butquickly return if she attempted to start running again. Running was the onlyactivitythatcausedthepain.Hercomplainthadbeenongoingforeightmonths,hadworsenedoverthepastthree,andwasstartingtoaffectherwork.Therewasnoprevioushistoryorrelatedtraumatotriggerthecomplaint.

Afterseeingdifferentpractitioners,whoallfocusedtheirtreatmentontheuppertrapezius, she visited an osteopathwho treated her cervical spine and rib area.Thetreatmentsshehadreceivedwerebiasedtowardtheapplicationofsofttissuetechniques to the affected area, namely the trapezius, levator scapulae,sternocleidomastoid (SCM), scalenes, and so on. The osteopath had also usedmanipulativetechniquesonthefacetjointsofhercervicalspine—C4/5andC5/6.Muscleenergytechniquesandtriggerpointreleaseswereusedinalocalizedarea,whichofferedreliefat the timebutmadenodifferencewhensheattempted torunmorethanfourmiles.Shehadnotundergoneanyscans(e.g.MRIorx-ray).

Figure1.1:Diagramofpainfularea—leftsuperiorscapula.

Assessment

Duringaconsultation(subjectivehistory)thephysicaltherapistwillaskspecificquestionsrelatingtothepatient’spresentingpainsothatapicturecanbeformedintheirmind.Thisisanormalprocessinorderforthephysicaltherapisttocomeup with a hypothesis; this type of initial diagnosis will then help the therapistdecideonwhat tissue(s)mightberesponsibleforcausingtheclient’spresentingpain/symptoms.For thepatient inquestion, thepotential tissues responsible forthepaintohersuperiorscapulaare:

•Uppertrapezius

•Levatorscapulae

•Scalenes

•Thoracicrib

•Cervicalrib(extraribformingfromthetransverseprocessofC7)

Once a subjective history has been conducted, the physical therapist thenproceeds toanobjectiveassessment: this iswhere the therapistusesspecializedtechniques to assess the musculoskeletal system to come up with a thoroughdiagnosis.Oneofthespecifictechniquesemployedbythetherapistcanbesimplerangeofmotion(ROM)teststhatareinitiallyperformedbythepatient;theseareknown as active range of motion (AROM) tests. This assessment is generallyfollowed by a series of passive range of motion (PROM) tests; these tests arenormally performed on the patient by the therapist, and are commonly used tochecktheintegrityoftheaffectedjoint.Resistedtestingcomesnext:thistypeofspecificmovementteststhepowerandinvolvementofthecontractiletissues,i.e.muscles and tendons. The physical therapist also uses palpatory awarenessthroughtheirfingertipstodecideontheconditionoftheaffectedtissues,andwillgenerallyincludespecialteststocomplementthediagnosis.

Thepotentialcausesofmypatient’spresentingpainare:

•ReferralpainfromcervicalfacetC4/5orC5/6

•Protectivespasm/strainofuppertrapeziusorlevatorscapulae

•Dysfunctionoftheglenohumeraljointoreventheacromioclavicularjoint(ACJ)orsternoclavicularjoint(SCJ)

•IntervertebraldiscbulgeofC4/5orC5/6

•Elevatedfirstrib

•Cervicalrib(extraribfromthetransverseprocessofC7)

•Relativeshortness/tightnessofthescalenes

•Positional—duetouppercrossedsyndromerelatedtoaforwardheadpostureandroundedshoulderscausedbytightpectoralsandSCM,andpossiblyweakrhomboidsandserratusanterior

•Upperlobeofleftlung,referringtothetrapezius

•Diaphragm—thisisinnervatedbythephrenicnerve,whichoriginatesfromthelevelofC3–5fromthecervicalspine;thedermatomefromC3–5can

causeareferredpatternofpainthatcanradiatetotheareaoftheshoulder(dermatomeisanareaofskinthatissuppliedfromasinglenerveroot)

Asyoucansee, therearemanypossiblecausesof thepatient’spresentingpain.This list is not exhaustive and highlights just some of the many avenues toconsider when confronted with a common complaint of “shoulder/trapeziuspain.”

TakingaHolisticApproach

Let’snowassessthecasestudypatientgloballyratherthanlocally,rememberingthatthepainonlycomesonafterrunningfourmiles.

WhenIseeanewpatientforthefirsttime,nomatterwhatthepresentingpainis,Inormallyassessthepelvisforpositionandmovement,asIconsiderthisareaofthebodyinparticulartobethe“foundation”foreverythingthatconnectstoit.Ioften find in clinic that when I correct a dysfunctional pelvis, my client’spresenting symptoms tend to settle down. However, when I assessed thisparticularpatient,Ifoundherpelviswaslevelandmovingcorrectly.Ithenwentontotestthefiringpatternsofthegluteusmaximus(referredtoastheGmaxforthe remainder of this book), which I often do with patients and athletes whoparticipate in regular sporting activities.However, I only test the firing patternsequenceonceIfeelthatthepelvisisinitscorrectposition;thelogichereisthatyouoftengetapositiveresultofthemusclemisfiringwhenthepelvisisslightlyoutofposition.

Withthepatientinquestion,Ifoundabilateralweakness/misfiringoftheGmax,but the firing on the right side seemed a bit slower. As I had not found anydysfunctioninthepelvis,Ipursuedthislineofapproachalittlefurther.

BeforewecontinueIwouldliketoposeafewquestionsforyoutothinkabout:

•HowdoesaweaknessoftheGmaxontherightsidecausepaininthelefttrapezius?

•IstherealinkbetweentheGmaxandthetrapezius,andifso,howisthispossible?

•Whatcanbedonetocorrecttheissue?

•Whatcanbedonetocorrecttheissue?

•Whathashappenedtocauseitinthefirstplace?

To answer these questions, we need to look at the functional anatomy of theGmax, and the relationship of the Gmax to other anatomical structures, asdetailedinlaterchapters.

GmaxFunctionTheGmaxoperatesmainlyasapowerfulhipextensorandalateralrotator,butitalso plays a part in stabilizing the sacroiliac joint (SIJ) by helping it to “forceclose”whilegoingthroughthegaitcycle.

Someof theGmaxmuscular fibersattach to thesacrotuberous ligament,whichrunsfromthesacrumtotheischialtuberosity(seefigure2.4).Thisligamenthasbeen termed the key ligament in helping to stabilize the SIJ. To gain a betterunderstanding of this action, we first need to consider two concepts—“formclosure”and“forceclosure”—whicharebothassociatedwithstabilityoftheSIJ(seefigure1.2).

Figure1.2:Formclosureandforceclosure.

Theshapeofthesacrum—alongwithitsridgesandgrooves,andthefactthatitiswedgedbetweentheilia—helpstobringnaturalstabilitytotheSIJ.Thisisknownasformclosure.Ifthearticularsurfacesofthesacrumandtheiliafittedtogetherwith perfect formclosure,mobilitywould be practically nonexistent.However,form closure of the SIJ is not perfect andmovement is possible,whichmeansstabilization during loading is required. This is achieved by increasingcompression across the joint at the moment of loading; the surrounding

ligaments, muscles, and fascia are responsible for this. The mechanism ofcompressionoftheSIJbytheseadditionalforcesiscalledforceclosure.

When the body isworking efficiently, the forces between the innominates andthe sacrumare adequately controlled, and loads canbe transferredbetween thetrunk,pelvis,andlegs.Sohowdowelinkthistothepatient’scomplaint?Inoneofmypreviousarticles(Gibbons2008),abouttrainingtheOxfordrowingteam,Iwrote about the posterior oblique “sling.”This structure directly links the rightGmax to the left latissimusdorsivia the thoracolumbarfascia (figure1.3).Thelatissimusdorsihasitsinsertionontheinnerpartofthehumerus,andoneofthefunctionsofthismuscleistokeepthescapulaagainstthethoraciccageandaidindepressionofthescapula.

Figure1.3:Posteriorobliquesling.

PiecingItAllTogether

So what do we know?We know that the right side of the patient’s Gmax isslightlyslowerintermsofitsfiringpatternandthatthismuscleplaysaroleintheforceclosureprocessof theSIJ.This tellsus that if theGmaxcannotperform

this functionof stabilizing theSIJ, then somethingelsewill assist in stabilizingthe joint. The left latissimus dorsi is the synergist that helps stabilize the rightGmax and, more importantly, the SIJ. As the patient participates in running,everytimeherrightlegcontactsthegroundandgoesthroughthegaitcycle,theleft latissimusdorsi is over-contracting.This causes the left scapula todepress,and the muscles that resist the downward depressive pull will be the uppertrapezius and the levator scapulae. Subsequently, thesemuscles start to fatigue;forthepatientinquestion,thisoccursatapproximatelyfourmiles,atwhichpointshefeelspaininherleftsuperiorscapula.

Treatment

Youmight think the easyway to treat theweakness in theGmax is to simplyprescribe strength-based exercises. However, in practice this is not always thecorrect solution, as sometimes the tighter antagonisticmuscle is responsible fortheapparentweakness.Themuscleinthiscaseistheiliopsoas(hipflexor),andshorteningofthiscanresultinaweaknessinhibitionoftheGmax.Myanswertothispuzzlewastostretchthepatient’srightiliopsoasmuscletoseeifitpromotedthe firing activation of theGmax,while at the same time introducing strengthexercisesfortheGmax.Allthiswillbeexplainedinmoredetailinchapter8andchapter12.

PrognosisandConclusion

I advised thepatient to abstain from running and togetherpartner to assist inlengthening the iliopsoas, rectus femoris, and adductors twice a day. Strengthexercises were also advised twice daily until the follow-on treatment (theseexercisesarediscussedinlaterchapters).Ireassessedher10dayslaterandfoundnormal firing of the Gmax on the hip extension firing pattern test, and areduction in the tightness of the associated iliopsoas, rectus femoris, andadductors. Because of these positive results, I advised her to run as far as feltcomfortable.Iwasnotsureifmytreatmentwasgoingtocorrecttheproblem,butshereportedthatshehadnopainduringorafterasix-milerun.ThepatientisstillpainfreeandcontinuestoregularlyusetheGmaxstrengtheningexercisesandthelengtheningtechniquesforthetightmuscles.

Thiscasestudydemonstratesthatveryoftentheunderlyingcauseofacondition

orproblemmaynotbelocaltowherethesymptoms/painpresents,whichmeansthatallavenuesneedtobefullyconsidered.Ihopethattheinformationfromthisstudyhasintriguedyouenoughtocontinuereading,astheinformationpresentedisjustatasterofwhatistocomeinthefollowingchapters.Remember,thisbookis what I call a jigsaw puzzle journey—if you stick with it, the picture willeventuallybecomealotclearer.

This chapter will covermuscle imbalance, which I feel is very relevant to thepotentialproblemsthatcancontributetodysfunctionalglutes.EventhoughIdonotrefertotheindividualmusclesoftheglutesveryoften,itisstillnecessarytounderstand the function of the various types ofmuscle and,more importantly,how theycan influence thepositionof thebody. Ifweexperiencepainwecansafely assume thatwemost likely have dysfunction somewhere in our body; ifthere is dysfunctionwe can say thatwe have an imbalance, and ifwe have animbalancethenIcanguaranteethatthegluteswillbeinvolvedsomewhereinthisdysfunctionalprocess.

People are commonly considered to be “creatures of habit”: we like to repeatthingsonaregularbasissothattheybecome“normal.”Let’s take,forexample,the iliopsoas muscle; I personally believe that this muscle is constantly in a“forcedshortened”positionformostofthetime,becauseaftergettingupinthemorningwenaturallysitdownatthekitchentabletohavebreakfast,getintoourcars,anddrivetowork.Onarrivalatworkmostofuswillsitatadeskformuchoftheday.Weevensitdownwhenwehavelunchorabreak.Attheendoftheworking daywe get back in the car and drive home, and then sit down for aneveningmeal,beforerelaxingandsittingeitherinanarmchairoronthesofatowatchTV.Whenwe eventuallymake it to bed,many of us find that the onlycomfortable sleeping position is on our side in a sort of fetal position, furtherexacerbatingtheproblem.Whenwewakeup,thewholeprocessisrepeated.

Iamsurethatbynowithasbecomeobvioustoyouthattheiliopsoasmuscleisnaturallybeingforcedintoashortenedpositionformostofthedayasaresultofour repetitive habits and lifestyles.Youwill read in later chapters that becausethismuscle is being held in this unnatural shortenedposition, itwill eventuallybecomeatightstructure.Atightnessoftheiliopsoascanthereforebeoneofthepieces in the “jigsaw puzzle” and can be a vital clue to a patient’s presentingsymptoms.Theiliopsoasmightbethe“key”tounlockingtheproblembecauseifleftinashortenedposition,thelengthofitsantagonistmuscle—inthiscasetheglutes—will potentially be altered. If thismuscle group is continually held in alengthenedposition for an extendedperiod of time then subsequentweakeningensues.

Posture

Definition:Postureistheattitudeorpositionofthebody(Thomas1997).

AccordingtoMartin(2002),postureshouldfulfillthreefunctions:

•Maintainingthealignmentofthebody’ssegmentsinanyposition:supine,prone,sitting,allfours,andstanding

•Anticipatingchangetoallowengagementinvoluntary,goal-directedmovements,suchasreachingandstepping

•Reactingtounexpectedperturbationsordisturbancesinbalance

Fromtheabove,itcanbeseenthatpostureisanactiveaswellasapurelystaticstateandthatitissynonymouswithbalance.Optimalposturemustbemaintainedatalltimes,notonlywhenholdingstaticpositions(e.g.sittingandstanding)butalsoduringmovement.

If optimal posture and postural control are to be encouraged during exerciseperformance, the principles of good static posture must be fully appreciated.Once these are understood, poor posture can be identified and correctivestrategiesadopted.

•Goodpostureisthestateofmuscularandskeletalbalancethatprotectsthesupportingstructuresofthebodyagainstinjuryorprogressivedeformity,irrespectiveoftheattitude(e.g.erect,lying,squatting,orstooping)inwhichthesestructuresareworkingorresting.

•Poorpostureisafaultyrelationshipofthevariouspartsofthebody,whichproducesincreasedstrainonthesupportingstructuresandinwhichthereislessefficientbalanceofthebodyoveritsbaseofsupport.

Theneuromuscularsystem,asweknow,ismadeupofslow-twitchandfast-twitchmuscle fibers, each having a different role in the body’s function. Slow-twitchfibers (Type I) are for sustained low-level activity, such asmaintaining correctposture,whereasfast-twitchfibers(TypeII)areforpowerful,grossmovements.

Musclescanalsobebrokendownintotwofurthercategories—tonic(orpostural)andphasic.

Tonic(Postural)andPhasicMuscles

Janda(1987)identifiedtwogroupsofmusclesonthebasisoftheirevolutionanddevelopment.Functionally,musclescanbeclassifiedastonicorphasic.Thetonicsystemconsists of the flexors,which develop later on to become the dominantstructure. Umphred (2001) identified that the tonic muscles are involved inrepetitiveorrhythmicactivityandareactivatedinflexorsynergies,whereasthephasic system consists of the extensors and emerges shortly after birth. Thephasicmusclesworkeccentricallyagainsttheforceofgravityandareinvolvedinextensor synergies. The division of muscles into predominantly phasic andpredominantlyposturalisgivenintable2.1,overleaf.

Predominantlyposturalmuscles Predominantlyphasicmuscles

ShouldergirdlePectoralismajor/minor RhomboidsLevatorscapulae LowertrapeziusUppertrapezius MidtrapeziusBicepsbrachii SeratusanteriorNeckextensors:ScalenesCervicalerectorsSternocleidomastoid

TricepsbrachiiNeckflexors:Supra-andinfrahyoid/Longuscolli

LowerarmWristflexors WristextensorsTrunkLumbarandcervicalerectors ThoracicerectorsQuadratuslumborum AbdominalsPelvisBicepsfemoris/Semitendinosus/SemimembranosusIliopsoasITBRectusfemoris

VastusmedialisVastuslateralisGluteusmaximusGluteusminimusandmedius

RectusfemorisAdductorsPiriformis/TensorfasciaelataeLowerlegGastrocnemius/Soleus Tibialisanterior/Peroneals

Table2.1:Phasicandposturalmusclesofthebody.

Previous authors have suggested thatmuscleswhichhave a stabilizing function(postural) have a natural tendency to shorten when stressed, and that othermuscles which play a more active/moving role (phasic) have a tendency tolengthen and can subsequently become inhibited (see table 2.2). The muscleswhichtendtoshortenhaveaprimaryposturalroleandarerelatedtothepotentialinhibitionweaknessoftheglutes,whichyouwillreadaboutlater.

Therearesomeexceptionstotherulewhichstatesthatcertainmusclesfollowthepatternofbecoming shortenedwhileothersbecome lengthened—somemusclesarecapableofmodifyingtheirstructure.Forexample,someauthorssuggestthatthescalenesareposturalinnature,whileotherssuggestthattheyarephasic.Weknowfromspecifictesting,dependingonwhatdysfunctionispresentwithinthemuscle framework, that the scalenes can be found to be held in a shortenedposition and tight, but at other times they can be found to be lengthened andweakened.

There is a distinction between postural and phasic muscles; however, manymusclescandisplaycharacteristicsofbothandcontainamixtureofTypeIandType II fibers.Thehamstringmuscles, for example, have a postural stabilizingfunction, yet are polyarticular (cross more than one joint) and are notoriouslypronetoshortening.

Postural PhasicFunction Posture MovementMuscletype TypeI TypeIIFatigue Late EarlyReaction Shortening Lengthening

Table2.2:Lengtheningandshorteningofmuscles.

PosturalMuscles

Alsoknownas tonicmuscles, theposturalmuscles have an antigravity role andarethereforeheavilyinvolvedinthemaintenanceofposture.Slow-twitchfibersaremoresuitedtomaintainingposture:theyarecapableofsustainedcontractionbutgenerallybecomeshortenedandsubsequentlytight.

Posturalmusclesareslow-twitchdominantbecauseoftheirresistancetofatigue,and are innervated by a smaller motor neuron. They therefore have a lowerexcitability threshold, which means the nerve impulse will reach the posturalmusclebeforethephasicmuscle.Withthissequenceofinnervation,theposturalmusclewill inhibit the phasic (antagonist)muscle, thus reducing its contractilepotentialandactivation.

Figure2.1:Posturalandphasicmuscles:(a)Anteriorview;(b)Posteriorview.Thebluemusclesare

predominantlypostural,andtheredmusclespredominantlyphasic.

PhasicMuscles

Movementisthemainfunctionofphasicmuscles.Thesemusclesareoftenmore

superficialthanposturalmusclesandtendtobepolyarticular.TheyarecomposedofpredominantlyTypeIIfibersandareundervoluntaryreflexcontrol.

A shortened, tight muscle often results in inhibition of the associated phasicmuscle,whosefunctionbecomesweakenedasaresult.Therelationshipbetweena tightness-pronemuscle and an associatedweakness-pronemuscle is oneway.As the tightness-prone muscle becomes tighter and subsequently stronger, thiscauses an inhibition of theweakness-pronemuscle, resulting in its lengtheningand consequent weakening: think about the previously mentioned relationshipbetweentheiliopsoasandtheglutes.

MuscleActivityBeforeandAfterStretchingLet’s look at some electromyography (EMG) studies of trunk muscle activitybeforeandafterstretchinghypertonicmuscles,inthiscasetheerectorspinae.Intable2.3thehypertonicerectorspinaeareindicatedasbeingactiveduringtrunkflexion. After stretching, these muscles are suppressed both in trunk flexion(whichallowsgreateractivationoftherectusabdominis)andintrunkextension.

Table2.3:EMGrecordingsofmuscleactivity.(Source:Hammer1999)

EffectsofMuscleImbalance

TheresearchresultsofJanda(1983)indicatethattightoroveractivemusclesnotonly hinder the agonist through Sherrington’s law of reciprocal inhibition(Sherrington 1907), but also become active in movements that they are notnormally associated with. This is the reason why, when trying to correct amusculoskeletal imbalance, you would encourage lengthening of an overactivemuscle by using a muscle energy technique (MET), prior to attempting tostrengthenaweakelongatedmuscle.

If muscle imbalances are not addressed, the body will be forced into acompensatoryposition,whichincreasesthestressplacedonthemusculoskeletalsystem, eventually leading to tissue breakdown, irritation, and injury. You arenow in a vicious circle of musculoskeletal deterioration as the tonic musclesshortenandthephasicmuscleslengthen(table2.4,overleaf).

Table2.4:Theviciouscircleofmusculoskeletaldeterioration.

Muscle imbalances are ultimately reflected in posture. As mentioned earlier,posturalmusclesareinnervatedbyasmallermotorneuronandthereforehavealowerexcitabilitythreshold.Sincethenerveimpulsereachestheposturalmusclebeforethephasicmuscle,theposturalmusclewillinhibitthephasic(antagonist)muscle,thusreducingthecontractilepotentialandactivation.

Whenmuscles are subject to faulty or repetitive loading, the posturalmusclesshorten and the phasic muscles weaken, thus altering their length–tensionrelationship.Consequently, posture is directly affectedbecause the surroundingmusclesdisplacethesofttissuesandtheskeleton.

CoreMuscleRelationships

Astheincidenceoflowerbackpainseemstobeontheincrease,wewillneedtolook at and understand the muscular relationships that affect core andlumbopelvicstabilityandhowMETscanbeincorporatedintotheassessmentandtreatmentplan.

Thepelvis,orSIJtobemoreprecise,hastwomainfactorsthataffectitsstability:

•Formclosure•Forceclosure

FormClosure

Formclosurearisesfromtheanatomicalalignmentofthebonesoftheinnominateandthesacrum,wherethesacrumformsakindofkeystonebetweenthewingsofthepelvis.TheSIJtransferslargeloadsanditsshapeisadaptedtothistask.Thearticularsurfacesarerelativelyflatandthishelpstotransfercompressionforcesand bendingmovements.However, a relatively flat joint is vulnerable to shearforces.TheSIJisprotectedfromtheseforcesinthreeways.First,thesacrumiswedge shaped and thus is stabilized by the innominates. Second, in contrast toother synovial joints, the articular cartilage is not smooth but rather irregular.Third, a frontal dissection through the SIJ reveals cartilage-covered boneextensionsprotrudingintothejoint—theso-called“ridges”and“grooves.”Theyseem irregular, but are in fact complementary, and this serves to stabilize thejointwhencompressionisapplied.

ForceClosure

If the articular surfacesof the sacrumand the innominates fitted togetherwithperfect form closure,mobilitywould be practically impossible.However, formclosure of the SIJ is not perfect and mobility is possible, albeit small, andthereforestabilizationduring loadingisrequired.This isachievedby increasingcompressionacrossthejointatthemomentofloading;theanatomicalstructuresresponsible for this compression are the ligaments, muscles, and fasciae. Themechanismofcompressionof theSIJby theseadditional forces is calledforce

closure. When the SIJ is compressed, friction of the joint increases andconsequentlyreinforcesformclosure.

SacroiliacStability

Severalligaments,muscles,andfascialsystemscontributetoforceclosureofthepelvis: collectively these have been called theosteoarticular-ligamentous system.Recall thatwhen the body isworking efficiently, the shear forces between theinnominates and the sacrum are adequately controlled and loads can betransferredbetweenthetrunk,pelvis,andlegs.

Asyouwillreadlateron,theGmaxplaysahighlysignificantroleinstabilizingthe sacroiliac joints, as some of the Gmax fibers merge and attach onto thesacrotuberousligamentaswellasontoaconnectivetissuestructureknownasthethoracolumbar fascia (TLF). The Gmax connects, via the TLF, to thecontralateral latissimus dorsi to form what is known as the posterior obliquemyofascial sling (see section “TheOuterCoreUnit: The IntegratedMyofascialSlingSystem”below).Weakness,orpossiblyamisfiringsequence,oftheGmaxwill predispose the sacroiliac joint to injury by decreasing the function of this(posterioroblique)myofascial sling.Aweaknessormisfiringof theGmax is apotential cause of a compensatory overactivation of the contralateral latissimusdorsi;walkingandrunning(gaitcycle)imposehighloadsonthesacroiliacjoint,so this weight-bearing joint will need to be stabilized because of the alteredcompensatorymechanism.

Figure2.2:Therelationshipbetweenform/forceclosureandsacroiliacstability.

Inwhichposition is thepelvicgirdle themost stable?Researchhas shown that

sacral nutation (a nodding type of movement of the sacrum between theinnominates) occurs when moving, for example, from a sitting position tostanding,andthatfullnutationoccursduringforwardorbackwardbendingofthetrunk.Thismotionofsacralnutationtightensthemajorligaments(sacrotuberous,sacrospinous,andinterosseous)oftheposteriorpelvis,andthistensionincreasesthecompressiveforceacrosstheSIJ.Theincreasedtensionprovidestherequiredstability that is neededby theSIJ during the gait cycle aswell aswhen simplyrisingfromasittingpositiontostanding.

SacralNutationandCounternutation

Osar (2012)mentions thatnutation is the anterior inferiormotionof the sacralbase, while counternutation is the posterior superiormotion of the sacral base.Nutation is necessary for the locking of the SIJ during unilateral stance. TheinabilitytonutatethesacrumisaleadingcauseofunilateralstanceinstabilityandoneofthecausesoftheclassicTrendelenburggait.Counternutation,ontheotherhand, is necessary in order to unlock the SIJ to allow anterior rotation of theinnominateandextensionofthehipjoint.Inabilitytounlockorcounternutatethesacrum leads to compensatory increases in lumbopelvic flexion, which in turnleadstoandperpetuateslumbarinstability.

Figure2.3:(a)Posteriorpelvicrotationandsacralnutation;(b)Anteriorpelvicrotationandsacral

counternutation.

ForceClosureLigaments

The main ligamentous structures that influence force closure are thesacrotuberousligament,whichconnectsthesacrumtotheischium(andhasbeentermedthekeyligament),andthelongdorsalsacroiliacligament,whichconnects

the thirdand fourth sacral segments to theposterior superior iliac spine (PSIS)(andalsoknownastheposteriorsacroiliacligament).

Figure2.4:Forceclosureligaments.

Ligamentscanincreasearticularcompressionwhentheyaretensedorlengthenedbythemovementofthebonestowhichtheyattach,orwhentheyaretensedbycontraction ofmuscles that insert into the bones. Tension in the sacrotuberousligamentcanbeincreasedbyposteriorrotationoftheinnominatebonerelativetothe sacrum, by nutation of the sacrum relative to the innominates, or bycontraction of the four muscles—biceps femoris, piriformis, Gmax, andmultifidus—thatattachtoit.

The main ligamentous restraint to counternutation of the sacrum, or anteriorrotationoftheinnominate,isthelongdorsalsacroiliacligamentortheposteriorsacroiliac ligament.This isa lessstableposition(comparedwiththepositionofnutation)forthepelvistoresisthorizontaland/orverticalloading,sincetheSIJisunder less compression and is not self-locked. The long dorsal ligament iscommonlyasourceofpainandmaybepalpatedjustbelowthelevelofthePSIS.

By themselves, ligaments cannotmaintain a stable pelvis—they rely on severalmuscle systems to assist them.There are two important groupsofmuscles thatcontribute tostabilityof the lowerbackandpelvis.Collectively theyhavebeencalledtheinnerunit(core)andtheouterunit(myofascialslingsystems).Theinnerunitconsistsofthetransversusabdominis,multifidus,diaphragm,andmusclesofthe pelvic floor—also collectively known as the core, or local stabilizers. Theouter unit consists of several “slings,” or systems ofmuscles (global stabilizersandmobilisersthatareanatomicallyconnectedandfunctionallyrelated).

ForceCouple

Definition: A force couple is a situation where two forces of equalmagnitude, but acting in opposite directions, are applied to an object andpurerotationresults(Abernethyetal.2004).

Anyalteredpositioningofthepelviscausedbypotentialmuscleimbalanceswillsubsequentlyaffecttherestofthekineticchain.Thereareseveralforcecouplesresponsible formaintainingproperpositioningandalignmentof thepelvis.Theforce couples responsible for controlling the sagittal and frontal planes for theposition of the pelvis are shown schematically in figures 2.5 (a–f) and 2.6respectively.

Figure2.5:(a)Sagittalplane(anterior)pelvicforcecouple.(b)Anteriortilt:musclesheldinashortened

position.(c)Anteriortilt:musclesheldinalengthenedposition.

Figure2.5:(d)Sagittalplane(posterior)pelvicforcecouple.(e)Posteriortilt:musclesheldinashortened

position.(f)Posteriortilt:musclesheldinalengthenedposition.

Figure2.6:Frontalplane(lateral)pelvicforcecouples.

TheInnerUnit:TheCore

Definition:Staticstabilityistheabilitytoremaininonepositionforalongtimewithoutlosinggoodstructuralalignment(Chek1999).

Staticstabilityisalsooftenreferredtoasposturalstability,althoughthismightbesomewhatmisleading,sinceasMartin(2002)states:“…postureismorethanjustmaintainingapositionofthebodysuchasstanding.Postureisactive,whetheritisinsustaininganexistingpostureormovingfromoneposturetoanother.”

Theinnerunit(figure2.7)consistsof:

•Transversusabdominis•Multifidus•Diaphragm•Musclesofthepelvicfloor

Figure2.7:Theinnerunit—thecore.

Only the transversus abdominis andmultifiduswill be covered in this book, asthesemusclesare specifically related toposturalandphasic imbalancesandare

easilypalpatedbythephysicaltherapist.Sincethediaphragmandmusclesofthepelvicflooraredifficulttopalpate,theywillnotbediscussedhere.

TransversusAbdominis

The transversus abdominis (TVA) is the deepest of the abdominal muscles. Itoriginates at the iliac crest, inguinal ligament, lumbar fascia, and associatedcartilageof the inferiorsixribs,andattaches to thexiphoidprocess, lineaalba,andpubis.

Themainactionof theTVAis tocompress theabdomenviaa“drawing-in”ofthe abdominal wall. This drawing-in is observable as a movement of theumbilicus(bellybutton)towardthespine.Themuscleneitherflexesnorextendsthespine.Kendalletal.(2010)alsostatethat“thismusclehasnoactioninlateralflexionexceptthatitactsto…stabilizethelineaalba,therebypermittingbetteractionbyanterolateraltrunkmuscles[internalandexternalobliques].”

TheTVAappearstobethekeymuscleoftheinnerunit.Richardsonetal.(1999)found that inpeoplewithoutbackpain, theTVAfired30millisecondsprior toshoulder movements and 110 milliseconds before leg movements. Thiscorroborates the key role of the TVA in providing the stability necessary toperformmovementsof theappendicularskeleton.As theTVAcontractsduringinspiration it pulls the central tendon inferiorly and flattens, thereby increasingtheverticallengthofthethoraciccavityandcompressingthelumbarmultifidus.

Multifidus

The multifidus is the most medial of the lumbar back muscles, and its fibersconverge near the lumbar spinous processes to an attachment known as themammillary process. The fibers radiate inferiorly, passing to the transverseprocessesofthevertebraethatlietwo,three,four,andfivelevelsbelow.Thosefibersthatextendbelowthelevelofthelastlumbarvertebra(L5)anchortotheilium and the sacrum. The multifidus is considered to be a series of smallermuscles,whicharefurtherdividedintosuperficialanddeepcomponents.

The role of the multifidus in producing an extension force is essential to thestabilityof the lumbar spine,aswellas functioning to resist forwardflexionof

the lumbar spine and the shear forces that are placed upon it. The multifidusmuscle also functions to take pressure off the intervertebral discs, so that thebody weight is evenly distributed throughout the whole vertebral column. Thesuperficial muscle component acts to keep the vertebral column relativelystraight,whilethefibersofthedeepmusclecomponentcontributetotheoverallstabilityofthespine.

Richardsonetal.(1999)identifiedthelumbarmultifidusandtheTVAasthekeystabilizers of the lumbar spine. Both muscles link in with the thoracolumbarfasciatoprovidewhatRichardsonetal.refertoas“anatural,deepmusclecorsettoprotectthebackfrominjury.”

HydraulicAmplifier

Described byEvanOsar (2012), the hydraulic amplifier effect occurswith thecontraction ofmuscles within their fascial envelopes. Allmuscles are investedinsidefasciaandas theycontract,pushout into thefascia,creatingastiffeningaround the joint. In the spine, contraction of the lumbar erector spinae andmultifiduswithin the thoracolumbar fascia creates an extension force, assistingextension of the spine.When the lumbosacralmultifidus contracts, it broadensposteriorlyintothelumbodorsalfascia.

Figure2.8:Asthemultifidiicontract,itpushesintothethoracolumbarfasciaandalongwithcontractionofthe

transversusabdominis,providesintersegmentalstability.

Figure2.9:a)Therelaxedmultifidimuscleintransversesection;b)Co-contractionofthetransversus

abdominisandmultifidicreatesastiffeningtensiononthethoracolumbarfasciatherebyproviding

intersegmentalstability.

Thiseffectisaidedbycontractionofthetransversusabdominis,whichpullsthethoracolumbar fascia tight around the contracting erector spinae andmultifidi,therebycreatingastablecolumn.

Figure2.10:a)Asthetransversusabdominiscontracts,ittensesthethoracolumbarfascia,whichallowsthe

multifidiandlumbarerectorspinaetocontractagainstitandaidspinalelongationandstiffness;b)Contraction

ofthepyramidalistensesthelineaalba(centraltendon),creatingastablebaseforcontractionofthe

transversusabdominis.

TheOuterCoreUnit:TheIntegratedMyofascialSlingSystem

Theforceclosuremusclesoftheoutercoreunitconsistoffourmyofascialslingsystems,knownastheposteriorlongitudinal,lateral,anterioroblique,andposterioroblique systems (figures 2.11–2.14). These myofascial slings provide forceclosureandsubsequentstabilityforthepelvicgirdle;failureorevenweaknessofany of these slings to secure pelvic stability can lead to lumbopelvic pain anddysfunctions. Although the muscles of the outer core unit can be trainedindividually, effective force closure requires specific co-activation and releaseforoptimalfunction.

Figure2.11:Posteriorlongitudinalsystem.

Figure2.12:Lateralsystem.

Theintegratedmyofascialslingsystemrepresentsmanyforcesandiscomposedof several muscles. Amusclemay participate inmore than one sling, and theslingsmay overlap and interconnect, depending on the task in hand. There are

severalslingsofmyofascialsystemsintheouterunit,including(butprobablynotlimitedto)acoronalsling(havingmedialandlateralcomponents),asagittalsling(having anterior and posterior components), and an oblique spiral sling. Thehypothesis is that the slings have no beginning or end, but rather connect asnecessarytoassistinthetransferenceofforces.Itispossiblethattheslingsareallpartofoneinterconnectedmyofascialsystem,andaslingthatisidentifiedduringanyparticularmotioncouldmerelybearesultoftheactivationofselectivepartsofthewholesling(Lee2004).

Figure2.13:Anteriorobliquesystem.

Figure2.14:Posteriorobliquesystem.

The identification and treatment of a specific muscle dysfunction (such asweakness, inappropriate recruitment, or tightness) is important when restoringforceclosure(secondcomponentofstability)andforunderstandingwhypartsofa sling may be restricted in motion or lacking in support. Note the followingpoints:

•Thefoursystemsoftheouterunitaredependentupontheinnerunitforthejointstiffnessandstabilitynecessaryforcreatinganeffectiveforcegenerationplatform.

•Failureoftheinnerunittoworkinthepresenceofouterunitdemandoftenresultsinmuscleimbalance,jointinjury,andpoorperformance.

•Theouterunitcannotbeeffectivelyconditionedbytheuseofmodernresistancemachines,asthespecifictrainingprovidedbythesetypesofmachinegenerallydoesnotrelatetoday-to-dayfunctionalmovements.

•Effectiveconditioningoftheouterunitshouldincludeexercisesthatrequireintegratedfunctionoftheinnerandouterunits,usingmovementpatternscommontoanygivenclient’sworkorsportenvironment(Chek1999).

PoorPosture

Poorposturemaybearesultofmanydifferentfactors.Itmaybeduetotraumasufferedbythebody,someformofdeformitywithinthemusculoskeletalsystem,or even faulty loading. Because sitting has become a position that our bodiesmaintain for long periods of time (possibly 8+ hours), most people in today’ssociety are losing the fight against gravity and altering their center of gravity(COG).Withcorrectposture,theposturalmusclesarefairlyinactiveandenergyefficient, only responding to disruptions in balance to maintain an uprightposition. Therefore, as onemoves away from ideal alignment, posturalmuscletoneincreases,thusleadingtohigherenergyexpenditure.

SagittalPosturalDeviations

Postural deviations can be observed from the sagittal plane, as seen in figures2.15–2.17.The texthighlightswhichparticularmusclesareprone to shorteningandbecomingtight,andthosethatarepronetolengtheningandbecomingweak.

Figure2.15:Flat-backposture.

Figure2.16:Kyphotic/lordoticposture.

Figure2.17:Sway-backposture.

PainSpasmCycle

Ischemiawill be a primary source of pain in the initial stages of poor posture.The blood flow through a muscle is inversely proportional to the level ofcontraction or activity, reaching almost zero at 50–60% of contraction. Somestudies have indicated that the body could not maintain homeostasis with asustainedisometriccontractionofover10%.

Theweightoftheheadisapproximately7%oftotalbodyweight(shouldersandarmsarearound14%).Thismeansthatforapersonweighing176lb.(80kg),theheadwillweigharound11to13lb.(5to6kg).Iftheheadandshouldersmoveforward,outofidealalignment,theactivationoftheneckextensorswillincreasedramatically, resulting in restricted blood flow. This prolonged isometriccontractionwillforcethemusclesintoanaerobicmetabolismandincreaselacticacidandotherirritatingmetaboliteaccumulation.Ifadequaterestisnotgiven,areflexcontractionofthealreadyischemicmusclesmaybeinitiated.Thispersonwillhavenowenteredthepainspasmcycle(figure2.18).

Figure2.18:Painspasmmodel.

We take walking for granted—it is something that we just do withoutunderstandingwhatexactly isgoingon—untilwesufferpainsomewhere inourbody,andthenthesimpleactionofwalkingbecomesverypainful.WhatIwouldlike to do in this chapter is to discuss in detailwhat exactly happenswhenwewalk (you might want to go through the movements yourself as they aredescribed).

GaitCycle

Definition: A gait cycle is a sequence of events in walking or running,beginning when one foot contacts the ground and ending when the samefootcontactsthegroundagain.

The gait cycle is divided into twomain phases: the stance phase and the swingphase. Each cycle begins at initial contact (also known as heel-strike) of theleading legwithastancephase,proceeds throughaswingphase,andendswiththenextcontactofthegroundwiththatsameleg.Thestancephaseissubdividedintoheel-strike,mid-stance,andpropulsionphases.

Humangaitisaverycomplicated,coordinatedseriesofmovements.Anotherwayof thinking about the gait cycle is that the stance phase is the weight-bearingcomponentofeachgaitcycle.Itisinitiatedbyheel-strikeandendswithtoe-offfromthesamefoot.Theswingphaseisinitiatedwithtoe-offandendswithheel-strike. It has been estimated that the stance phase accounts for approximately60%ofasinglegaitcycle,andtheswingphaseforapproximately40%.

Figure3.1:Stanceandswingphasesofthegaitcycle.

Heel-Strike

Ifyouthinkaboutthepositionofyourbodyjustbeforeyoucontactthegroundwithyourrightlegduringthecontactphaseofthestancephase,therighthipisinapositionofflexion,thekneeisextended,theankleisdorsiflexed,andthefootis in apositionof supination.The tibialis anteriormuscle,with thehelpof thetibialisposterior,workstomaintaintheankle/footinthepositionofdorsiflexionandinversion(inversionispartofthemotionreferredtoassupination).

Figure3.2:Thepositionofthelegjustbeforeheel-strike.

Innormalgaitthefootstrikesthegroundatthebeginningoftheheel-strikeinasupinated position of approximately 2 degrees. A normal foot will then movethrough 5–6 degrees of pronation at the subtalar joint (STJ) to a position ofapproximately3–4degreesofpronation,asthiswillallowthefoottofunctionasa“mobileadaptor.”

AMyofascialLink

As a result of the foot being dorsiflexed and supinated, the tibialis anterior(which is themainmuscle responsible for this anatomical position and has aninsertiononthemedialcuneiformand1stmetatarsal)isnowpartofalinksystemthatwewillcallamyofascialsling.Thissling,startingfromtheinitialoriginofthetibialisanterior,continuesastheinsertionoftheperoneuslongus(ontothe1stmetatarsal and medial cuneiform, as in the case of the tibialis anterior) to itsmuscularoriginonthelateralsideandheadofthefibula.Thisbonylandmarkisalso where the biceps femoris muscle inserts. The sling now continues as thebiceps femoris muscle toward its origin on the ischial tuberosity, where themuscleattachestothetuberosityviathesacrotuberousligament;oftenthebicepsfemorisdirectlyattachestothisligamentratherthantotheischialtuberosity,andsomeauthorshavementionedthatpotentially30%ofthebicepsfemorisattachesdirectlytotheinferiorlateralangle(ILA)ofthesacrum.Theslingthencarriesonasthesacrotuberousligament,whichattachestotheinferioraspectofthesacrumattheILAandfasciallyconnectstothecontralateralmultifidiandtotheerectorspinae that continue to the base of the occipital bone. Thismyofascial sling isknownastheposteriorlongitudinalsling(PLS).

Figure3.3:Apersonwalking,withtheposteriorlongitudinalmuscleshighlighted.

Soevenbeforeyoucontact theground, theposterior longitudinal sling isbeingfascially tensioned; the increased tension is focused on the sacrotuberousligamentviatheattachmentofthebicepsfemoris.ThisconnectionwillassisttheforceclosuremechanismprocessoftheSIJ;insimpleterms,thiscreatesastablepelvisfortheinitiationoftheweight-bearinggaitcycle.Youmayalsonoticethatthe right ilium (see figure 3.4) undergoes posterior rotation during the swingphaseandthiswillassisttheclosureoftheSIJbecauseoftheincreasedtensionofthesacrotuberousligament.

Figure3.4:Rightiliuminposteriorrotation—sacrotuberousligamenttensioned.

Youmightwanttostandandslowlygothroughthefollowingmovementssothatyou can get a sense of what happens with your body in normal walking. Asexplainedabove, justbefore theheel-strikephaseyourhipwillbe flexed,yourknee extended, andyour ankledorsiflexedwith the foot supinated.The tibialisanteriorandtibialisposteriormaintainthispositionoftheankleandfoot,andasyoucontacttheground,thesetwomusclesareresponsibleforcontrollingtherateofpronationthroughtheSTJbycontractingeccentrically.

Asyourrightlegmovesfromheel-striketotoe-off,yourbodyweightbeginstomoveoveryourrightleg,causingyourpelvistoshiftlaterallytotheright.Asthemovementcontinuestowardtoe-off,yourrightpelvicinnominatebonebeginstorotateanteriorlywhileyourleftinnominatebonebeginstorotateposteriorly.

Asyoucontinuewiththegaitcycle,younowenterthemid-stancephaseofgaitand this is where the hamstrings should reduce their tension by the natural

anteriorrotationof thepelvisand theslackeningof thesacrotuberous ligament.This is the point during themid-stance phasewhere theGmax should take theroleofextension.

Phasic contraction of the Gmax occurs in the mid-stance phase: the Gmaxsimultaneouslycontractswiththecontralaterallatissimusdorsi—itisthismusclethat will extend the arm throughwhat is known as counterrotation, to assist inpropulsion. The thoracolumbar fascia, which is a sheet of connective tissue, islocatedbetweentheGmaxandthecontralaterallatissimusdorsi,andthisfascialstructureisforcedtoincreaseitstensionbecauseofthecontractionsoftheGmaxandlatissimusdorsi.ThisincreasedtensionwillassistinstabilizingtheSIJofthestancelegthroughforceclosure.

If you look at figure 3.5 overleaf, you can see that just before heel-strike, theGmaxwill reachmaximumstretch as the latissimusdorsi is being stretchedbythe forward swing of the opposite arm.Heel-strike signifies a transition to thepropulsivephaseofgait,atwhichtimetheGmaxcontractionissuperimposedonthatofthehamstrings.

Activation of the Gmax occurs in conjunction with contraction of thecontralaterallatissimusdorsi,whichisnowextendingthearminunisonwiththepropelling leg. The synergistic contraction of the Gmax and latissimus dorsicreatestensioninthethoracolumbarfascia,whichwillbereleasedinasurgeofenergy that will assist the muscles of locomotion, reducing the overall energyexpenditure of the gait cycle. Janda (1992, 1996) mentions that poor Gmaxstrengthandactivationispostulatedtodecreasetheefficiencyofgait.

Figure3.5:Apersonrunning,withtheposteriorobliquemuscleshighlighted.

Asweprogress from themid-stancephase to heel-lift andpropulsion, the footbegins to re-supinateandpasses throughaneutralpositionwhen thepropulsivephasebegins;thefootcontinuesinsupinationthroughtoe-off.Asaresultofthefoot supinating during the mid-stance propulsive period, the foot is convertedfroma“mobileadaptor”(whichiswhatitisduringthecontactperiod)toa“rigidlever” as the mid-tarsal joint locks into a supinated position. With the footfunctioningasarigidlever(asaresultofthelockedmid-tarsaljoint)duringthetime immediately preceding toe-off, the weight of the body is propelledmoreefficiently.

PelvisMotion

Nextwewilltakealookatthepelvisandhowitfunctionsduringthemid-stancephase. As the right innominate bone starts to rotate anteriorly from an initialposteriorrotatedposition,thesacrumwillbeforcedtomoveintowhatiscalledarighttorsionontherightobliqueaxis(RonR).Inotherwords,thesacrumrotatestotheright,andsidebendstotheleft,becausetheleftsacralbasemovesintoananteriornutationposition (this is alsoknownasType I spinalmechanics, as therotationandside-bendingarecoupledtooppositesides)asshownisfigure3.6a.Owing to the kinematics of the sacrum, the lumbar spine rotates left and sidebendstotherightasshownisfigure3.6b,thethoracicspinerotatesrightandsidebendstotheleft,andthecervicalspinerotatesrightandsidebendstotheright.The cervical spine coupling is opposite to that of the other vertebrae since itsspinalmechanicsareType II (Type IImeans that rotationandside-bendingarecoupledtothesameside).Astheleftlegmovesfromweightbearingtotoe-off,the left innominate, thesacrum,and the lumbarand thoracicvertebraeundergotorsion, rotation, and side-bending in a similarmanner to that described above,butwithmovementsintheoppositedirections.

Figure3.6:Sacralrotationandlumbarcounterrotation.

The anterior oblique also works in conjunction with the stance leg adductors,ipsilateral internaloblique,andcontralateralexternalobliquemuscles,as shown

infigure3.7.Theseintegratedmusclecontractionshelpstabilizethebodyontopofthestancelegandassistinrotatingthepelvisforwardforoptimumpropulsioninpreparationfortheensuingheel-strike.

Figure3.7:Apersonrunning,withanteriorslingmuscleshighlighted.

Theswingphaseofgaitutilizesthelateralsystem,aswehaveenteredthesingle-leg stance position.This sling connects the gluteusmedius (Gmed) and gluteusminimus (Gmin) of the stance leg, and the ipsilateral adductors, with thecontralateral quadratus lumborum (QL). Contraction of the left Gmed andadductorsstabilizesthepelvis,andactivationofthecontralateralQLwillassistinelevationofthepelvis;thiswillallowenoughliftofthepelvistopermitthelegtogo through the swing phase of gait. The lateral sling plays a critical role, as itassistsinstabilizingthespineandhipjointsinthefrontalplaneandisanecessarycontributortotheoverallstabilityofthepelvisandtrunk.

Figure3.8:Astep-upindicatesanexampleoftheswingphaseofgait,withlateralslingmuscleshighlighted.

Maitland (2001) mentions that proper body movement while walking isinfluenced by the ability of the sacrum to cope with left torsion on the leftobliqueaxis(LonL)andrighttorsionontherightobliqueaxis(RonR).Sincemostwalkingisaccomplishedwithyourvertebralcolumnrelativelyuprightandvertical, for the purpose of this discussionwewill assume that your spine andsacrumareinneutralwhileyouwalk.

The way our axial skeletal system alternately undulates in side-bending androtation as we walk is very interesting and extremely important to our overallwell-being. It is a movement that is reminiscent of the undulating action of asnakeas itslithers throughthegrass.Thebigdifferencebetweenasnakeandahuman,ofcourse,isthatoursnakelikespinehasendedupbeinggiventwolegsonwhichtowalk.

Themajorityofpatientsvisitingmyclinicpresentwithpainsomewhereintheirbodies.Partofmyinitialassessmentistohavethepatientstandwiththeirbacktome;withtheminthisposition,Iplacebothmyhandsontopoftheiriliaccresttoseeifthereisanypelvicobliquity,inotherwordsaloworahighside,asshowninfigure4.1.VeryoftenIdofindthatthereisadiscrepancyintheleveloftheheightoftheiliaccrestbetweenthetwosides,whichcouldpossiblyindicatealeglength discrepancy (LLD), or, as it has been alternatively termed, a short legsyndrome or a long leg syndrome.LLD ispossibly themost significantposturalasymmetry that presents itself to the physical therapist. The existence of aconsiderabledifferencebetweenthetwosidescanbeverydetrimentaltohowwefunctionon aday-to-daybasis aswell as during the gait cycle: thediscrepancycansignificantlyaffectouroverallposture.

Figure4.1:Measurementofleglengthbypalpationoftheiliaccrest.

Definition:Leg length discrepancy (LLD) is a conditionwhere one leg isshorterthantheother.

Onehastodecideifthereisan“actual”(or“true”)leglengthdiscrepancyoran

“apparent” leg length discrepancy, as LLD has been implicated in all sorts ofdeficiencyrelatedtoourgaitandrunningmechanics.LLDhasalsobeenlinkedtoposturaldysfunctions,aswellas to increased incidenceof scoliosis, lowerbackand sacroiliac pain, and osteoarthritis (OA) of the hip and knee. Even stressfracturesof thehip,spine,and lowerextremityhavebeenrelated tochanges inleglength.

Theactual(true)leglengthmeasurementisthelengththatistypicallydeterminedby theuseof a tapemeasure fromapoint on thepelvis—the anterior superioriliacspine(ASIS)—tothemedialmalleolus,asshowninfigure4.2;theASISisnormallyusedasthelandmark,sinceitisimpossibletopalpatethefemurbelowthe iliac crest. Before taking thismeasurement, it is beneficial tomeasure thedistancefromtheASISontheleftandrightsidestotheumbilicus,asshowninfigure4.3,toascertainifanypelvicrotationispresent.Ifadifferenceinthetwomeasurements is found, the pelvic rotations need to be corrected before areassessmentisdone.

Figure4.2:Trueleglengthmeasurement,takenfromtheASIStothemedialmalleolus.

Figure4.3:MeasurementtakenfromtheASIStotheumbilicus.

IfthemeasurementstakenfromtheASIStothemedialmalleolusonbothsidesarethesame,itcanthenbeassumedthatthelengthofeachlimbisequal;ontheotherhand,ifthemeasurementsdiffer,onecanassumethatanactualleglengthdiscrepancyispresent.

Theapparent leglengthmeasurementistakenfromtheumbilicustothemedialmalleolus, as shown in figure4.4. If themeasurements takenonboth sides aredifferent,onecanassumethatadysfunctionexistssomewherewhichwillrequirefurtherinvestigation.

Figure4.4:Apparentleglengthmeasurement,takenfromtheumbilicustothemedialmalleolus.

TypesofLLD

LLDcanbedividedintothreemaingroups:

1.Structural:Thisisanactual(ortrue)shorteningoftheskeletalsystem,typicallycausedbyoneoffourthings:

•Congenitaldefect,e.g.congenitaldysplasiaofthehipjoint•Surgery,e.g.totalhipreplacement(THR)•Trauma,e.g.fracturedfemurortibia•Diseaseprocess,e.g.tumor,arthritis,orPerthesdisease

Fracturedbonesinchildrenhavebeenknowntogrowfasterformanyyearsafter the healing process: this can naturally result in the limb becominganatomicallylonger.

2.Functional:Thiscanbeadevelopmentfromalteredbiomechanicsofthelowerbody,suchasankleandfootover-pronationorsupination,pelvicobliquity,muscleimbalances(asaresultof,forinstance,aweakGmedortightadductors),hiporkneejointdysfunction,andevenpoorinnercorestabilization,tonameafew.

3.Idiopathic:Ifthereareobviousfindingsduringthehistorytakingandassessmentprocess,thephysicaltherapistmayhaveanideaastothecauseofthepatient’sLLD.However,ifthetherapistcannotascertainareasonforthechangeinthepresentingleglength,theconditionwouldbeclassifiedasidiopathic,whichmeansthatitarisesindependently,notasaresultofsomeothercondition.

Figure4.5:Leftlonglegsyndromeversusrightshortlegsyndrome.

Assessment

Thetherapisthastobeveryintuitiveduringtheinitialassessment.Whentheiliaccrest is palpated on a patient in a standing position, the therapist needs to beawareofa“pelvicshift”asthepatientstands.Letmegiveyouanexample:ifthepatienthasaweakGmedmuscleontheleft,thepelviswillappeartodroptotherightanddeviateorlaterallyshifttotheleft,whichwillcausetheleftiliaccresttoappearelevatedonthatside(left),givingtheappearanceofalongerleftleg.

Whenthepatientpresentstotheclinic,wecanassumethatthepainhasexistedfor a while, and so we can say that it is at the chronic stage. Because of thenaturalovercompensatorymechanismsthatoccurthroughchronicity,theposturalmuscles are probably held in a shortened and subsequently tight position; onemuscleinparticularthathasatendencytoshortenistheQL.Aproblemcanarisewhenthepatientliesontheirback(supineposition)sothatyoucanobservethepositions of the left and rightmedialmalleoliwhen looking for any leg lengthdiscrepancy.Youmaynownoticethat the leftmedialmalleolusisnearertothepatient’sheadthantheoneontheright,givingtheappearanceofashortleftlegasaresultofatightleftQL.Whenthepatientwasstanding,however,youmayhaveconvincedyourselfthatthepatient’sleftleglookedlonger!

Thismightinitiallyseemconfusing,butjustthinkaboutitforamoment.CoulditnotsimplymeanthatwhenthepatientadoptsastandingpositiontheGmedontheleftsideisweak,causingthepelvistoshifttothesideofweakness?Conversely,isitnotpossiblethatwhenthepatientisinasupineposition,theleftQLisheldinashortenedposition,whichisresponsibleforhitchingupthepelvis,havingtheeffect of pulling the leg closer to the head and thus making the leg appearshorter?

Whenyouare standing, theweakmuscles show themselves;whenyouarelying,theshortmusclesshowthemselves.

FootandAnklePosition

Oneofthemostneglectedaspectsofthebodywhenpatientspresenttotheclinicis the position of the lower limb. Osteopaths, chiropractors, and physicaltherapistsseelotsofpatientswhoinitiallypresentwithlowerbackandsacroiliacpain. These specialist therapists naturally spend a lot of time observing andassessing the pelvis and lumbar spine to ascertain which tissue is giving thepersonthepain.Thispresentingpainmay,however,justbeasymptom,andthecauseofthepaincouldbesomewhereelse,awayfromtheactualsiteofthepain.

The only person interested in the pain is your patient; you the therapistshouldtrytofindthecauseofthepainandnottreatwhereitsimplyhurts.

Itisveryimportantthatwhenassessingyourpatientsyouobservethepositionofthelowerlimbandinparticularthefootandanklecomplex,asafaultyfootandankle structure canprofoundly affect leg length and the natural position of thepelvis.Themost commonasymmetrical footposition thatpatientspresentwithhastobewhatiscommonlycalledanover-pronatedfoot,asshowninfigure4.6.Ithasbeenwidely thought thatwhenweactuallypresentwitha true leg lengthdiscrepancy,thebodywilltrytocompensateforthelongerlegthroughloweringthemedial archof the footbypronatingat theSTJ.Theactionofpronation iscalled tri-planar motion and consists of three movements: dorsiflexion of theankle,eversion,andabductionofthefootcomplex.Thepositionofthisincreasedpronation is basically the body’s natural compensatory mechanism to try to“shorten”thelegbecauseitisanatomicallylonger.

The plantar surface of our feet has thousands of sensory receptors that areresponsibleforthepositionofthefoot;thesmallestshiftinweightwillbeenoughto signal thebrain to induceacompensatory reaction.On thecontralateral side(shorterleg),thecompensatorymechanismwillcausethemedialarchtoadoptasupinated position (tri-planar motion of plantar flexion, inversion, andadduction).Thecompensatorymechanismchangesthepositionofthearchinanattempttolengthentheapparentshorterleg.Whenphysicaltherapistsassesstheirpatients theywill need to check for this compensatory pattern, because, if leftunchecked, excessive foot pronation caused by an anatomically longer leg(subsequent supination of the contralateral foot as compensation) will in turn

cause an internal rotation of the lower extremity and contralateral externalrotation.Thiswill thenhavetheeffectofaltering thewholekineticchainfromthefootallthewayuptotheocciput.

Figure4.6:Over-pronationsyndrome.

TrueLLDandtheRelationshiptothePelvis

Let’s continue with a “thought process” just for amoment. Now consider thatyourpatienthasalongerlegontheleftside,whichyouhaveascertainedbecauseofthehigherpositionoftheiliaccrestandthepossiblecompensatorypronationof theSTJon thesameside.Before Icontinuewith thediscussion, justhaveathinktoyourselfaboutwhatpositiontheinnominatebonemightbeiniftheleftleg,say,isanatomicallylonger.

Theinnominaterotationwillnaturallybecoupledwithaleglengthdiscrepancyasaresultofthecompensatorymechanisms:ifyoulookatfigure4.7overleaf,youwill see that thefemoralheadon the long-legsideforces the innominate intoasuperiorandposteriorlyrotatedposition.Conversely,theinnominateonthelowfemoral head side drops down and anteriorly rotates, as shown in figure 4.8overleaf.Whatwehavenow,therefore,istheleftinnominatebeingforcedintoaposteriorrotationandtherightinnominateintoananteriorrotation.Thinkaboutwhatliesbetweenthetwoinnominates—yes,thesacrumbone.Asaresultofthecompensatoryrotationofbothoftheinnominatebonesinoppositedirectionstoeachother,amotionofthesacrumoccurs,knowninosteopathictermsasaleft-on-left (L-on-L) sacral torsion (figure 4.9 overleaf). An L-on-L sacral torsionmeansthatthesacrumhasrotatedtotheleftontheleftobliqueaxisandhassidebent to the right, as it is ruled by Type I spinalmechanics (rotation and side-bendingarecoupled toopposite sides, as establishedbyFryette (1918) and thelaw of spinal mechanics). This complexity which has been described of theinnominaterotationsthatarecoupledwithasacraltorsionisusuallydepictedasapelvic torsion, or even a pelvic obliquity, andwill require a good understandingbeforeatreatmentplanisintroduced.

Figure4.7:Longleginnominatecompensation.

Figure4.8:Shortleginnominatecompensation.

Figure4.9:L-on-Lsacraltorsion.

TrueLLDandtheRelationshipbetweentheTrunkandtheHead

You will notice in figure 4.10 that on the left side there is a lower shoulderpositionon thehigh innominateside: this isacommonfinding in thecaseofacompensatoryfunctionalscoliosis.Someauthors,however,haveconsidered thistooccurasaresultofa“handednesspattern”:forexample,ifyouarelefthanded,theleftshouldermightappeartobelower,andifyouarerighthanded,therightshouldermightappeartobelower.

Figure4.10:Functionalscoliosiscompensation.

Whatelsedoyouobserveinfigure4.10?Ifyoulookatwhatishappeningtotheleftquadratus lumborum,youwouldassume that thismuscle isbeingheld in ashortened position because of the higher left innominate. This assumption iscorrect, as you can also see that the lumbar spine is side bending toward thelongerleftlegandrotatingtowardtheshorterrightleg.

Asaresultoftheascendingfunctionalscoliosis,therightshoulderishigher.Youmightalsonoticeashort“C”curveinthecervicalspine;thiswillprobablycause

thescalenes,SCM,uppertrapezius,andpossiblythelevatorscapulaemusclesonthe right side to adopt a shortenedand subsequently tightposition.This typicaladaptationofmuscularimbalancewillhelpmaintainanerectheadpositionwiththeeyeslevel.Thebodywillalwayswanttobelevelnomatterwhatandwilldoalmost anything to accomplish this, including enduring pain to maintainequilibrium. Common painful conditions that patients might present with areheadaches, active trigger points, tinnitus, temporomandibular joint (TMJ)dysfunction,andeveneyeandfacialpain.

LLDandtheGaitCycle

Aswewalk,ifourgaitcyclepatternhasbeenalteredbecauseofanactualoranapparentLLD,theshorterlegwillfeellikeitissteppingdown,andthelonglegwillcompensatebyasortof“vaulting”motion. It isalmost likestepping intoasmall pothole with every step you take; imagine repeating this at least ten tofifteen thousand times a day—it will easily cause potential pain patterns ofdysfunction! Common compensations are sometimes seen when patients areaskedtowalk:ontheshort-legside,thepatientmighthaveatendencytowalkontheirtoes,andonthelong-legside,thepatientmayhaveatendencytoflextheirknee,butthiswilldependonthediscrepancy.

For thebody tobe an effective locomotorduring the gait cycle, awell-alignedandsymmetricalbodyisessential.Whenthepositionsoftheinnominatebonesofthepelvisarealteredbyactualorapparentleglengthdiscrepancies,itiseasytoseehowpatientscanpresentwithpain,notonlyatthesacroiliacjointandlumbarspinebutalsoeverywhereelseintheirbodythatisgoingthroughacompensationpattern.

ImentionedearlierthattherecouldbeaweaknessoftheGmedononesideofthebody,andashortnessissuewiththetensorfasciaelatae(TFL)andiliotibialband(ITB)ontheotherside. If there isweaknessof theGmed, thepatientcanhaveeitheraTrendelenburgpatternofgaitoracompensatoryTrendelenburgpatternofgait (this is explained inmoredetail in chapter6).Whicheverwayyou lookatthis,thepatientisgoingtohaveanantalgictypeofgait,whichsimplymeansthattheywill walkwith some form of limp; this compensation can only cause onethingovertimeandthatwillsimplybepain.

SummaryofCompensationstotheIliopsoas

•Theiliopsoasmuscleisgenerallytightonthesideoftheshortleg.Notethataleftiliopsoasmusclespasmwillcauseapelvicsideshifttotheright,mimickingashortleftleg.

•Theinnominatebonemaycompensatebyrotatinganteriorlyonthesideoftheshortleg,functionallylengtheningthatleg,whiletheinnominateonthelongsidemaydotheopposite.

•Unilateralspasmoftheiliopsoascreateslumbarconcavityontheoppositesideandsetsupapositivesideshiftonthesideoppositetothespasm.Itisimportantthatthephysicaltherapistalwaysassessforandtreatiliopsoasspasminthecaseofasuspectedshortlegorapositivepelviclateralsideshift.

•Iliopsoasspasmpainisworseonstandingfromaseatedposition,andlesspainisperceivedastheiliopsoasstretchesout.

SummaryofCompensationstotheSacrumandLumbarSpine

•Sacrumtypicallyrotatestowardthelonglegandsidebendstowardtheshortleg.

•Posteriorsacrummightbeassociatedwithsame-sidepiriformisspasm.•Anteriorsacrummightbeassociatedwithsame-sideGmedspasm.•Lumbarspinetypicallysidebendstothelong-legsideandrotatestowardthesideofthelowsacralbase/shortleg.

•Facetpainduetocompressioniscommonontheconcavitysideofthelumbarspine.

•Iliolumbarligamentcancausepainasitisstretchedontheconvexsideofthelumbarspineandhasbeenarguedtoreferpaintothegroin,testicle,andmedialthighonthesamesideasthestretchedligament.

Insummary,whenlookingattheleveloftheiliaccrest,onehastodetermineifthere is a leg length discrepancy. If there is, one then has to ascertain if thedysfunction is a true discrepancy or a functional discrepancy, as thecompensationpatterncanchangedependingonthediagnosis.Forexample,ifyoufindatrueanatomicalleglengthdiscrepancy,theinnominateboneonthelongerleg will try to compensate by rotating posteriorly, as seen in figure 4.7 andexplainedearlier.Moreover,thefemurandlowerlimbontheanatomicallylongerlegwill follow the compensatorymodel by rotatingmedially, as seen in figure4.5,andthefootwilltrytopronateattheSTJ,sincethelongerlegwillattempttoshorten itself. At the same time, the actual shorter leg will compensate bysupinating at the anklemortise; this in effect can cause the tibia and femur torotateexternally and the innominatebone to rotate anteriorly as the leg tries tomakeitselfappearlonger.

Over-PronationSyndrome

Let’slookatanothercompensationmodelforapatientwhoappearstohavealeglengthdiscrepancy.In thiscase it isafunctionalLLD,andtheapparentshorterlegofthepatientexhibitsanover-pronationoftheSTJ,ratherthanthelongerlegcompensating by pronating to shorten itself. As a result, the body will try tocompensatebycausinganinternalrotationofthetibiaandfemur(figure4.11);thiswillhavetheeffectoftheinnominatebonerotatinganteriorly,whichinturncancauseanincreasedlumbarlordosiswithsubsequentlowerbackpain.

Figure4.11:Afootinover-pronationwithinternaltibialrotation.

Over-pronation is a common pattern found in themajority of people to someextentoranother.Itisbestidentifiedwiththepatientstandingbarefoot.Thebigclueisthatonearchislowerorflatterthantheother:thelowerarchsideisover-pronating.Sometimes,bothsidesmaybeover-pronating,butonesideisgenerallyover-pronatingmore than theother, orone sidemightbenormal and theothersidelower.Itiseasytoconfirmtheconditionbysimplyplacingonefingerunderthe patient’s arch, noting how much of your finger goes underneath, andcomparingtheresultwiththeotherside.Aretheythesameordifferent?Ifoneside is noticeably lower than theother, youhave found apatientwith anover-pronation syndrome. Another test to confirm over-pronation is to observe the

Achillestendonfromtheposterioraspect:youwill typicallynoticeabowingonthesidewiththelowerarch.

Itshouldbenotedthatover-pronationsyndromecanoriginatenotonlyfromthefootandanklebutalsofromtheinnominateofthatside.Whenthefootandanklecomplex over-pronates, the innominate bone will normally rotate anteriorly.However,ifwelookatitfromtheotherwayaround,ananteriorrotationoftheinnominatecanforcethemedialarchofthefootintoanover-pronatedposition.Thisbecomesachickenand theeggsituation,but that is irrelevant,as theonlyconsiderationiswhateverpresentsitselfnow.Inmyexperience,youmightneedto correct the innominate’s rotation and the over-pronation to help reduce thepatient’spresentingsymptoms.

YoucanseealreadythatbothcompensatorymechanismshaveapronationissueattheSTJ;however,thetrueleglengthcompensationofthelongerlegforcedtheinnominate bone to rotate posteriorly, whereas the functional leg lengthdiscrepancyoftheover-pronationsyndromecausedtheinnominatebonetorotateanteriorly.

You can probably gather from all the information above that there can be somuchgoingonatthesametimethroughoutthekineticchain;everythingthathasbeenmentionedcanaffectthe lengthoftheleg.It iscorrecttoassumethatthisareaofdiscussionissomewhatcomplex,anditmightbedifficulttoknowwheretostartintheassessmentoreveninthetreatmentprogram.

Inall thathasbeendiscussedabove, there liesapotentialsolutiontothejigsawpuzzleofpatients’symptomsanddysfunctions.ThereexistswhatIcallakey tounlocking the problem; the difficulty in physical therapy, however, is findingwheretostartand“insertthekey”(excusetheexpression).Icanguaranteethat,overtheyears,inexperiencedtherapistswillhavetimeandtimeagaininsertedthekeyintothewrongplace, i.e.wherethepatientfeelsthepainandnotwheretheproblemlies.RecallthewisewordsofDr.IdaRolf!

WhenIteachphysicaltherapiststoday,sometimesduringthepracticalsessionsIsay“Treatwhatyou find”; thebodywillhopefullyguide themonto thecorrectpathway. If, after three or even four physical therapy sessions, a patient’ssymptoms are not reducing, then you the therapist will need to change yourthoughtprocessandtreatotherareasthatyouinitiallyfeltmightnotberelatedto

thecauseofthepatient’spresentingpainpatterns.

LLDandtheGlutes

Sohowdoesall this affect theglutes?Whenyouhaveacompensationpattern,the femur not only rotates to compensate in the transverse plane, but alsoexperiencesacompensatorymechanismofadductionandabductioninthefrontalplane.Thus,insimpleterms,ifyouhavealowerlimbthatisheldinanadductedposition then the abductor muscle group can be forced into a lengthened andsubsequentlyweakenedposition,whiletheadductorswillbeheldinashortenedandsubsequentlytightposition.Foralegthatisheldinabduction,thesituationisreversed.

Ifyoulookbackatfigure4.5youwillseethattheleftlegappearslongerbecauseofthehigherleftiliaccrest,theinnominatehasrotatedposteriorly,thefemurhasinternallyrotated,andthefoothaspronated.Inthiscompensationtheleftlegwillbeinapositionofadduction(figure4.12),andconsequentlytherightlegwillbeheld in a position of abduction (figure 4.13). This will have an effect on themusculature of the associated areas: some of these muscles will be held in ashortenedpositionandsomeinalengthenedposition.

Figure4.12:Leftlegcompensations—adductorsandQLshortandtight,withGmedandTFLlongandweak.

Figure4.13:Rightlegcompensations—adductorsandQLlongandweak,withGmedandTFLshortandtight.

StandingBalanceTest

Whenapatientisaskedtostandononelegandlifttheoppositekneetowardtheirwaist,thephysicaltherapistneedstoobservethelevelofthePSISasthepatienttransferstheirweighttooneleg.Thepatientshouldbeabletoshifttheirweightonto thestance leg(theright leg infigure4.14),withgoodmuscularcontroloftheGmedofthatleg.IfthePSISdipsdownonthelegthatisbeinglifted(theleftleginfigure4.14)ratherthanremaininglevel,itmightbeassumedthattheGmedontheothersideisunabletocontrolthemovement;thepatientmightthenhaveanalteredpatternofgaitwhentheygothroughthegaitcycle,asshowninfigure4.15.ThisalteredgaitpatterniscalledaTrendelenburggaitandisillustratedforaweak left Gmed in figure 4.16. If this dysfunctional gait is present over aprolonged period, a compensatory Trendelenburg might develop, as shown infigure4.17.Thereasonsforthisalteredgaitcanbenumeroustosaytheleast,butonecausecouldbethatoneofthelegsisheldinanadductedpositionbecauseoftheshorteningoftheadductors(asmentionedabove).Thisalteredpatternwillinturnresultinareciprocalinhibition:theabductors—inparticulartheGmed—willnow be held in a lengthened position that can then predispose the Gmed tobecomingweak.

Figure4.14:Standingbalancetest—normal.

Figure4.15:PositivetestforweaknessoftherightGmed—thePSISdipsdownontheleft.

Figure4.16:Trendelenburggait—weakleftGmed.

Figure4.17:CompensatoryTrendelenburggait—weakleftGmed.

WhenIteachthestandingbalancetest(figure4.14),Isaytomystudentsthatyouneedtolookoutforthreethings.Thefirst,asImentionedabove,isthepositionof thePSISas thepatient transfers theirweight fromone leg to theother.Thesecond is how much movement occurs as the patient shifts onto the weight-bearing leg; youmaynotice one side shiftingmore than theother, indicating apossibleGmedweakness.Finally,thethirdishowstablethepatientiswhentheystandononelegcomparedwiththeother.Youwillbeamazedhowmanyveryfitathletesstruggletostandononelegunaidedandmaintaingoodcontrol.

Hopefully,afterreadingthischapter,youwillhavesomeunderstandingofwhatishappeningwhenapatientpresentswithmusculoskeletaldysfunctions,suchasleglengthdiscrepancy,over-pronationsyndrome,andmuscleimbalances.Inthenext chapter I will continue with the journey on this theme by looking at thefunctionalanatomyoftheGmax.Then,inchapter6,wewilllookmorecloselyatthefunctionoftheGmedandhowitcanalterourgaitpatterns.

This chapter will focus on the gluteus maximus (Gmax) and how this musclecouldberesponsibleformanyofthecomplaintsthatpatientsandathletespresentwith, especially painful symptoms in the area of the lower back. TheGmax, Ifeel,isrelativelyneglectedbymostphysicaltherapistsIcomeintocontactwith.Perhaps the reason for this neglect is that the Gmax does not normally itselfpresentwithpain,andhencethisamazingandfunctionalmuscleisleftonwhatIcalltheneglectshelf.

GmaxAnatomy

Figure5.1:Origin,insertion,action,andnerveinnervationoftheGmax.

FunctionoftheGmax

From a functional perspective, the Gmax performs several key roles incontrollingtherelationshipbetweenthepelvis,trunk,andfemur.Thismuscleiscapable of abducting and laterally rotating the hip, which helps to control thealignment of the kneewith the lower limb.For example, in stair climbing, theGmaxwill laterallyrotateandabduct thehip tokeep the lower limbinoptimalalignment,whileatthesametimethehipextendstocarrythebodyupwardontothe next step.When the Gmax is weak or misfiring, the knee can be seen todeviatemediallyandthepelviscanalsobeobservedtotiplaterally.

TheGmaxalsohasaroleinstabilizingtheSIJsandhasbeendescribedasoneoftheforceclosuremuscles.SomeoftheGmaxfibersattachtothesacrotuberousligament and the thoracolumbar fascia, which is a very strong, non-contractileconnectivetissuethat is tensionedbytheactivationofmusclesconnectingto it.Oneof theconnections to thisfascia is the latissimusdorsi.TheGmaxformsapartnershipwiththecontralaterallatissimusdorsiviathethoracolumbarfascia—thispartnershipconnectionisknownastheposteriorobliquesling(seefigure5.2).This sling increases thecompression force to theSIJduring theweight-bearingsingle-legstanceinthegaitcycle.

Figure5.2:Posteriorobliqueslingandtheconnectionwiththelatissimusdorsi.

Misfiring or weakness in the Gmax reduces the effectiveness of the posteriorobliquesling,whichwillpredisposetheSIJstosubsequentinjury.Thebodywillthen try to compensate for this weakness by increasing tension via thethoracolumbar fascia by in turn increasing the activation of the contralaterallatissimus dorsi. As with any compensatory mechanism, “structure affectsfunction” and “function affects structure.” This means that other areas of thebody are affected: for example, the shoulder mechanics are altered since thelatissimus dorsi has attachments on the humerus and scapula. If the latissimusdorsiisparticularlyactivebecauseofthecompensation,thiscanbeobservedasoneshoulderappearinglowerthantheotherduringastep-upora lungetypeofmotion.

As explained in chapter 3, theGmax plays a significant role in the gait cycle,working in conjunction with the hamstrings. Just before heel-strike, thehamstrings will activate, which will increase the tension to the SIJs via theattachmentonthesacrotuberousligament.Thisconnectionassistsinthelockingmechanism of the SIJs for the weight-bearing cycle. From heel-strike to mid-stance of the gait cycle, the Gmax increases its activation and the hamstrings

decrease theirs. The Gmax significantly increases the stabilization of the SIJsduring early and mid-stance phases through the attachments of the posteriorobliquesling.

Weakness ormisfiring in theGmaxwill cause the hamstrings to remain activeduringthegaitcycleinordertomaintainstabilityoftheSIJsandthepositionofthe pelvis. The resultant overactivation of the hamstrings will subject them tocontinualandabnormalstrain.

As I saidearlier, the focusof thischapter is to lookatwhathappenswhen theGmaxisinvolved.GenerallytheGmaxfollowsatraitofbecomingweakenedifthe antagonisticmuscles havebecome short and tight.However, theGmax canalso testweak if there is aneurologicaldisorderaffecting theL5andS1nerveroot (which innervates theGmaxmuscle), in turn having an impact onmusclecontraction.Thisaspectwillbediscussedingreaterdetailinchapter11.

Themainmuscles that cancauseaneurological inhibition to theGmaxare theiliopsoas, rectusfemoris,andadductors,as theyallareclassifiedashipflexors,whicharetheantagonisticmusclestothehipextensionactionoftheGmax.

The assessment of the iliopsoas and other associated shortened antagonisticmuscles will be discussed in chapter 8. Once that assessment has been fullyunderstood, I will then teach you how to normalize the tight and shortenedantagonistic muscles by the use of myofascial and muscle energy techniques.Aftermasteringtheseadvancedtechniques,thephysicaltherapistwillbeabletoincorporatethemintotheirowntreatmentmodalitywiththeaimofencouragingthe lengthening of the tight tissues. This will then promote a normal neutralpositionofthepelvisandlumbarspine,andinturnhopefullyhavetheeffectof“switching”theweakenedGmaxbackon.

AssessmentoftheGmax

InthissectionIwilldiscussthehipextensionfiringpatterntest,whichisusedfordetermining the correct firing order of the hip extensors (including the Gmaxmuscle).Theaimofthetestistoascertaintheactualfiringsequenceofagroupof muscles to ensure that all are firing correctly, just like the cylinders of anengine.Amisfiringpatternwillcommonlybefoundinathletesandpatients.

HipExtensionFiringPatternTest

Figure 5.3 shows the correct firing pattern of hip joint extension. The normalmuscleactivationsequenceis:

1.Gluteusmaximus2.Hamstrings3.Contralaterallumbarextensors4.Ipsilaterallumbarextensors5.Contralateralthoracolumbarextensors6.Ipsilateralthoracolumbarextensors

Figure5.3:Hipextensionfiringpattern.

Thehipextensionfiringpatterntestisuniqueinitsapplication.Thinkofyourselfasacarwithsixcylindersinyourengine:basicallythatiswhatyourbodyis—anengine. The engine has a certain way of firing and so does your body. Forexample,theengineinacarwillnotfireitsindividualcylindersinthenumericalorder1–2–3–4–5–6;itwillfireinapre-definedoptimumsequence,say1–3–5–6–4–2.Ifwehaveourcarservicedandthemechanicmistakes twoof the leadsandputsthembackincorrectly,theenginewillstillworkbutnotveryefficiently;moreover,itwilleventuallybreakdown.Ourbodiesarenodifferent:inourcase,ifweareparticularlyactivebuthaveamisfiringdysfunction,ourbodieswillalsobreakdown,ultimatelycausinguspain.

Sequence1The therapist places their fingertips lightly on the patient’s left hamstrings andleftGmax(figures5.4(a)and(b)),andthepatientisaskedtolifttheirleftleg2″

(5cm)offthecouch(figure5.4(c)).Thetherapisttriestoidentifywhichmusclefiresfirstandnotestheresultofthisfirstsequenceintable5.1.

Figure5.4:Hipextensionfiringpattern—sequence1:(a)Thetherapistlightlypalpatesthepatient’sleft

hamstringsandGmax;(b)Close-upviewofthetherapist’shandposition;(c)Thepatientliftstheirleftlegoff

thecouch.

Sequence2Thetherapistplaces their thumbs lightlyonthepatient’serectorspinae,andthepatientisaskedtolifttheirleftleg2″offthecouch(figure5.5(a)and(b)).Thetherapistidentifiesandnotesintable5.1whicherectormusclefiresfirst.

Figure5.5:Hipextensionfiringpattern—sequence2:(a)Thetherapistlightlypalpatesthepatient’serector

spinae;(b)Thepatientliftstheirleftlegoffthecouch.

Table5.1:Hipextensionfiringpattern—leftside.

Table5.2:Hipextensionfiringpattern—rightside.

Sequences1and2arethenrepeatedwiththerightlegandtheresultsrecordedintable 5.2. Having done this, the therapist can determine whether or not themusclesare firingcorrectly.The firingpattern shouldbe: (1)gluteusmaximus;(2)hamstrings;(3)contralateralerectorspinae;and,lastly,(4)ipsilateralerectorspinae.

If,whenpalpatinginsequence1,thegluteusmaximusisfoundtofirefirst,youcan safely say that this is correct. The same applies in sequence 2: if thecontralateralerectorspinaecontractsfirst,thisisalsothecorrectsequence.

However,ifyoufeelthatthehamstringsarenumber1inthesequence,orthattheipsilateral erector spinae is number 1 and the gluteus maximus is not felt tocontract, you can deduce that this is a misfiring pattern. If the misfiringdysfunctionisnotcorrected,ourbody(theengine)willstarttobreakdownandacompensatorypatternofdysfunctionwillbecreated.

Inmyexperience I have found that in a lot ofpatients, thehamstrings and theipsilateral erector spinaeare typically first tocontract and theGmax isnumberfour in the sequence. In these cases the erector spinae and the hamstringswillbecomethedominantmusclesinassistingthehipinanextensionmovement.Thiscan cause excessive anterior tilting of the pelviswith a resultant hyperlordosis,whichcanleadtoinflammationofthelowerlumbarfacetjoints.Tocorrectthemisfiringsequence,weneedtolookatchapter8onmusclelengthtestingandtheuse ofMETs and myofascial techniques to treat and normalize shortened andtighttissues.

Notethat thefiringpatternsofmuscles5and6havenotbeendiscussedin thischapter,becauseweneedtomakesurethatthecorrectfiringorderofmuscles1–4 is established. I also find thatwhen themuscle1–4 firing sequencehasbeencorrected, the firingpatternofmuscles5 and6 is generally self-correctingandtendstofollowthenormalfiringpatternsequence.

CaseStudy

IhavehadthegoodfortunetobethesportsosteopathlookingaftertheOxfordUniversityBoatClubforseveralyears,particularlyinpreparationfortheannualboatraceagainstCambridgeUniversity.Duringthoseyearsyoucanimaginehowmany of the rowers I have assessed and treated. One of the most commoncomplaints thata rowerpresents tomeatmysports injuryclinic is lowerbackpain.Thistypeofpaincanincludeamultitudeofpathologiesthatincludefacetjoint syndrome, lower lumbar disc bulge, iliolumbar ligament sprain, multifidistrain—thelistgoesonandon.

Before rushing in to treat the area of pain, the physical therapist should askthemselves the following question: Is the patient’s pain a “symptom,” or is thepain the actual “cause”? Recall what Dr. Ida Rolf, the founder of the Rolfingtechnique,said:“Whereyouthinkthepainis,theproblemisnot.”ItrulybelieveinthisstatementwhenIassessmypatients.

During the initiation talkwith the rowing squad, one of the questions I ask is:“Whohasbackpain?”Theresponseisgenerallyfairlyconsistent:around30–40%ofthewholesquadsaytheydo,withthepercentagebeingabitlessorabitmorefromoneyear to thenext.Of the30–40%, I canguarantee that inat least50–60% of these rowers presenting with lower back pain, the Gmax is the mainculpritoftheirperceivedsymptoms.

IfIamhonestIcanmentionnumerousspecificcasesoflowerbackpainwiththemaincausebeingsomeissuethatincorporatedtheGmax.Forthisbook,however,Iwillfocusononecasestudyinparticular, involvingapatientwhomIwillcallMr.Fit.

Mr.Fit is a24-year-oldelite rowerwhohascompetedatOlympic level, sohisrowing technique ought to be faultless; thiswas indeed the case, as the rowingcoacheshaddonetheirjobproperly.ForaslongasMr.Fitremembers,therehadalwaysbeenanissuewithhisso-called“tight”hamstringsandpainfullowerback.Themorehewasactiveinrowing,theworsehewouldfeelinrelationtohislowerbackpainandperceptionoftighthamstrings.Hewouldsaytomethathealwaysstretchedhishamstringseverydayandyethehasneverfeltanyimprovementin

thelengthofthesemuscles,nomatterhowmuchstretchinghedoes.

Most rowerswill trainwithweights andoftenperformbodyweightexercises tohelppromotetheinnercorestrengthandstabilityrequiredtobeaneffectiveteammember inwhicheverdisciplineof rowing theypursue.This typeof training isregularly scheduled in their program and is generally very positive for theprogressionof the athlete.Nevertheless, in some instances the specific trainingthe rower follows religiously can be detrimental to their overallwell-being andcanbetheprecursorofpainlateronintheirrowingcareer.

Beforebecominganosteopath,IwasaphysicaltrainerintheBritishArmy,soIamveryexperienced in trainingand implementing thephysical requirementsofathletes.Duringmy time in the army I have seennumerous injuries that I feelresult from incorrect training; thementality of the forces used tobe thatwhenyouaretoldtojump,youreply“Howhigh?”becauseyoudonotquestionwhatyouare told todo. Iampleased tosay that thingsaredifferent today,andnowthat trainingprogramshaveadvancedover the last10years, fewer soldiersandathletesaregettinginjured.

ExerciseHistory

ThroughspecificquestioningintheconsultationwithMr.Fit,itbecameclearthatfor many years he had been following a heavy weight-training program thatfocusedalotondeepsquatting,deadlifting,andfullsit-upsusingmedicineballs.

Mr.Fitwasaskedtodemonstratesomeoftheexerciseshewasdoinginhiswork-outs;Iaskedtoseeinparticularhistechniqueforsquats,deadlifts,andlunges.Withoutgoingintotoomuchdetail,whenMr.Fitperformedsquatsandlunges,hiskneeswereseentodeviatemediallyontheeccentricmotionoftheexercise,and the overall movement looked unstable. Because of the athlete’s perceivedtightness in his hamstrings, hisROMwas very limitedwhendemonstrating thedeadlift.Hewasobservedtoroundhis lowerbackratherthankeephis lumbarspineinaneutralposition,whichmeantthatmostofthemovementthroughthisexercisewasperformedusinghislowerbackandhardlyanyothermuscles.

Thefullsit-upsthatMr.Fithaddoneeverydayforaslongashecouldrememberwereoveractivatinghisiliopsoas:theiliopsoasisthemainprimemoverinthefullsit-up,sothisisnotagoodabdominalexercise.Hehadbeenadvisedtoperform

sit-upstocounteracthislowerbackpainbyaphysicaltherapistwhohadtoldhimthat they were “good core exercises,” but the exercise was in fact over timecausing his iliopsoas to become chronically short and tight. I strongly disagreewith thephysical therapist’scomment that full sit-upsareagoodcoreexercise,andtoldMr.Fitthatthecontinualuseofthisexercisewasoneofthereasonswhyhislowerbackpainwasbeingmaintained.FromthatdayonwardMr.Fitstoppeddoingfullsit-upsandbegantoaddinalternativeexercisesthatIshowedhim.

OnExamination

Mr.Fit’sposturewasverylordoticinthelumbarregion,withabilateralanteriortiltofhispelvis;painwas localizedtohiscentral lowerback,aroundtheL5/S1region. The following muscles when tested were found to be in a shortenedpositionandwhatIwouldconsequentlyconsidertobetight:

•Iliopsoas•Rectusfemoris•Adductors•Lumbarerectorspinae•Quadratuslumborum

Figure5.6 shows thatwhen the specifiedmuscles contract, the innominatewillrotateinananteriordirection,whichwillsubsequentlycauseananteriortiltandalumbarlordosis.

Figure5.6:Hyperlordoticpositionandthemusclesresponsible.

Figure5.7:Musclesresponsibleforaposteriortiltoraposteriorrotationoftheinnominate.

Iwillfocusmoreonthemusclesintheabovelist(andinparticulartheiliopsoas)inchapter8,asIconsiderthesetightmusclegroupstoberesponsibleforalotoflower back pain. For now, I want to look at what happens to the antagonisticmusclesinfigure5.7whenwehavethisalteredposture.

Youcansee that theposturedemonstrated infigure5.6exhibitsananterior tiltwitha lumbar lordosis; themuscles listedare thoseresponsibleforbringing thepelvisbackintoaneutralpositionbyrotatingtheinnominateposteriorly,aswellascausing the lumbarspine toflex.However,becauseof the increasedanteriortilt and lordosis, the muscles that are listed (gluteus muscles, abdominals) areforcedintoalengthenedposition.Thesemusclescanthereforebecomeweakasacompensatoryconsequencethroughaneurologicalinhibitionduetotheoppositemusclesbeingheldinashortenedposition(iliopsoas,rectusfemoris,andlumbarspineerectorspinae).

GmaxFiringPatternAssessment

Next inmyassessmentcriteria Iwanted toevaluate thefunctionalcapabilityoftheGmaxofMr.Fit,asthisisthemainrowing-strokemusclethathelpstopropeltheboat effectively.When I performed thehip extension firingpattern test onhim(seefigure5.3)hewasverymuch“misfiringonallcylinders”—excuse theexpression,buthewas.Hewassodominantinthehamstringsandtheipsilaterallumbar spine that theGmaxwas virtually “asleep” and I felt it was lying verydormantasifithadbeenswitchedoff.

Treatment

MytreatmentprotocolforMr.Fitwastofollowaplanthatisbasicallyoutlinedintheindividualchaptersofthisbook;thetreatmentandrehabilitationsessionstookplace at regular intervals and incorporated exercise and remedial therapy asdemonstrated and discussed throughout the forthcoming chapters. Indeed, onecouldsaythatthisentirebookhasbeenwrittenonthebasisofMr.Fit’streatmentplan,witha focuson thisparticularcase study togiveyou, the reader, abetterunderstandingofdysfunctionalpatterns andhowweas therapistsneed to thinkoutsidetheboxinordertoproperlycarryoutrehabilitation.(InthecaseofMr.Fit, I am pleased to report that my treatment regime successfully resolved his

lower back and hamstrings problems, and enabled him to continue withcompetitiverowingfreefromtheselimitations.)

Iwouldlikeyoutoreadcarefullyeachofthefollowingchaptersandthencometo your own conclusions about this case study and treatment plan. Give somethought to the differential diagnosis and hypothesis, and to my eventualconclusionandhowrealistically Ihad toapproach this individual’s treatment inorder to fix, rather than just relieve, the symptom and underlying problem.Failuretodothismightotherwisehaveledtoanexacerbationofsymptomsandfurtherproblemslateron.

Conclusion

As you read each of the following chapters I hope that another piece of thejigsaw puzzle will fall into place, with the final piece being located—andthereforeeverythingbecomingapparent—inchapter12.Iamsurethatwhenyoureadcertainsectionsyouwillattimesdoubt,question,oragreewithmythoughtprocess; by the end, however, I hope you will have a better understanding.Moreover,IhopethatIwillhavegivenyoufoodforthoughtsothatyoustarttothinkabout thebodyasawholeandfamiliarizeyourselfwithslingsandchainsanddysfunctionalpatterns.Youwillthenbeabletoconfidentlyusevarioustypesoftherapyandspecificexercisestofullyrehabilitateyourpatients/clients.Trytounderstandmy thought process and clinical reasoning in coming to a particularconclusionandinreachingadecisiononthecourseofremedialactionthatIfeltwasnecessarytotake.

ThecasestudyoutlinedaboveforMr.Fitisjustoneexampleofmanypossibleanddiversesituationsthatcanbeencounteredatasportsinjuryclinic.Table5.3shows, on the left, some common examples of pain and dysfunction that anathlete,orevenanon-athleticpatient,canpresentwith;thepotentialfindingsfortheirpresentingsymptomsareshownontherightsideofthetable.

Athletepresentswith Whatcanitimply? Likelyfinding

Tight/painfulhamstringsorlumbarparaspinalmuscles

Faultyposteriorchainmuscleactivationpattern

Gmaxweaknessordelayedtimingonsameside

Insufficientforwardorupwardpowerproductionfromthelegs

Pelvicpositiondroppedwhenrunning Tight/painfuladductormagnus(innerthigh)Asymmetricalbodyorientation

Faultyhipextensionpattern:adductormagnusbeingoverusedtoextendthehip

Gmaxfunctiondecreasedonsameside

Asymmetricalbodyorientation

Asymmetricalbodyorientation Betterbalanceonesidethantheother Excessivelytightlatissimusdorsi(rememberingthatthedominantarmwilloftenbeslightlylessflexiblethanthenon-dominantone)

Faultyposteriorobliquesling

Gmaxfunctiondecreasedonoppositeside

Table5.3:Gmaxsummary.(Source:Elphinston2013)

GmedAnatomy

Figure6.1:Origin,insertion,action,andnerveinnervationoftheGmed.

FunctionoftheGmed

As explained in chapter 3 the Gmed is predominantly used in the gait cycle,especiallyduring the initialcontactwith thegroundandthestancephaseof thecycle.Broadlyspeaking,theGmedisresponsibleformaintainingthepositionofthepelvisaswewalkfromAtoB.

TheGmedshouldbeassessedineveryrunninginjurythatapatientmaypresentwith.Manyathletespresenttomyclinicwithoveruserunningtypesofinjurytothe lower limb and trunk, and the majority of them present with poor Gmedfunction. I have come to the conclusion that the strength and control of thismuscle is probably the most important overall component in achieving abiomechanically efficient running pattern. This is not so surprising when youconsider that during running you are always either completely in the air ordynamically balanced on one leg.All physical therapist practitioners should beabletoassessandrestoretheGmedfunction.

Let’s takeacloser lookat theanatomyoftheGmed:themuscleattachestotheentire length of the iliac crest, to the external ilium between the posterior andanteriorgluteallines,totheglutealfascia,totheposteriorborderoftheTFL,andtotheoverlyingITB.TheGmedisdividedintothreedistinctportions—anterior,middle, and posterior—which collectively form a broad conjoined tendon thatwraps around, and inserts onto, the greater trochanter of the femur. Themorevertical anterior and middle portions of the Gmed appear to be in a betterpositionforabductingthehipthanisthemorehorizontalposteriorportion.

TherehasbeenmuchdebateoverwhethertheGmedisprimarilyactivatedduringmedial rotation or during lateral rotation. In 2003 a study by Ireland et al.demonstratedthathipabductionandlateralrotationweresignificantlyweakerinfemalesubjectswithpatellofemoralpainthaninmatchedcontrols.Thisweaknessof lateral rotationwas attributed toGmeddysfunction. In contrast,Earl (2005)observedthehighestactivationoftheGmedintasksthatinvolvedacombinationofabductionandmedialrotation.

Asmentionedabove,theGmedhasaposteriorfiberinitsstructureaswellasananteriorcomponent;itistheposteriorfibersthatweastherapistsareconcerned

with.TheGmedposteriorfibersworkinconjunctionwiththeGmax,andthesemusclescontrol thepositionof thehip intoanexternal rotation,whichhelps toalignthehip,knee,andlowerlimbasthegaitcycleisinitiated.

As an example, consider a patient who is asked to walk while the therapistobserves theprocess.When thepatientputs theirweighton their left legat theinitialcontactphaseofthecycle,theGmedisresponsibleinpartforthestabilitymechanismactingonthelowerlimb;thiswillalsoassistintheoverallalignmentof the lower limb.Thepatientcontinueswith thegaitcycleandnowenters thestancephase.TheGmedinthisphaseisresponsibleforabductingtherighthip,whichisthenseentostarttoliftslightlyhigherthantheleftside.Thisprocessisveryimportant,asitallowstherightlegtoswingduringtheswingphaseofgait.

If there is anyweakness in the left Gmed, the bodywill respond in twowaysduring thegaitcycle:either thepelviswill tipdownon thecontralateral side tothe stance leg (right in this case), giving the appearance of a Trendelenburgpatternofgait (figure6.2(a));oracompensatoryTrendelenburgpatternwillbeadopted, in which the patient will be observed to shift their whole trunkexcessivelytotheweakerhip(figure6.2(b)).

Figure6.2:(a)Trendelenburggait;(b)CompensatoryTrendelenburggait.

Whenwe stand on one leg, we activate the lateral sling, which consists of theGmed,Gmin, adductorson the ipsilateral side, and theQLon thecontralateralside (figure 6.3). As explained earlier, if we present with weakness, this is

probably a result ofoveractivation inothermusclesowing to the compensationprocess.PatientswhopresentwithweaknessintheirGmed(posteriorfibers)tendtohaveoveractivityoftheadductorsandITBviatheconnectionfromtheTFL;thepiriformiscanalsohaveanoveractiverole if theGmedposteriorfibersareshowntobeweak.

TheGmediskeytodynamicpelvicstability.Inmyexperience,runnerswithpoordynamic pelvic stability will shorten their stride length and adopt a moreshuffling pattern to reduce the ground reaction force at contact and therebydecreasetheamountofmusclecontrolrequiredtomaintainpelvicposture.

Figure6.3:Lateralsling.

Gmedweaknesswillhaveimplicationsallthewaydownthekineticchain.Fromheelcontacttothemid-stancephase,aweaknessoftheGmedallows:

•excessiveadductionandinternalrotationofthefemur;•thekneetodriftintoavalgusorpossiblyvarusposition;•thelowerlimb(tibia)torotateinternallyrelativetothepositionofthefoot;•increasedweighttransfertothemedialaspectofthefoot;

•increasedpronationoftheSTJ.

AsyoucanseefromtheaboveconsequencesofaweaknessinthefunctionoftheGmed, the athlete is at continual risk of any sports-related injury conditionrelatingtoincreasedand/orprolongedover-pronationoftheSTJ,suchasmedialtibialstresssyndrome(shinsplints),plantarfasciitis,orAchillestendinopathy.

AstrongGmaxandGmedisastableknee.

AssessmentoftheGmed

WheneverI lookatpatientswhopresentwithkneeor lower lumbarspinepain,part of my assessment process includes checking the strength of the glutealmuscles and in particular the Gmed. In this section I will discuss the hipabduction firing pattern test, which is used for determining the correct firingorderofthehipabductors(includingtheGmedmuscle).

HipAbductionFiringPatternTest

To check the firing sequence on the left side, the patient adopts a side-lyingposturewithboth legs togetherand their left legon top. In thissequence, threemuscles will be tested: Gmed, TFL, and QL. The therapist palpates the QLmuscle by placing their right hand lightly on the muscle. Next, to palpate theGmedandTFL,thetherapistplacedtheirfingerontheTFLandtheirthumbontheGmed,asshowninfigures6.4(a)and(b).

Figure6.4:(a)PalpationoftheQL,Gmed,andTFL;(b)Close-upofthehandposition.

Thepatientisaskedtolift their left legintoabduction,afewinchesfromtheirrightleg,whilethetherapistnotesthefiringsequence(figure6.5).Itisimportanttocheck foranycompensatoryorcheating recruitment.The ideaof this test isthatthepatientmustbeabletoabducttheirhipwithout(1)hitchingtheleftsideof their pelvis (hip hitching would mean they were activating the quadratuslumborum),(2)falling intoananteriorpelvic tilt,or(3)allowingtheirpelvis totipbackward.

Figure6.5:Asthepatientabductstheirlefthip,thetherapistnotesthefiringsequence.

ThecorrectfiringsequenceshouldbeGmed,followedbyTFL,andfinallyQLataround 25 degrees of pelvis elevation. If the QL or the TFL fires first, thisindicatesamisfiringsequence,resultinginadaptiveshortness.

Once we have ascertained the firing sequence for hip abduction, we have todecideonthenextstep.MostpatientsfeelthattheyneedtostrengthentheweakGmedmusclebygoingto thegym,especially if theyhavebeentold it isweak,andtheydolotsofside-lyingabductionexercises.ThedifficultyinstrengtheningtheapparentweakGmedmuscleisthatthisparticularexercisewillnot,Irepeatnot, strengthen the Gmed, especially if the TFL and QL are the dominantabductors.Thepiriformiswillalsogetinvolved,asit isaweakabductor,whichcan cause a pelvic/sacroiliac dysfunction, further complicating the underlyingissue.

SotheansweristoinitiallypostponethestrengtheningoftheGmedandfocusonthe shortened/tight tissues of the adductors, TFL, and QL. In theory, bylengthening the tight tissues, the lengthened and weakened tissue will becomeshorterandautomaticallyregainitsstrength.If,afteraperiodoftime(twoweekshas been recommended), the Gmed has not regained its strength, specific andfunctionalstrengthexercisesforthismusclecanbeadded.

GluteusMediusAnterior/PosteriorFibersStrengthTest

TotesttheleftGmed,thepatientadoptsaside-lyingposture,withtheirleft leguppermost.The therapistpalpates thepatient’sGmedwith their righthand,andthepatientisaskedtoraisetheirleftlegintoabduction,afewinchesawayfromtheright leg,andhold thisposition isometrically tostartwith.Placing their lefthandnearthepatient’sknee,thetherapistappliesadownwardpressuretotheleg.

Thepatientisaskedtoresistthepressure(figure6.6);iftheyareabletodoso,theGmedisclassifiedasnormal.

Figure6.6:Thepatientabductingtheirlefthipagainstresistancefromthetherapist.

GluteusMediusPosteriorFibersStrengthTest

Intestingtheleftside,toputmoreemphasisontheposteriorfibersoftheGmed,the therapist controls the patient’s left hip into slight extension and externalrotation, as shown in figure 6.7. The therapist applies a downward pressure asbefore(figure6.8);ifthepatientisabletoresistthisforce,theGmedposteriorfibers are classified as normal. If you want to assess muscular endurance asopposed to strength, ask the patient to hold the abducted leg andmaintain thepositionforatleast30seconds.

Figure6.7:Externalrotationofthehip,whichemphasizestheposteriorfibersoftheGmed.

Figure6.8:Thetherapistappliesadownwardpressuretothepatient’sabductedhip.

Theinformationpresented in table6.1(similar to table5.3 inchapter5for theGmax)willenableyoutoidentifypossiblepainanddysfunctionsthatarerelatedtotheGmed.

Athletepresentswith

Whatcanitimply? Likelyfinding

Swaggerorpendulumgait

Faultyweightbearingstrategy Gmedweakness/timingproblem

Tightquadratuslumborum(sidetrunkmuscles)

Difficultyorientatingthetrunkverticallyoverthepelvisingait,requiringoveruseofsidetrunkmuscles

Gmeddysfunctioneitherside

Tightpiriformis Faultypelviccontrolinweightbearingrequiringgreatercoronalplanecontrol

Gmeddysfunctionsameside

TightITB/lateralkneepain/kneecappain

Faultyhipabductionorhipflexionstrategy

DysfunctionofGmedorpsoas,sameside

Table6.1:Gmedsummary.(Source:Elphinston2013)

SinceIamdiscussinghowtomaximize theglutes through lengthening the tightantagonist muscles, I need to explain the role of muscle energy techniques(METs)sothatyouhaveabetterunderstandingofwhenandwhytoemploythistype of treatment. Physical therapists have a toolbox of various techniques attheirdisposaltohelpreleaseandrelaxmuscles,whichwillthenassistthepatient’sbody topromote thehealingmechanisms.METs, firstdescribedbyMitchell in1948,areonesuchtoolthatifusedcorrectlycanhaveamajorinfluenceonthepatient’s well-being. (The reader is referred to Gibbons (2012) for a fulleraccountofMETs.)

Definition:Muscle energy techniques (METs) are a form of osteopathicmanipulative diagnosis and treatment in which the patient’s muscles areactivelyusedonrequest,fromapreciselycontrolledposition,inaspecificdirection,andagainstadistinctlyexecutedcounterforce.

METsareuniqueintheirapplicationinthatthepatientprovidestheinitialeffortand the practitioner just facilitates the process.Theprimary force comes fromthe contraction of the patient’s soft tissues (muscles), which is then utilized toassist and correct the presenting musculoskeletal dysfunction. This treatmentmethodisgenerallyclassifiedasadirectformoftechniqueasopposedtoindirect,since the use of muscular effort is from a controlled position, in a specificdirection, and against a distant counterforce that is usually offered by thepractitioner.

SomeoftheBenefitsofMETs

When teaching the concept of METs to my students, one of the benefits Iemphasize is their use in normalizing joint range, rather than in improvingflexibility.Thismightsoundcounterintuitive;whatIamsayingisif,forexample,yourpatientcannotrotatetheirneck(cervicalspine)totherightasfarastheycanto the left, theyhave a restriction of the cervical spine in a right rotation.Thenormalrotationalrangeofthecervicalspineis80degrees,butlet’ssaythepatientcanonly rotate70degrees to the right.This iswhereMETscome in.After anMEThasbeenemployedon the tight restrictivemuscles,hopefully thecervicalspinewillthenbecapableofrotatingto80degrees—thepatienthasmadealltheeffortandyou, thepractitioner,haveencouraged thecervical spine intofurtherright rotation.Youhavenow improved the joint range to “normal.”This isnotstretching in the strictest sense—even though the overall flexibility has beenimproved,it isonlytothepointofachievingwhatisconsideredtobeanormaljointrange.

DependingonthecontextandthetypeofMETemployed,theobjectivesofthistreatmentcaninclude:

•Restoringnormaltoneinhypertonicmuscles•Strengtheningweakmuscles•Preparingmusclesforsubsequentstretching•Increasingjointmobility

RestoringNormalToneinHypertonicMuscles

ThroughthesimpleprocessofMETs,weasphysical therapists try toachievearelaxation in the hypertonic shortenedmuscles. Ifwe think of a joint as beinglimited in its ROM, then through the initial identification of the hypertonicstructures,wecanemploythetechniquestohelpachievenormalityinthetissues.Certaintypesofmassagetherapycanalsohelpusachievethisrelaxationeffect,and generally an MET is applied in conjunction with massage therapy. Ipersonally feel that massage with motion is one of the best tools a physicaltherapisthas.

StrengtheningWeakMuscles

METscanbeused in thestrengtheningofweakorevenflaccidmuscles,as thepatientsareasked tocontract themusclesprior to the lengtheningprocess.ThetherapistshouldbeabletomodifytheMETbyaskingthepatienttocontractthemuscle that has been classified as weak, against a resistance applied by thetherapist(isometriccontraction),thetimingofwhichcanbevaried.Forexample,thepatientcanbeaskedtoresistthemovementusingapproximately20–30%oftheirmaximumcapability for 5–15 seconds.They are then asked to repeat theprocess five to eight times, resting for10–15 secondsbetween repetitions.Thepatient’sperformancecanbenotedandimprovedovertime.

PreparingMusclesforSubsequentStretching

In certain circumstances, what sport your patient participates in will bedeterminedbywhatROMtheyhaveattheirjoints.Everybodycanimprovetheirflexibility,andMETscanbeusedtohelpachievethisgoal.Rememberthat thefocusofMETsistotrytoimprovethenormalROMofajoint.

Ifyouwanttoimprovethepatient’sflexibilitypast thepointofnormal,amoreaggressiveMETapproachmightberecommended.Thiscouldbeintheformofasking the patient to contract a bit firmer than the standard 10–20% of themuscle’s capability.For example,we can ask thepatient to contract using, say,40–70%ofthemuscle’scapability.Thisincreasedcontractionwillhelpstimulatemoremotor units to fire, in turn causing an increased stimulation of theGolgitendon organ (GTO). This will then have the effect of relaxing more of themuscle,allowingittobelengthenedevenfurther.Eitherway,onceanMEThasbeenincorporatedintothetreatmentplan,aflexibilityprogramcanfollow.

IncreasingJointMobility

OneofmyfavoritesayingswhenIteachmuscletestingcoursesis:“Astiffjointcanbecomeatightmuscle,andatightmusclecanbecomeastiffjoint.”Doesthisnotmakeperfectsense?

When you use an MET correctly, it is one of the best ways to improve themobility of the joint, even though you are relaxing the muscles initially. The

focusoftheMETistogetthepatienttocontractthemuscles;thissubsequentlycauses a relaxation period, allowing a greaterROM to be achievedwithin thatspecificjoint.

PhysiologicalEffectsofMETs

Postural deviations are described in chapter 2 and by using the techniquesdemonstratedinthisbook,wecaninitiallyidentifywhichmusclesareclassifiedasshortandwhateffects thishasonone’sbodypositionandtherelationship tothe glutes.Once thesemuscles have been identified through the given specifictests, we will be able to use an MET to help correct these dysfunctions; acorrectivetreatmentplancanthenbedesignedtohelpmaximizetheglutes.

TherearetwomaineffectsofMETsandtheseareexplainedonthebasisoftwodistinctphysiologicalprocesses:

•Post-isometricrelaxation(PIR)•Reciprocalinhibition(RI)

WhenweuseMETs,certainneurologicalinfluencesoccur.BeforewediscussthemainprocessofPIR/RI,weneedtoconsiderthetwotypesofreceptorinvolvedinthestretchreflex:

•Musclespindles,whicharesensitivetochange,andspeedofchange,inlengthofmusclefibers

•GTOs,whichdetectprolongedchangeintension

Stretching themuscle causes an increase in the impulses transmitted from themuscle spindle to theposteriorhorn cell (PHC)of the spinal cord. In turn, theanteriorhorncell (AHC) transmitsan increase inmotor impulses to themusclefibers, creating a protective tension to resist the stretch. However, increasedtensionafterafewsecondsissensedwithintheGTOs,whichtransmitimpulsesto the PHC. These impulses have an inhibitory effect on the increased motorstimulusattheAHC.Thisinhibitoryeffectcausesareductioninmotorimpulsesandconsequentrelaxation.Thisimpliesthattheprolongedstretchofthemuscleswill increase the stretching capability because the protective relaxation of theGTOs overrides the protective contraction due to the muscle spindles. A faststretchofthemusclespindles,however,willcauseimmediatemusclecontractionandsinceitisnotsustained,therewillbenoinhibitoryaction.Thisisknownasthebasicreflexarc.

PIRresults fromaneurological feedback through thespinalcord to themuscleitselfwhenan isometriccontraction is sustained,causinga reduction in toneofthe muscle which has been contracted. This reduction in tone lasts forapproximately20–25seconds,duringwhichtimethe tissuescanbemoreeasilymovedtoanewrestinglength.

Figure7.1:The‘stretchreflexarc’.Aquick‘stretchbyhand’toactivatethemusclespindles.

WhenRIisemployed,thereductionintonereliesonthephysiologicalinhibitingeffectofantagonistsonthecontractionofamuscle.Whenthemotorneuronsofthe contracting agonist muscle receive excitatory impulses from the afferentpathway,themotorneuronsoftheopposingantagonistmusclereceiveinhibitoryimpulses at the same time, which prevent it contracting. It follows thatcontraction or extended stretch of the agonist muscle must elicit relaxation orinhibit the antagonist; however, a fast stretch of the agonist will facilitate acontractionoftheagonist.

Figure7.2:Post-isometricrelaxation(PIR),andreciprocalinhibition(RI).

Arefractoryperiod (thebriefperiodneeded to restore the restingpotential)ofabout20secondsoccurswithRI;however,RIisthoughttobelesspowerfulthanPIR.Therapistsneed tobeable tousebothapproaches,because theuseof theagonist may sometimes be inappropriate owing to pain or injury. Since theamount of force used with an MET is minimal, the risk of injury or tissuedamagewillbereduced.

METMethodofApplication

“PointofBind”orthe“RestrictionBarrier”

Inthisbooktheword“bind”ismentionednumeroustimes.Thepointofbind,orrestriction barrier, occurs when resistance is first felt by the palpatinghand/fingers of the therapist. Through experience and continual practice, thetherapistwillbeabletopalpatearesistanceofthesofttissuesastheaffectedareaisgentlytakenintothepositionofbind.Thispositionofbindisnotthepositionofstretch—itisthepositionjustbeforethepointofstretch.Thetherapistshouldbeabletofeelthedifferenceandnotwaitforthepatienttosaywhentheyfeelastretch has occurred. Inmost applications ofMETs, the point of bind, or justshortofthepointofbind,isthepreferredpositioninwhichtoperformanMET.Clearly, an MET is a fairly mild form of stretching compared with othertechniques, so one can assume it is therefore more appropriate in therehabilitationprocess.Itshouldbeborneinmindthatmostproblemswithmuscleshortening will occur in postural muscles. Since these muscles are composedpredominantlyofslow-twitchfibers,amilderformofstretchingisperhapsmoreappropriate.

Procedure

•Thepatient’slimbistakentothepointwhereresistanceisfelt,i.e.thepointofbind.Itcanbemorecomfortableforthepatientifyoueaseofftoapointslightlyshortofthepointofbindintheaffectedareathatyouaregoingtotreat,especiallyifthesetissuesareinthechronicstage.

•Thepatientisaskedtoisometricallycontractthemuscletobetreated(PIR)ortheantagonist(RI),usingapproximately10–20%ofthemuscle’sstrengthcapabilityagainstaresistancethatisappliedbythetherapist.

•ThepatientshouldbeusingtheagonistifthemethodofapproachisPIR;thiswillreleasethetight,shortenedstructuresdirectly.

•IftheRImethodofMETisused,thepatientisaskedtocontracttheantagonistisometrically;thiswillinducearelaxationeffectintheoppositemusclegroup(agonist)thatwouldstillbeclassifiedasthetightandshortened

structures.(SeethePIRexamplebelow.)•Thepatientisaskedtoslowlyintroduceanisometriccontraction,lastingbetween10and12seconds,avoidinganyjerkingofthetreatedarea.Thiscontraction,asexplainedabove,isthetimenecessarytoloadtheGTOs,whichallowsthemtobecomeactiveandtoinfluencetheintrafusalfibersfromthemusclespindles.Thishastheeffectofoverridingtheinfluencefromthemusclespindles,whichinhibitsmuscletone.Thetherapistthenhastheopportunitytotaketheaffectedareatoanewpositionwithminimaleffort.

•Thecontractionbythepatientshouldcausenodiscomfortorstrain.•Thepatientistoldtorelaxfullybytakingadeepbreathin,andastheybreatheout,thetherapistpassivelytakesthespecificjointthatlengthensthehypertonicmuscletoanewposition,whichthereforenormalizesjointrange.

•Afteranisometriccontraction,whichinducesaPIR,thereisarelaxationperiodof15–30seconds;thisperiodcanbetheperfecttimetostretchthetissuestotheirnewrestinglength.

•Repeatthisprocessuntilnofurtherprogressismade(normallythreetofourtimes)andholdthefinalrestingpositionforapproximately25–30seconds.Aperiodof25–30secondsisconsideredtobeenoughtimefortheneurologicalsystemtolockontothisnewrestingposition.

•Thistypeoftechniqueisexcellentforrelaxingandreleasingtoneintight,shortenedsofttissues.

AcuteandChronicConditions

ThesofttissueconditionsthataretreatedusingMETsaregenerallyclassifiedaseitheracuteorchronic,andthistendstorelatetotissuesthathavehadsomeformof strain or trauma.METs can be used for both acute and chronic conditions.Acute involves anything that is obviously acute in termsof symptoms, pain, orspasm, as well as anything that has emerged during the previous three to fourweeks.AnythingolderandofalessobviouslyacutenatureisregardedaschronicindeterminingwhichvariationofMETissuitable.

Ifyoufeel thepresentingcondition is relativelyacute(occurringwithin the lastthreeweeks), the isometric contraction can be performed at the point of bind.After thepatienthascontracted themuscle isometricallyfor thedurationof10

seconds,thetherapistthentakestheaffectedareatothenewpointofbind.

In chronic conditions (persisting for more than three weeks), the isometriccontractionstartsfromapositionjustbeforethepointofbind.Afterthepatienthas contracted the muscle for 10 seconds, the therapist then goes through thepointofbindandencouragesthespecificareaintothenewposition.

PIRversusRI

Howmuchpainthepatientispresentingwithisgenerallythedecidingfactorindetermining which method to initially apply. The PIR method is usually thetechniqueofchoiceformusclesthatareclassifiedasshortandtight,asitisthesemusclesthatareinitiallycontractedintheprocessofreleasingandrelaxing.

However, onoccasion thepatient experiences discomfortwhen the agonist, i.e.theshortenedstructure,iscontracted;inthiscaseitwouldseemmoreappropriateto contract the opposite muscle group (antagonist), as this would reduce thepatient’s perception of pain, but still induce a relaxation in the painful tissues.Hence, theuseof theRImethod, using the antagonists,which areusuallypainfree, will generally be the first choice if there is increased sensitivity in theprimaryshortenedtissues.

When the patient’s initial pain has been reduced by the appropriate treatment,PIRtechniquescanbeincorporated(asexplainedearlier,PIRusesanisometriccontractionofthetightshortenedstructures, incontrast totheantagonistsbeingused in the RImethod). To some extent, themain factor in deciding the bestapproach is whether the sensitive tissue is in the acute stage or in the chronicstage.

AfterhavingusedPIRandRIonaregularbasis,Ihavefoundthatthebestresultsof lengthening the hypertonic structures are achieved with PIR (provided thepatienthasnopainduringthis technique).However,onceIhaveperformedthePIRmethod,ifIfeelmoreROMisneededintheshortenedtighttissue,Ibringinto play the antagonists using the RI method for approximately two morerepetitions. This approach for my patients has had the desired effect ofimprovingtheoverallROM.

PIRExample

We are now going to apply a PIRmethod ofMET treatment to the adductorpollicismuscle (pollicis relates to the thumb, or pollex).Youmight consider itmore appropriate to demonstrate how METs work by means of an examplerelated the glutes; however, I wanted the therapist to be able to practice the

technique on themselves first, so that they can better understand the METconcept. Once the technique has been understood and subsequently practicedusing this simple example, the therapist will then be ready to tackle morecomplexMETswiththeaimofhelpingtorestorefunctiontothevitalglutes.

Place your left (or right) hand onto a blank piece of paper and,with the handopenasmuchaspossible,drawaroundthefingersandthethumb(figure7.3).

Figure7.3:Thedistancebetweenthethumbandfingerismeasured.

Removethepaperandactivelyabductthethumbasfarasyoucan,untilapointofbindisfelt.Next,placethefingersofyourrighthandontopoftheleftthumband, using an isometric contraction, adduct your thumb against the downwardpressureofthefingers,sothatanisometriccontractionisachieved(figure7.4).After applying this pressure for 10 seconds, breathe in, and on the exhalationpassively take the thumb into further abduction (but do not force the thumb).Repeatthissequencetwomoretimesandonthelastrepetition,holdtheisometriccontractionforatleast20–25seconds.

Figure7.4:Adductingthethumbagainstaresistanceappliedbytheoppositehand.

Nowplaceyourhandbackonthepieceofpaperanddrawarounditagain(figure7.5);hopefullyyouwillseethatthethumbhasabductedfurtherthanbefore.

Figure7.5:ThehandredrawnaftertheMETtreatmentusingPIR.

Thefocusofthischapterwillbetoidentifytherelativeshortnessandsubsequenttightnesspatternswithinsofttissuestructures,i.e.specificmusclesthatarepronetoshorteningandbecomingtight. Ihavealreadydiscussedwhytheantagonisticmuscles can become lengthened and weakened; this is applicable to both theGmax and the Gmed, as they are both part of the phasic muscle group. Theremedyisnottostrengthentheso-called“weak”muscles:encouragingstrength-basedexercisewillnot assist these specificmuscles in regaining theirmuscularstrength, since they are held in a weakened position by the short and tightantagonists.

Sherrington’s law of reciprocal inhibition (Sherrington 1907) states that ahypertonicantagonistmusclemaybereflexivelyinhibitingitsagonist.Therefore,inthepresenceofshortandsubsequentlytightantagonisticmuscles,wemustfirstlook at restoring normal muscle tone and/or length before attempting tostrengthenaweakenedorinhibitedmuscle.Theansweristosomehowchangethehypertonicityof these shortenedmusclesby encouraging them to lengthen; thiscanbedonebyusingacombinationofMETs(e.g.PIR)andspecificmyofascialrelease techniques, before we add in specific strengthening exercises for theglutesasdescribedinchapter12.

Kankaanpaaetal. (1998) andO’Sullivanetal. (1997) researched theeffectsofpain inhibition and altered control of lumbopelvic posture on the creation ofimbalances in the activation patterns of global muscles such as the Gmax andGmed. Hungerford et al. (2003) reported that as a result of such imbalances,thesemusclesmaybemoreactivelysubstitutedbythebicepsfemoris,iliopsoas,TFL,andadductormuscles.

Remember which muscles are antagonistic to the glutes? Well, the Gmax inparticularisapowerfulhipextensorsoitsantagonisthastobethehipflexors—the main muscles responsible for hip flexion—specifically the iliopsoas andrectusfemoris.TheGmedisapowerfulhipabductorsoitsantagonisthastobetheadductors.Onewayofencouragingacorrecthipextensionfiringpatternistoidentifyandcorrectahipflexorlengthissue:iftheflexorsaretestedasshort,anMEToramyofascial release techniquecanbeutilized tonormalize the restinglength of these shortened structures. This process of lengthening the shortenedstructurescanbeappliedforaperiodofapproximatelytwoweeks;ifthespecific

firing pattern has not improved after this time, strengthening protocols for theGmaxcanthenbeincorporatedintothetreatmentplanasdescribedlater.

TheantagonistsoftheGmaxandGmedaretherefore:

•Iliopsoas(comprisingthepsoasmajorandiliacus)•Rectusfemoris•Adductors

Thesemuscleswillnowbediscussedinmoredetail.(Thereareotherassociatedmuscles,buttheywillnotbecoveredinthisbook.)

IliopsoasAnatomy

Figure8.1:Origin,insertion,action,andnerveinnervationoftheiliopsoas.

AssessmentoftheIliopsoas

ModifiedThomasTestTotesttherighthip,thepatientisaskedtoliebackontheedgeofacouchwhileholding onto their left knee.As they roll backward, the patient pulls their leftkneeasfarastheycantowardtheirchest,asshowninfigure8.2.Thefullflexionofthehipencouragesfullposteriorrotationoftheinnominateboneandhelpstoflattenthelordosis.Fromthisposition,thetherapistlooksatwherethepatient’srightkneelies,relativetotherighthip.Thepositionofthekneeshouldbejustbelowthe levelof thehip; figure8.2demonstratesanormal lengthof the rightiliopsoas.

Figure8.2:Therightkneeisbelowthelevelofthehip,indicatinganormallengthoftheiliopsoas.

In figure 8.3 the therapist is demonstratingwith their arms the position of theright hip compared with the right knee. You can see that the hip is held in aflexedposition,whichconfirmsthetightnessoftherightiliopsoasinthiscase.

Figure8.3:Atightrightiliopsoasisconfirmed.Atightrectusfemoriscanalsobeseen.

WiththepatientintheModifiedThomasTestposition,thetherapistcanapplyanabduction of the hip (figure 8.4), and an adduction of the hip (figure 8.5). Arange of motion (ROM) of 10–15 degrees for each of these is commonlyacceptedtobenormal.

Ifthehipisrestrictedinabduction,i.e.abindoccursatanangleoflessthan10–15degrees,themusclesoftheadductorgroupareheldinashortenedposition;iftheadductionmovement is restricted, the ITBandTFLareheld ina shortenedposition.

Figure8.4:Restrictedhipadduction,indicatingtightadductors.

Figure8.5:Restrictedhipadduction,indicatingatightITB/TFL.

METTreatmentoftheIliopsoas

To treat the right side, thepatient adopts the sameposition as in theModifiedThomasTestabove.Thepatient’sleftfootisplacedintothetherapist’srightsideandpressureisappliedbythetherapisttoinducefullflexionofthepatient’slefthip.Stabilizingthepatient’srighthipwiththeirrighthand,thetherapistputstheirleft hand just above the patient’s right knee. The patient is asked to flex theirrighthipagainstthetherapist’sresistancefor10seconds,asshowninfigure8.6.

Figure8.6:Thepatientflexestheirrighthipagainstresistancefromthetherapist’slefthand,whilethehipis

beingstabilizedbythetherapist’srighthand.

Following the isometric contraction, and on the relaxation phase, the therapistslowlyappliesadownwardpressure.Thiswillcausethehiptopassivelygointoextensionandwillinducealengtheningoftherightiliopsoas,asshowninfigure8.7.Gravitywillalsoplayapartinthistechnique,byassistinginthelengtheningoftheiliopsoas.

Figure8.7:Thetherapistpassivelyextendsthehiptolengthentheiliopsoas,withtheassistanceofgravity.

Alternatively, it ispossibletocontract theiliopsoasfromtheflexedposition,asshowninfigure8.8.Thisisnormallyusediftheoriginalmethodofactivatingtheiliopsoascausesdiscomforttothepatient.Allowingthehiptobeinamoreflexedpositionwill slacken the iliopsoas,whichwill assist in its contraction and helpreducethediscomfort.

Figure8.8:Thepatientresistshipflexionfromaflexedposition.

The patient is asked to flex their right hip against a resistance applied by thetherapist’s left hand (figure 8.8). After a 10-second contraction, and on therelaxation phase, the therapist lengthens the iliopsoas by taking the hip into anextendedposition,asdemonstratedinfigure8.9.

Figure8.9:Lengtheningoftherightiliopsoas.

Tip:Thepsoasmajorisalsoknownasfiletmignon,whichisapieceofbeeftaken from the tenderloin. A bilateral shortness of the psoas major cancausethepelvistoanteriorlytilt,inturncausingthelumbarspinetoadoptapositionofhyperlordosis.Thiscanresultincompressionofthefacetjoints,leadingtolowerbackpain.

Note: If full sit-ups are performed on a regular basis, the iliopsoas ispredominantly the muscle being used. Repeated sit-ups will make theiliopsoasstrongerandtighter,andresultinweaknessoftheabdominals;thiscanmaintainapatient’slowerbackpain.

To prove the involvement of the iliopsoas, have your patient lie on their backwith their kneesbent.Hold thepatient’s ankles and ask them todorsiflex theirankles while you resist the movement. This will stimulate the anterior chainmusculature,includingtheiliopsoas,whichispartofthischain.Thepatientthenperformsthefullsit-upmovement(mostfit individualswillbeabletodomanysit-ups).

Todeactivateorswitchofftheiliopsoas,thepatientisaskedtoplantarflextheirankles (insteadofdorsiflexing them),or tosqueeze theirglutes.Eitherof theseactionsstimulatestheposteriorchainmusculature,causingtheiliopsoastoswitchoff, as activation of the glutealmuscles results in a relaxation of the iliopsoasthroughRI.Whenthepatientisnowaskedtoperformthesit-up,themovementwillprovetobe impossible,confirmingthat the iliopsoas isgenerally theprimemoverinafullsit-up.

MyofascialTreatmentofthePsoasMajor

Thepsoasmajorcanbeinvolvedinnumerouspatternsofdysfunctiongenerallyinvolving the pelvis and the lumbar and thoracic spines. Some authors suggestthatthelowermedialfiberscancontributetomaintainingahyperlordoticcurve,whereas the upper lateral fibers can contribute to maintaining a flat-backposition.

ThetechniqueIdescribeforthereleaseofthepsoasmajorcanbeveryawkwardto perform correctly because of the anatomy of the muscle and associatedstructuresof the internalorgans.WhatIamtryingtosayis thatyouhavetobeverycarefulwhenattempting topalpateand treat thepsoasmajoras itcanand

willbevery tender,especially if it isheld inashortenedposition.Thephysicaltherapistneedstobeguidedbyanexperiencedtherapistwhentreatingthisareaandshouldnottrytotreatthepsoasmajorjustbyreadingthisbook.

LocatingthePsoasMajorHaveyourpatientsupinewiththeirleftkneebentandthefootflat.Nextlocatetheumbilicusofthepatientandcomeapproximately2″laterallyand2″caudally(downward), as shown in figure 8.10. This particular area enables the physicaltherapisttopalpateandtreatthepsoasmajor.Havethepatientbendtheirkneeasbefore,asthiswillhelprelaxthepsoasmajor.Startbyslowlyandgentlyplacingyour fingertips through the soft tissues until you make contact with a firmerstructure,asshowninfigure8.11.Whenyoufeelthatyouhavelocatedthepsoasmajor,askyourpatienttoliftthatlegoffthecouchaninchandyouwillfeelthecontraction of themuscle, whichwill confirm that you are in the correct area(figure8.12).Ifyoudonotfeelthemusclecontact,youmayneedtomovealittlemoremedially,towardthespine.Onceyouareincontact,thepatientmayreportbeingunabletolifttheleg;thismightbeanindicationofaweakenedmuscleandthatthepressureyouareapplyingiscausinganinhibition.

Figure8.10:Psoasmajorlocationasdrawnontheabdomen.

Figure8.11:Palpationoftheleftpsoasmajorthroughtheabdomen.

Figure8.12:Palpationoftheleftpsoasmajorthroughtheabdomen—leftleglifted.

StartPositionThepatientliessupine,withtheirkneesbent.Thetherapistpalpatestheleftpsoasmajorasexplainedabove,withreinforcementfromthefingersoftheotherhand.Thepatientisthenaskedtoflexthehiptoascertainthecorrectpositioningofthehandsandtoisolatethepsoasmajor,asseeninfigure8.12.Thelateralfibersofthepsoasmajoraretheonesyouaremostlikelytoengage.Ifyouwanttotargetthemedialfibers,keepincontactwiththebulkofthemuscleasyouslowlyrollover it to engage the lower fibers.Thiswill also guide you andhelpmove anyfragilestructuresandvesselsoutthewaybeforeyouapplyfirmerpressure.Thepatientistheninstructedtoslidetheirheelalongthecouchasslowlyastheycanwhile the therapist maintains pressure on the psoas major; this technique isdescribedas “locking” thepsoasmajoras thepatient lengthens themuscle (seefigure8.13).

If this concept isdifficult tounderstand, anotherwayof thinkingabout it is asfollows. Imagine inserting a key into a door; this is analogous to your fingers(key) pressing onto the psoas major (door); the patient straightening their legcorrespondsto“openingthedoor.”

Oncethepatienthasstraightenedtheirlegasfarastheycan,thetherapisteasesoffon thecontactpressurebeingapplied thepsoasmajor,and theprocedure isrepeatedanothertwoorthreetimes,oruntilachangeinthetissuetextureisfelt.

Figure8.13:Patientlengthenstheirleftlegwhilethetherapistappliespressuretotheleftpsoasmajor.

Correctbreathing technique could alsobeverybeneficial to the lengtheningofthepsoasmajorbecauseofthemuscle’sattachmenttothediaphragm.InormallyinstructmypatienttotakeabreathinasIapplypressuretothepsoasmajorwithmyfingertips;asthepatientstraightenstheirleg,Iaskthemtoexhalefullyontherelaxationphase.

VariationsoftheTechniqueThetechniquedescribedaboveiswhatIcallthestartingtechnique,asoncethisisperformed correctly, the technique can be slightly altered to achieve a moredesirableeffect.

As mentioned above, the starting technique is performed by the therapistapplyingpressureto“lock”thetissue;however,sincethetherapist’sfingertipsarein a locked position, a slight pressure can be applied toward the lumbar spine(psoasmajororigin)asthepatientlowerstheirleg.Thismighthavetheeffectofencouragingabetterlengtheningofthepsoasmajor.

Another great technique that I include for lengthening the psoasmajor, whichworksverywellformeinmyclinic,istheuseofthearm.Thestartingpositionofthis technique variation is shown in figure 8.14: the therapist palpates the leftpsoasmajorasthepatientliftstheirleftleg2″offthecouch,whileliftingtheirleftarmoffthecouchat thesametime.Thepatient is thenaskedtobreatheinand start straightening their left leg;while exhaling, the patient is instructed tostretch their arm above their head to try to reach as far as is comfortable, asshown in figure 8.15. This procedure seems to have a tremendous effect onlengtheningthepsoasmajor.

Figure8.14:Patientinthestartingposition,withthetherapistapplyingpressuretotheleftpsoasmajor.

Figure8.15:Patientstraightenstheirleftlegandarm,whilethetherapistappliespressuretotheleftpsoas

major.

Avariationoftheabovetechniqueusingthearmistoaskthepatienttosidebendtotherightattheendofthelengtheningphase,asshowninfigure8.16.

Figure8.16:Patientlengthenstheirleftlegandarmandthensidebendstotheright,whilethetherapistapplies

pressuretotheleftpsoasmajor.

RectusFemorisAnatomy

Figure8.17:Origin,insertion,action,andnerveinnervationoftherectusfemoris.

AssessmentoftheRectusFemoris

ModifiedThomasTestThis test is an excellent way of identifying shortness not only in the rectusfemoris but also in the iliopsoas as explained earlier. To test the right rectusfemoris,thepatientadoptsthepositionasdemonstratedinfigure8.18,inwhichtheyareholdingontotheirleftleg.

Figure8.18:Totesttherightrectusfemoris,thepatientliesonthecouchandholdsontotheirleftleg.Anormal

lengthoftherectusfemorisisshown.

The patient is asked to pull their left knee toward their chest, as this willposteriorlyrotatetheinnominateboneonthatside;thiswillbethetestposition.Fromthisposition, the therapist looksat thepositionof thepatient’srightkneeandrightankle.Theangularpositionofthekneetotheankleshouldbeabout90degrees;anormallengthoftherightrectusfemorisisshowninfigure8.18.

Infigure8.19thetherapistdemonstratesthepositionoftherightkneecomparedwith the right ankle. Here, the lower leg is seen to be held in an extendedposition,whichconfirmsthetightnessoftherightrectusfemoris.Youwillalsonotice the position of the hip—it is held in a flexed position. This indicates atightnessoftheiliopsoasandwasdiscussedearlier.

Figure8.19:Thekneeisheldinextension,indicatingatightrectusfemoris.

METTreatmentoftheRectusFemoris

Thepatientisaskedtoadoptaproneposition,andthetherapistpassivelyflexesthe patient’s right knee until a bind is felt. At the same time, the therapiststabilizes the sacrumwith their right hand, whichwill prevent the pelvis fromrotatinganteriorlyandstressingthelowerlumbarspinefacetjoints.

Note: If you consider the patient to have an increased lumbar lordosis, apillowcanbeplacedundertheirstomach.Thiswillhelpflattenthelordosisandcanreduceanypotentialdiscomfort.

From the position of bind, the patient is asked to extend their knee against aresistanceappliedby the therapist (figure8.20).After a10-secondcontraction,and on the relaxation phase, the therapist encourages the knee into furtherflexion,whichwilllengthentherectusfemoris,asshowninfigure8.21.

Figure8.20:Thepatientextendstheirkneewhilethetherapistappliesresistance.

Figure8.21:Thetherapistpassivelyflexesthepatient’skneetolengthentherectusfemoriswhilestabilizingthe

lumbarspine.

Figure8.22demonstratesafurtherlengtheningattheoriginoftherectusfemoris.The initial contraction is exactly the sameasdepicted in figure8.20.After thecontraction,andontherelaxationphase,thetherapistcontrolsthepositionofthepelviswiththeirrighthandastheyslowlyflexthekneeandextendthehipwiththeirleftarm,bothatthesametime.Thiswillinducealengtheningattheoriginandattheinsertionoftherectusfemoris.

Figure8.22:Thetherapistflexesthepatient’sknee,stabilizesthelumbarspine,andthenextendsthehipjoint.

AlternativeMETTreatmentoftheRectusFemoris

SomepatientsmayfindthatthepreviousMETfortherectusfemorisputsastrainon their lowerback.AnalternativeandpossiblyamoreeffectiveMETfor therectusfemorisisbasedontheModifiedThomasTestposition.

ThepatientadoptsthepositionoftheModifiedThomasTestasdescribedearlier.The therapist controls the position of the patient’s right thigh, and slowly andpassively flexes the patient’s right knee toward their bottom. A bind will bereached very quickly in this position, so take extra care when performing thistechniqueforthefirsttime.

From the position of bind, the patient is asked to extend their knee against a

resistanceappliedbythetherapist(figure8.23).Afterthe10-secondcontraction,and on the relaxation phase, the therapist passively takes the knee into furtherflexion (figure 8.24). This is a very effective way to lengthen a tight rectusfemoris.

Figure8.23:Thetherapistpalpatestherectusfemoris,andthepatientextendstheirknee.

Figure8.24:Thetherapistpassivelyflexesthepatient’skneetolengthentherectusfemoris.

Tip: Bilateral hypertonicity of the rectus femoriswill cause the pelvis toadoptananterior tilt, resulting in lowerbackpaindue to the fifth lumbarvertebrafacetjointsbeingforcedintoalordoticposition.

AdductorsAnatomy

Figure8.25:Origin,insertion,action,andnerveinnervationoftheadductors.

AssessmentoftheAdductors

HipAbductionTestTo test the left side, the patient adopts a supine position on the couch. Thetherapist takesholdof thepatient’s left legandpassivelyabducts thehipwhilepalpatingtheadductorswiththeirrighthand(figure8.26).Whentheyfeelabind,thepositionisnoted;thenormalROMforpassiveabductionis45degrees.Iftherangeislessthanthis,atightleftadductorgroupisindicated.

Figure8.26:Thetherapistabductsandpalpatestheadductorsforbind.

However,thereisanexceptiontotherule.IftheROMislessthan45degrees,itcould be that the medial hamstrings are restricting the movement of passiveabduction. To differentiate between the short adductors and the medialhamstrings, the knee is flexed to 90 degrees (figure 8.27); if the range nowincreases,thisindicatesshortnessinthemedialhamstrings.

Figure8.27:Thekneeisbenttoisolatetheshortadductors.

Insummary,toidentifyifthehamstringsaretherestrictivefactor,thetherapistpassivelyflexesthekneeandthencontinueswiththepassiveabduction,asshowninfigure8.27.IftheROMimproves,thehamstringsaretherestrictivetissuesandnottheshortadductors.

Note: The term short adductor refers to all of the adductormuscles thatattachtothefemur,theexceptionbeingthegracilis.Thisparticularmuscleattachestoapointbelowtheknee,onthepesanserinusareaofthemedialknee,andactsonthekneeaswellasonthehip.

METTreatmentoftheAdductors

Oneofthemosteffectivewaysoflengtheningtheadductors(short)istoutilizeanMETfromthepositionthatisdemonstratedinfigure8.28.Thepatientadoptsasupinepositionwiththeirkneesbentandheelstogether;thehipsareslowlyandpassivelytakenintoabductionbythetherapistuntilabindisfeltintheadductors.

Figure8.28:Thepatientadductstheirlegsagainstresistancefromthetherapist.

From the position of bind, the patient is asked to adduct their hips against aresistance applied by the therapist, to contract the short adductors.After a 10-secondcontraction,andontherelaxationphase,thehipsarepassivelytakenintofurtherabductionbythetherapist(figure8.29).

Figure8.29:Thetherapistlengthenstheadductors.

Tip:Overactivityoftheadductorswillresultinaweaknessinhibitionoftheabductors, in particular the gluteus medius. This can result in aTrendelenburgpatternofgaitasexplainedinchapter6.

Now thinkback to thechapteron thegait cycle, as this is the areaweneed tofocusonwhen trying todecide if thepatient’spresentingkneeor anklepain iscausedbyaweaknessormisfiringoftheglutes.

KneeAnatomy

Figure9.1:Thekneejointandassociatedsofttissuestructures.

CommonKneeInjuries

There are a multitude of conditions and injuries that affect the knee joint. Acommoncomplaintispatellofemoralpainsyndrome(PFPS),whichcausespaintotheanterioraspectoftheknee.Somepatientsmayhaveissueswiththeinternalstructures of the knee, such as the meniscus, which helps stabilize the knee.Soccer players and skiers commonly suffer from medial collateral ligament(MCL) sprains. Another common complaint, especially in runners andmanifestinginthelateralaspectoftheknee,is“runner’sknee”;however,wewillrefer to this conditionby itsmedicalname—iliotibial bandfriction syndrome—whichrelatestothetissuethatisresponsibleforthepain.

Clearly, not all the above-mentioned conditions and injuries result from issueswiththeglutes.However,sincethisbookisdedicatedtomaximizingtheglutes,thequestionIaskyouisthis:Couldthoseinjuriesthatrelatetothekneejointbeadirect,orlikelierstillanindirect,resultoftheglutes?Ifyouranswerisyes,thenthenextquestionIputtoyouis:Howcantheglutesberesponsibleforthepainthatyourpatientispresentingwith?Haveathinkaboutthesetwoquestionsforafewmomentsbeforeyoureadanyfurther.

WhenI teachphysical therapycoursesandIfocuson the injuries that relate tothekneejoint,Igenerallysaytomystudentsorcolleaguesthatwhentheyhavepatients who present with pain, one has to decide if the pain is purely a“symptom”ratherthananactual“cause”oftheirpain.Outofallthejointsinthebody, I consider the knee joint in particular to be theweak link in the kineticchain, but it is commonly not, and I repeat not, the underlining cause of thepatient’spain.

I often say to my students during lectures that the only person interested orfixatedontheareaofpainisthepatient,forobviousreasons.Idonotmeanthatasa therapist Iamnot interested inapatient’spain,becauseclearly it isavitalpieceofinformation.However,beyonditsrelevanceinhistory-taking,thepainismerelya symptomofunderlyingdysfunctionand isoften secondary to the realproblem. It is tooeasy as a therapist tobecomeobsessedwith the areaofpainratherthantryingtodeterminetheunderlyingcause.It isverytemptingtotreatonly the areaofpresentingpain, andyourpatientwill expect this.However, if

everytimeyousawyourpatientsyouweretofocusonandtreatonlytheareaofpain,thenIcanguaranteethatthemajorityofthemwouldnotgetanybetter.

You will need to be like a detective and try to work out the location of thedysfunctions andpossibleweak links that canbe responsible for their pain.AsDr. IdaRolf,who invented thesoft tissue techniqueRolfingandhas taught thephysicaltherapistTomMyers,states,“Whereyouthinkthepainis,theproblemis not.” I fully understand this statement and I hope that when I lecture, themessageismadeclearinwhatIsay.

In discussing the following knee syndromes and the potential causes through aweaknessoftheglutes,Iwilltrymybestnottoovercomplicatetheissueofhowandwhythisweaknesscanberesponsibleforpaintothekneejoint.Iwouldlikemy account to be intelligible to all physical therapists,with the aimof helpingthemachieveabettersuccessratewiththeirpatients.

GmedandGmaxCausingIliotibialBandFrictionSyndrome

TheTFLmuscleattaches to theanterior iliumandconnects to the ITB,a thickband of connective tissue (fascia) that crosses the hip joint. The ITB extendsdistally, continuing down the lateral thigh to insert at Gerdy’s tubercle on thelateral tibial condyle. It alsohas an insertionon the lateral patellar retinaculumandonsomefibersattachingtothebicepsfemoristendon.Asyouwillreadlater,theITBhasadirecteffectonthetrackingmechanismofthepatellofemoraljoint.

WhatIsIliotibialBandFrictionSyndrome?

Iliotibialbandfrictionsyndrome(ITBFS)isawidespreadkneeinjuryinathletes,especiallythosewholiketorunorcycle.Themostcommonsymptomis lateralknee pain resulting from inflammation of the distal portion of the ITB as itcrosses the lateral femoral epicondyle. In some athletes, repetitive flexion andextensionof thekneeresults in thedistal ITBbecoming irritatedand inflamed,causingdiffuselateralkneepain.ITBFScancreatealotoffrustrationinathletesandgenerallyleadstocessationofexercise.AlthoughITBFSiseasilydiagnosedclinically,itcanbeextremelychallengingtotreat.

Figure9.2:Iliotibialbandfrictionsyndrome(ITBFS).

WhenapatientpresentswithITBFS,thepainisgenerallylocalizedatthelateralfemoral epicondyle, on the lateral side of theknee.Most ITBpain tends to beconfinedtopatientswhoparticipateinrunningandoccurslessfrequentlyinthosewhocycle—hencethenamerunner’sknee thatiscommonlyassociatedwiththiscondition.Patientsgenerallycomplainofpainatthelateralsideofthekneeaftertheyhaverunacertaindistance,usuallybetween2and4km.

It isknownthat60–70%of thewalkingorrunningcycle isspenton thestancephase,whichisrestrictedtoonelegata time(with30–40%beingspentontheswingphase).Ifyourecallthelateralslingdiscussioninearlierchapters,weknowthatthestancephaseincorporatestheabductors,adductorsontheipsilateralleg,and the QL on the contralateral leg. Let’s imagine just for a minute that theadductorsaretightandthereforeheldinashortenedposition,and,asaresult,theantagonisticgroup(i.e.theabductors—theGmedinparticular)lengthenthroughreciprocalinhibitionandsubsequentlyweaken.Inthiscasesomethingelseneedstotaketheroleoftheweakabductorsduringthestancephase:thisiswheretheTFLenterstheequation.Eventhoughitdoesnotwanttotaketherole,theTFLsimply has no choice—as I keep mentioning, the body is extremely good atcompensating.OncetheTFLhasadopteditsnewrole,theeffectisanincreasedtension through the ITB, which subsequently causes a potential for friction tooccur at the site where it crosses the lateral side of the knee, i.e. the lateralfemoralcondyle.

Let’s look at it from another angle.We know that the function of themusclesinserting into theITB(TFL) is toabduct the leg.TheGmed,which inserts intothefemur, isalsoanabductor; if thismuscle isweak, theITBwillassist in theroleofabductingandconsequentlybecomeoverworked.TheITB,however,doesnothaveaninsertionthatoffersafavorablemechanicaladvantage:infact,itisata considerable disadvantage for the purpose of hip and leg abduction activity.Therefore,when theGmed isweak, theTFLmust contractmore intensely andoveralongerperiodoftime,thusplacingextrastrainontheITB.

WeknowthatboththeGmaxandtheTFLinsertintotheITBandareresponsiblefor the stabilization of the lower extremity during the stance phase of the gaitcycle.WhentheGmaxisinhibited,theTFLisleftunchecked:thiswillcreateamoreanteriorpulloftheITBoverthelateralfemoralcondyle,whichcanresultin

africtionsyndrome.

Thehipabductors,andinparticulartheglutes,mustsupporttwoandahalftimesthe body weight in single-leg stance and significantly more when running.Weakness inhibition of the glutes, which has been related to ankle instability(BeckmanandBuchanan1995),cancauseasynergisticdominanceoftheTFLinfrontalplanestabilizationofthelowerlimb;this,asexplainedabove,canleadtoafrictionsyndrome.

AstudybyFredericsonetal.(2000)corroboratesthetheorythatGmedweaknessisacontributingfactortoITBFSandconfirmsthatretrainingforstrengthgainsisaneffectivetreatment.Theseauthorsmeasuredhipabductorstrengthinagroupof injured male and female subjects, and found an average deficit of 2% ingluteusmedius strength on the injured side comparedwith the uninjured side.After a six-week retraining program, average hip abductor torque improved by34.9%infemalesand51.4%inmales;22ofthe24injuredathleteswereabletoreturn to pain-free running. Most importantly, no injury recurrences werereportedatasix-monthfollow-up.

GmedCausingPatellofemoralPainSyndrome

WhatIsPatellofemoralPainSyndrome?

Patellofemoralpainsyndrome(PFPS)hasmanynames—chondromalaciapatellae,anterior knee pain,maltracking syndrome, and retropatellar pain, to give but afew. In simple terms, it is the patellofemoral joint that is causing the patient’spain.Theproblemlieseitherinthearticularcartilagelocatedwithinthetrochleargrooveof the femur,or in theunderlyingarticular cartilagebeneath thepatella(orpossiblyinboth).

Figure9.3:Patellofemoralpainsyndrome(PFPS).

Tounderstandhowthistypeofpainoccurs,anunderstandingofthestructureofthe knee joint and the associated patella will be beneficial. The patella is atriangularbonethatrunsinagrooveinthedistalaspectofthefemurcalledthetrochleargroove.Thequadricepstendoninsertssuperiorlyintothepatella,andthepatellaconnectsinferiorlytothetibialtuberositybymeansofatendoncalledthepatellartendon,knownmedicallyastheligamentumpatellae.Oneachsideofthefibroustissuethatsurroundsthekneejointtherearesofttissueattachmentscalledretinaculae; themedial side also receives attachments from the insertion of thefibersofthevastusmedialis(VM)andthevastusmedialisoblique(VMO).

The patellamoves within the trochlear groove as the knee flexes and extends.Incorrect trackingofthepatella in thisgroovecancausefrictionat thesidesofthegroove,whichwilleventuallyleadtopainandinflammation.Inmostcasesofthistypeofkneepainthepatellagenerallytrackslaterallytowardtheoutsideoftheknee.Asaresultoftheexcessivelateraltracking,stresscanalsobeplacedonthe fibrous tissue on the inside of the knee, which can also be a source ofinflammation and pain. Simply put, anything that changes the way the patellamoveswithinthegroovecanleadtoPFPS.

InthediscussiononlateralkneepainImentionedthattheITBhasanattachmentto the lateral patellar retinaculum. Any increase in tension of the ITB willthereforehaveaneffectonthelateralretinaculum,whichwillcausealateraldriftofthepositionofthepatellaandleadtoamaltrackingtypeofsyndrome.Thereisonemuscleinthekneejointthatisabitofananomaly—theVM;whatImeanbycalling it an anomaly is that thismuscle becomes inhibited very quickly whenthereispainandswellingpresentinthejoint.Dr.ChrisNorris(2011)mentionsinhisbookonsportsinjuriesthatittakesonlyasmallamountoffluid—10mL(~□fl.oz.)—tocause inhibitionof theVM,whereas it takesapproximately60mLtocauseinhibitionoftherectusfemoris.Wealsoknowthatrehabilitationofthe VM is more difficult than one imagines, as I have already said that thismuscledoesnotliketoactivateinthepresenceofpainandswelling.Untilthesetwo factors are taken out of the equation, the patient will experience ongoingkneepain.

GmedCausingMCLPainandMeniscalPain

There are other factors regarding theGmed that need tobe taken into accountwhenitisaquestionofmedialorlateralkneepain:“medialkneedrift,”whichisavalguspositionofthetibiofemoraljoint;and,lesscommon,“lateralkneedrift,”which is a varus position of the tibiofemoral joint.When a patient or athleteconsults their physical therapistwithkneepain, theymight havebeen told thatoneofthecausesoftheirkneepainisaweaknessfoundintheGmaxorGmed.Isitnotlogicaltotrytounderstandtheconceptofhowaweaknessoftheglutesisresponsible for their knee pain?TheGmed posterior fibers assist theGmax incontrollingthealignmentofthehipthroughthekneetothefootduringthegaitcycle.IfforsomereasontheGmedposteriorfibersareweak,thekneecandriftmediallywhenwalkingorrunning.

Figure9.4:Thekneejoint,showingthemeniscusandtheMCL.

Whichmuscle isantagonistic to theGmed?Theanswer is theadductors,andifthere is an underlying factor that causes the adductors to become tight andshortened, this might in turn be a causative factor for weakness of the Gmedposterior fibers. If the adductors are short, they are generally in a hypertonicstate. In this case,whenwe contact the ground during the gait cycle, themainstabilizingmuscleofthelateralslingshouldbetheGmed,asthisalsokeepsthealignmentofthepelvis.

Iftheadductorsreceivemoreneuralstimulusfromtheobturatornerve(aswhentheadductorshavebecomethemainstabilizingmuscleinsteadoftheGmed),thiscompensationpatternwillnaturallytakethehipintoanincreasedmedialrotation,adduction,andhipflexion.Asaresult,thekneedriftsmedially(valgusposition)becauseof the increasedmedialrotationof thefemurcausedby thehypertonicadductorsandtheweakenedGmed.AsthiscompensationpatterncontinuesitcanbeprecursorytoloadingoftheMCLandtheunderlyingattachmenttothemedialmeniscus because of the altered biomechanics.Moreover, the lateral meniscuscanalsobeinvolvedowingtoacompressiveforcecausedbytheincreasedvalguspositionoftheknee.

Becauseofthevarusposition,lateralkneedriftisrarelyseeninthesportsinjuryclinic. There is limited information in the literature about this condition andmany physical therapists may not be aware of it. Lateral knee drift can beobserved in a patient performing a single-leg squat if they have aweakness intheirGmedorGmax.Itcanalsooccurwhenanathleteisrunningandtheyhaveananterior-tiltedpelviswithaforwardtrunkposition.Atheel-strikethekneecanbeforcedintoalateralshiftsothattheGmedisoffloadedandthefoot/ankleisforcedintoamoresupinatedposition.Thisexcessivelateraldriftofthekneewillplace increased strain on the medial meniscus because of the increasedcompressionofthevarusposition;itcanalsooverloadtheITBandthepopliteusmuscle.

Atightmusclewillpullthejointintoadysfunctionalposition,andaweakmusclewillallowittohappen.

RelationshipoftheGmedandGmaxtoAnkleSprains

Figure9.5:Theanklejoint,showingthelateralligaments.

Theankleisthemostfrequentlyinjuredjoint,bothinathleticsandindailylife.Ankle sprains are themost common athletic injury, and 70–85% of these areinversion-type sprains. It has been reported that 10–30% of people with acuteinversion-type sprains develop chronic mechanical instabilities as well asfunctionaldeficits,andapproximately80%ofanklesprainsrecur.AccordingtotheUKNationalHealthService(NHS),anklespraininjuriesaccountforaround1–1.5million visits to accident and emergency (A&E) departments in the UKeachyear;itisestimatedthateverydayover27,000peopleintheUSAsprainanankle.

Ongoingrecurrentanklesprainswill,overtime,leadtochronicankleinstabilityissues thatwill then cause kinetic chain dysfunctions. These abnormalitieswillhave a knock-on effect on the homeostasis of the whole body, as theproprioceptiveneuralsenseswillnowbereduced,andthestabilitycompensatorymechanismswillbealtered.

Theankle is averycomplex jointcomprising the talus, tibia, and fibulabones.The lateral ligaments of the ankle are themost susceptible to injury, and it isestimatedthatatheel-strike,uptofivetimesthebody’sweightisloadedontothisjoint.Theanteriortalofibular ligament(ATFL)isgenerallythemostcommonlyinjured,followedbythecalcaneofibularligament(CFL).

Friel et al., in 2006, conducted a study about ipsilateral hip abductorweakness

afteraninversionanklesprain;theirresultsshowedthathipabductionandplantarflexion were significantly weaker on the involved side. They concluded thatunilateral ankle sprains led to weaker hip abduction (Gmed), and suggestedexercisestostrengthenthehipabductorswhendevelopingrehabilitationprotocolsforankleinversionsprains.

Theinfluenceofapreviousanklespraininrelationtothefiringorderandtimingof the posterior trunk and legmuscles during the hip extension firing testwasinvestigatedbyBullock-Saxtonetal. in1994.Thoseauthorsfoundasignificantdifference in the onset of theGmax activity (delayed onset) in the groupwithpreviousanklesprainscomparedwiththecontrolgroup.

In2010Leaveyetal.reportedtheresultsofastudyofthecomparativeeffectsofbalance and strength programs, and a combination of the two, on dynamicpostural control. The authors proposed using two types of strategies formaintaining dynamic postural control, specifically a hip strategy and an anklestrategy.For theankle strategy they suggestedutilizing theperonealmuscles tomaintainbalance,whileforthehipstrategytheGmedmusclewasrecommendedfor correcting balance and posture. They mention that an individual does notusually strengthen the Gmed muscle when attempting to increase dynamicposturalcontrolfollowinga lateralanklesprain.Inmostrehabilitationprotocolsfor an inversion sprain, ankle strength training and proprioception training aretypicallyencouraged,astheseareusedtoregainlossesinbalancethatmayhaveoccurred. It was also suggested that the weakened Gmedmay cause defectivedynamic postural control to worsen, leading to the biomechanics of the entirelower extremity becoming altered; this in turn potentially results in faultymovements,makingindividualspronetofutureankleinjuries.

Schmitz et al., in2002,demonstrated throughanEMGstudy that therewas anincrease inGmed activity during sudden ankle inversion in healthy subjects aswellasinthosewithfunctionallyunstableankles.

LumbarSpineAnatomy

Between each of the five lumbar vertebrae there is a structure known as anintervertebraldisc;intotalwehave23ofthesestructuresinthehumanvertebralcolumn.Adisc ismadeupof three components: a toughouter shell called theannulus fibrosus; an inner gel-like substance in the center called the nucleuspulposus;andanattachmenttothevertebralbodiescalledthevertebralendplate.Aswegetolder,thecenterofthediscstartstolosewatercontent,aprocessthatwillnaturallymakethedisc lesselasticand lesseffectiveasacushionorshockabsorber.

Nerve roots exit the spinal canal through small passageways between thevertebraeandthediscs:suchapassagewayisknownasanintervertebralforamen.Painandothersymptomscandevelopwhenadamageddiscpushesintothespinalcanalornerveroots—aconditioncommonlyreferredtoasaherniateddisc.

Figure10.1:Anatomyofthelumbarspineandtheintervertebraldisc.

DiscHerniation

Herniateddiscsareoftenreferredtoas“bulgingdiscs,”“prolapseddiscs,”oreven“slippeddiscs.”Thesetermsarederivedfromthenatureoftheactionofthegel-likecontentof thenucleuspulposusbeing forcedoutof thecenterof thedisc.Justtoclarify,thediscitselfdoesnotslip;however,thenucleuspulposustissuethatislocatedinthecenterofthedisccanbeplacedundersomuchpressurethatitcancausetheannulusfibrosustoherniateorevenrupture.Theseverityofthedischerniationmaycausethebulgingtissuetopressagainstoneormoreofthespinalnerves,whichcancauselocalandreferredpain,numbness,orweaknessinthe lower back, leg, or even ankle and foot. Approximately 85–95% of discherniations will occur either at the lumbar segments L4–L5 or at L5–S1; thenerve compression caused by the contact with the disc contents will possiblyresultinperceivedpainalongtheL4,L5,orS1nerverootpathway.

Figure10.2:Discherniation.

DegenerativeDiscDisease

Degenerative disc disease (DDD) tends to be linked to the ageing process andreferstoasyndromeinwhichapainfuldisccancauseassociatedchroniclowerbackpain,whichcanradiatetothehipregion.Theconditiongenerallyoccursasa consequence of some form of injury to the lower back and the associatedstructures, such as the intervertebral discs. A sustained injury can cause aninflammatoryprocessandsubsequentweaknessoftheoutersubstanceofthedisc(annulusfibrosus),whichwillthenhaveapronouncedeffectontheinnernucleuspulposus.This reactivemechanismwill createexcessivemovementbecause thedisc can no longer control the motion of the vertebral bodies that are locatedaboveandbelowthedisc.Thisexcessivemovement,combinedwith thenaturalinflammatory response, will produce chemicals that will irritate the local area,whichwillcommonlyproducesymptomsofchroniclowerbackpain.

Figure10.3:Degenerativediscdisease(DDD).

DDD has been shown to cause an increase in the number of clusters ofchondrocytes (cells that form the cartilaginous matrix and consist mainly ofcollagen)intheannulusfibrosus(consistingoffibrocartilage).Overaprolongedperiodoftimetheinnergelatinousnucleuspulposuscanchangetofibrocartilage,andithasbeenshownthattheouterannuluscanbecomedamagedinareasthatallowsomeofthenucleusmaterialtoherniatethrough,causingthedisctoshrinkandeventuallyleadingtotheformationofbonyspurscalledosteophytes.

Unlike the muscles in the back, the discs of the lumbar spine do not have anaturalbloodsupplyandthereforecannothealthemselves;thepainfulsymptomsofDDDcan thereforebecomechronic, eventually leading to further problems,suchasdiscalherniation,facetjointpain,nerverootcompression,spondylolysis,andspinalstenosis.

FacetJointSyndrome/Disease

The facet joints in the vertebral column are located posterior to the vertebralbody, and their role is to assist the spine in performing movements such asflexion, extension, side-bending, and rotation.Depending on their location andorientation,thefacetjointswillallowcertaintypesofmotionbutrestrictothers:forexample,thelumbarspineislimitedinrotation,butflexionandextensionarefreelypermitted.Inthethoracicspine,rotationandflexionarefreelypermitted;extension,however,islimitedbythefacetjoints(butalsobytheribs).

Figure10.4:Facetjointsyndrome.

Eachindividualvertebrahastwofacetjoints: thesuperiorarticularfacet,whichfacesupwardandworkssimilartoahinge,andtheinferiorarticularfacetlocatedbelowit.TheL4inferiorfacetjoint,forexample,articulateswiththeL5superiorfacetjoint.

Likeallothersynovialjointslocatedinthebody,eachfacetjointissurroundedby a capsule of connective tissue and produces synovial fluid to nourish andlubricate the joint. The surfaces of the joint are coated with cartilage, whichhelps each joint to move (articulate) smoothly. The facet joint is highlyinnervatedwithpainreceptors,makingitsusceptibletoproducingbackpain.

Facet joints have a tendency to slide over each other, so they are naturally inconstantmotionwith the spine and, like all types ofweight-bearing joint, theycansimplywearoutandstarttodegenerateovertime.Whenfacetjointsbecome

irritated(thecartilagecaneventear),thiswillcauseareactionoftheboneofthejoint underneath the facet joint to start producingosteophytes, leading to facetjoint hypertrophy, which is the precursor of facet joint disease/syndrome. Thistypeofsyndromeordiseaseprocessisverycommoninmanypatientspresentingwithchronicbackpain.

BackPainandItsRelationshiptotheGlutes

Sohowandwhydoesweaknessoftheglutescausepaintothelumbarspine?

Recall,fromthediscussioninchapter3oftheroleoftheGmedduringthegaitcycle, that a weakness of the Gmed can cause either a Trendelenburg or acompensatoryTrendelenburgpatternof gait.Think about this, and thepossibleconsequencesofthisweakness,forasecond!Asyoustepontoyourleftleg,thelateralslinghastocomeintoplay:theleftGmedisthemainmuscleresponsibleforthecontroloftheheightoftherightsideofthepelvisasyoutrytostabilizeontheleftleg.IftheGmedmuscleontheleftisweak,thepelviswilldip(totheright)asyoubearweight.Thedippingactionwillcausethelumbarspinetosidebend(totheleft)andthefacetjointsontheleftsidetocompress,aswellasthediscandtheexitingnerveroot,resultinginpain.Thisside-bendingtotheleftcanalsocausetheiliolumbarligamentontherightsideofthespine,aswellasotherstructuressuchasthejointcapsuleofthefacetjoints,tobeplacedinastretchedposition,whichcanalsobeasourceofpain.

IftheleftGmedisweak,theoppositeside(right)QLwillcompensateandworkharder as it tries to take on the role of the weak muscle. This increasedcompensatorypatternwillcauseovertimeanadaptiveshorteningoftherightQLthatcanresultintheformationoftriggerpointsandsubsequentpain.

Consider thefollowingscenario:apatientpresents to theclinicwithright-sidedQLpainwhentheywalk/runforacertainlengthoftime.ThephysicaltherapistpalpatestherightQL,saysitis“tight,”andproceedstoreleasethetriggerpointsthat might have developed within the QL. A contract/relax type of technique,suchasanMET,mightthenbeusedtoencouragenormalityofthelengthoftheQL.Thepatientandtherapistareveryhappywiththetreatment.However,asthepatientwalksbacktotheircartheQLpainresumes—why?BecauseaweakleftGmedisforcingtherightQLtoworkalotharderthanithasbeendesignedtodo,andthetherapisthasonlytreatedthepresentingsymptoms!

Continuingnowwiththegaitcycle,youarenowenteringthemid-stancephaseofgait. This is where the tension of the hamstrings should reduce by the naturalanteriorrotationof thepelvisand theslackeningof thesacrotuberous ligament,

andwheretheGmaxshouldtaketheroleofextension.However,iftheGmaxisweak or misfiring, something else has to take this role; since part of theattachmentof theGmax ison the sacrotuberous ligament, the replacementalsoneedstobeattachedtothisligament,asitispartoftheforceclosuremechanism.

AweakormisfiringGmaxmight lead to the creationof several compensatorypatterns. First of all, let’s look at the case when a patient has a weak Gmax,potentially caused by weakness inhibition, commonly known as reciprocalinhibition throughtheantagonistic tightnessof the iliopsoas,rectusfemoris,andadductors.Thissofttissuetightnessoftheanteriormuscleswilllimittheamountof extension of the hip joint during the gait cycle. As a compensation theinnominatebonewillbeforcedtorotatemoreintoananteriorposition,andthecontralateral innominate will be forced to rotating further into a posteriorposition.Thehamstrings,andinparticularthebicepsfemoris,willbepartofthecompensation pattern by assisting the increased anterior rotation of theinnominateasaresultoftheweaknessoftheGmax.Sahrmanin2002suggestedthat if the hamstrings are dominant because of inhibition of the Gmax, ananteriorshearofthetrochantercanbepalpatedduringthepronelegextension.

Thisnowgetsalittlecomplex,asthebitinbetweenthetwoinnominates,i.e.thesacrum,willnowhavetorotateandsidebendabitmorethannormalbecauseofthe increased innominate rotation.The sacrumwillnowhave tocompensatebyincreasing its torsion(rotation inonedirectionandside-bending in theoppositedirectione.g.rotationleft,side-bendingright)) inonedirection,eitheraL-on-Lsacraltorsion(rotationleftontheleftobliqueaxis)asseenbyfig10.5aoraR-on-R sacral torsion (rotation right on the right oblique axis) as shown by fig10.5b.Thelumbarspineasshownbythetwofigureswillhavetocompensatebypotentiallycounterrotatingabitmoreintheoppositedirectiontothesacrum.

Figure10.5:Sacraltorsion:(a)L-on-L;(b)R-on-R.

Thereisanaturalrotationofthesacralandlumbarspinesduringthegaitcycle;however, because of the increased innominate rotation, the sacrum and lumbarspineshavenochoicebuttocompensateaswell.Inbetweenthelumbarspineandthesacrum(L5andS1)thereliesadisc; imaginenowthisdiscbeing“torqued”between the twospinalsegments.Thisactionwillhaveanegativeeffecton thedisc—itislikesqueezingwateroutofasponge,anddiscsdonotlikethattypeofincreasedmotion!

ThoracolumbarFasciaandItsRelationshiptotheGmax

Thethoracolumbarfascia(TLF)isathick,strongsheetofaligamentoustypeofconnective tissue, which connects with, and covers, the muscles of the trunk,hips,andshoulders.ThenormalfunctionoftheGmaxwillbetoexertapullingactiononthefascia, therebytensingits lowerend,asshowninfigure10.6;youcanseefromthediagramthat there isaconnectionbetween theGmaxand thecontralaterallatissimusdorsimusclebymeansoftheposteriorlayeroftheTLF.Bothofthesemusclesconducttheforcescontralaterally(i.e.totheoppositeside)duringthegaitcycle(viatheposteriorobliquesling),whichthencausesincreasedtensionthroughtheTLF.ThisfunctionisveryimportantforrotationofthetrunkandforforceclosurestabilizationofthelowerlumbarspineandtheSIJ.

Figure10.6:Thethoracolumbarfascia(TLF)andtheconnectiontotheGmax.

Thereisalsoaco-contractionofthedeepermusclesoflumbarstability—i.e.theTVAandthemultifidus.Thesemusclesco-contractwhenyoumovea limbandwere discussed in chapter 2. As far as I am aware, there has been nothingpublishedrecentlyabouttheTVAandmultifidusbeingspecificallytriggeredbyengagement of the Gmax. However, I personally think that the TVA muscledefinitely responds toGmaxcontraction, and I suspect that themultifidusdoestoo,astheyallhaveanassociationwiththesacrotuberousligamentofthepelvis(eitherdirectlyorindirectly),whichassistsinforceclosureoftheSIJ.

Hopefully,after reading thischapteryounowhaveanunderstanding that if theGmaxisweakormisfires,itsfunctionoftensingtheTLFisreduced,whichwillcause a natural overactivation of the contralateral latissimus and the ipsilateralmultifidus,aswellasstimulatingothercompensatorymechanisms.

When a patient presents with pain in their body it is the role of the physicaltherapist to determinewhether the pain is the actual cause or a symptom.Thetherapistalsohastodecideifthepresentingpainismusculoskeletalinoriginandnotaresultofotherpathologicaldiseaseprocesses.

Havingperformedathoroughconsultationandphysicalexamination,thephysicaltherapistmightestablishthattheGmax(orpossiblytheGmed)testsasweakorexhibits amisfiring sequence.The therapistmight thencome to the conclusionthatthisweaknessisthemaincausativefactorofthepatient’spresentingpain.

We have already looked at how the relative shortness of the iliopsoas, rectusfemoris,andadductorscanberesponsiblefortheapparentweaknessinhibitionormisfiring of the glutes. These threemuscles are antagonistic to theGmax andGmed,andbecauseof theiranatomicalposition,anyshortness in thesemusclescanresultinacompensatoryneurologicalweaknessinhibitionoftheglutes.

If the therapist determines that the patient’s presenting pain is caused by aweakness or misfiring dysfunction pattern, a lengthening program of theiliopsoas,rectusfemoris,andadductorsshouldbeinstigatedimmediatelyoveraperiod of no less than two weeks, to see if the patient’s symptoms reduce orcease.

However, many times when patients present with pain, and a weakness issuspected tobecaused through inhibitionof theshortantagonisticmusculature,eventhoughthepatientsfollowalengtheningprogramasmentionedearlier,thereis no resolution of the symptoms. Why, might one ask? Well, perhaps theweakness iscausedby theneurological system,but ina totallydifferentway tothatIhavesuggestedthroughoutthisbook.

Statisticsshowthatfouroutoffivepatientswillpresentwithlowerbackpainatsomepointintheirlives.Someofthesepatientswillhavebeentoldthatapainofdiscogenic origin is responsible for their symptoms on the basis of either aphysical examination with specific testing or the results of anMRI (magneticresonanceimaging)scan.Eitherway,thesimplefactisthattheintervertebraldiscisresponsiblefortheirperceivedpain.However,onehastobecarefulhere:theissuenormallyrelatestothecontentofthedisc,i.e.thenucleuspulposus,which

for some reasonhasmigrated itsway through the annulus fibrosus, and is nowtouching a pain-sensitive structure—for example, the posterior longitudinalligament—and,moreimportantly,oneoftheexitingperipheralnerveroots.

Anin-depthstudyoftheneurologicalsystemisnotwithinthescopeofthisbook,asIwanttokeepthediscussionsimple.Iwould,however,liketoexplainacoupleofthingsthatmighthelpyoutounderstandthiscomplexbutfascinatingsystem.

Ialreadymentionedinchapter5thatwhenpatientsandathletestestpositiveforweaknessoramisfiringof theGmaxorGmed,for themuscles tocontract, themuscleneedsanervesupplytobeabletoperformthisfunction!Whichnerve,Ihearyouask?Well,theGmaxisinnervatedbytheinferiorglutealnervefromthe5th lumbarand1stsacralnerveroots(L5,S1).Thelevelbetweenthe5th lumbarsegment and the 1st sacral segment, commonly known as theL5/S1 disc, is animportantarea,asadiscinjuryherecanaffecttheGmax.Typically,ifthereisadisc bulge of some sort at this specific spinal location, the disc content thatprotrudes can make contact either with the exiting L5 nerve root or, morecommonly,with thedescendingS1nerve root.Whenaperipheralnerve root iscontacted in this way by a bulging disc, the sensory component of the nervepathwaywillbeinterrupted,whichwillnormallycauseareferralpatternofpaintoaspecificareaofthebodyknownasadermatome(seefigure11.1).Thediscprotrusioncanalsocauseaninterruptionofthemotorcomponentofthenerveaswellasthesensorycomponent;thiswillaffectthecontractibilityofthosemuscles(includingtheGmax)whichareservedbythisnerve,andwhicharecollectivelyknownasamyotome.

Figure11.1:Dermatomemapofthebody.

TheS1myotomeistestedthroughtheresistedcontractionofthemusclesoftheGmax (figure 11.2), gastrocnemius, and peroneals (figure 11.3).However, onemustbecarefulbecauseifthecontractilepowerofonlytheGmaxistested,andthe same test is not performed on the other two muscles (gastrocnemius andperoneals),onewouldconclude theGmaxisweak throughapossible inhibitionofthetightantagonistsandnot,Irepeatnot, throughaneurologicaldysfunctionoftheS1nerverootcausedbyapotentialdiscprolapse.

Figure11.2:ThepatientcontractstheGmax(S1myotome).

Figure11.3:Thepatientcontractstheperonealmusclegroup(S1myotome).

However,itisnotassimpleasthat,eventhoughIwouldliketosayitis.WhatIam trying to say is that when a patient has a disc protrusion that is pressingagainstanyperipheralnerve root, there isusuallya referralpatternofpain thattendstooriginatefromthelumbarspineandcanmanifestitselfallthewaydownthelegandevenendupinthefoot(sciatica).Ifyoudosuspectanerverootpaincomingfromthelowerleveloftheintervertebraldisc(L5/S1)thenyouhavetobeabitcautiousintermsoftreatment,aspatientscommonlyhaveasubstantialamountofpainandthismightbethecauseoftheweakGmax.

Note: If apatienthas adiscprotrusion touching themotor componentoftheS1nerveroot,theymightbeunabletoplantarflextheirankle(calfraisemovement),becausethisnervecontrolsthecontractionofthetricepssurae(gastrocnemiusandsoleus).

Another neurological test for differentiating between a weakness of theGmaxfrom an S1 nerve root compression and an inhibitionweakness is the use of areflexhammer:theAchillestendonofthegentlydorsiflexedfootistappedtoseeifthereisanormalreflexresponsefromtheS1nerveroot(figure11.4).

Figure11.4:TestingtheAchillesreflexusingareflexhammer.

AsregardstheGmed,thenerveresponsibleforthecontractionofthismuscleisthe superior gluteal nerve, which originates from the L4/L5 level. One cantherefore assume that a confirmeddisc protrusion at this location could be thecauseoftheperceivedweaknessoftheGmedwithanassociatedTrendelenburgpatternofgait,ratherthanashortantagonisticmuscleoftheadductorscausingaweaknessinhibition.

Note:IfapatienthasadiscprotrusionatthelevelofL4/5,theymighthaveaweakness indorsiflexing theirankle(seefigure11.5),since thenerveatthis level controls the contraction of the tibialis anterior and extensordigitorumlongus.

Figure11.5:Thepatientcontractsthedorsiflexors(L4/5myotome).

To differentiate between a weakness of the Gmed from an L4 nerve rootcompression and an inhibition weakness, a neurological test using a reflexhammercanonceagainbeperformed: thepatellar tendonof theflexedknee istappedtoseeifthereisanormalreflexresponsefromtheL4nerveroot(figure11.6).

Figure11.6:Testingthepatellarreflexusingareflexhammer.

HipCapsulitisandtheIliofemoralLigament

Anotherpossiblecauseofweakness inhibitionof theGmax is thejointcapsulehavingtightenedup:thiscausesareflexivespasmintheiliopsoasandhencetheweaknessinhibitionoftheGmax.Today’ssocietyis“addicted”totrunkflexion:whatImeanbythisisthatmostpeopletendtositalot,drivealot,andsleepalot.Thinkofthecommonpositionofthehipjointandtrunkduringthesepositions,and the relevance of the anterior structures such as the iliopsoas, hip jointcapsule,and iliofemoral ligament (seefigure11.7).All theseanteriorstructuresmight become compromised in one way or another by adapting to this flexedposition.

Figure11.7:Hipjointcapsuleandtheassociatedstructures.

Withatightiliopsoasacommonfindingisthattheinnominateboneisanteriorlyrotated on the same side. Imagine, then, a patient with a tight capsule andiliopsoasandananteriorlyrotatedinnominateonthatside.Whentheywalk,thehip has to naturally extend; as they perform this function, the tight structuresmentioned will limit the hip extension movement. To try to compensate, theinnominatebonewill rotate even further into anterior rotation,whichwill havetheeffectofswitchingofftheGmaxandswitchingonthehamstrings,potentiallycausingmicrotraumaand tears.At the same time, theopposite side innominatebonewillrotatefurtherposteriorly.

Asaconsequenceofallthesecompensations,thelumbarspinecanbeforcedintoan extension position known as a lordosis; this increased lordotic position willplaceextraloadingonthefacetjointsofthelowertwolumbarvertebrae(L4/L5),onthefacetjointsofthe5thlumbarand1stsacralsegments(L5/S1),andontheassociatedintervertebraldiscswiththeexitingnerveroots.

Before discussing the actual stabilization exercises for theGmax andGmed, abriefreviewofthefindingsofstudiesthathavebeencarriedoutinthisareawillbeuseful.

LiteratureReview

Borenetal. (2011)conducteda study involvinganEMGanalysisof theGmedand Gmax during rehabilitation exercises performed by 26 healthy subjects.SurfaceEMGelectrodeswereplacedontheGmaxandGmedtomeasuremuscleactivity during the performance of 18 specific exercises. Maximal voluntaryisometriccontraction(MVIC)wascalculatedforeachmusclegroup inorder toexpresseachexerciseasapercentageoftheMVICandtoenableastandardizedcomparison across subjects to be made. Rank ordering of the exercises wasdeterminedusingtheaveragepercentMVICpeakactivityforeachexercise.

Theauthorsconcludedthatfiveoftheeighteenexercisesproducedgreaterthan70%MVICoftheGmedmuscle.Inrankorder,fromthehighestEMGvaluetothelowest,theseexerciseswere:

•Sideplankabductionwithdominantlegonthebottom(103%MVIC)•Sideplankabductionwithdominantlegontop(89%MVIC)•Single-legsquat(82%MVIC)•Openclamshell—level4(77%MVIC)•Frontplankwithhipextension(75%MVIC)

With regard to the Gmax, five exercises recruited that muscle with reportedvaluesgreaterthan70%MVIC.Inrankorder,fromthehighestEMGvaluetothelowest,theseexerciseswere:

•Frontplankwithhipextension(106%MVIC)•Glutealsqueeze(81%MVIC)•Sideplankabductionwithdominantlegontop(73%MVIC)•Sideplankabductionwithdominantlegonthebottom(71%MVIC)•Single-legsquat(71%MVIC)

Oftheselatterexercises,allbutone(theglutealsqueeze)producedgreaterthan70%MVICinbothGmaxandGmedmuscles.

A1999 studybyBaueretal. found thatweight-bearing strengtheningexercisesproduce significantly higher Gmed activity than non-weight-bearing exercises.This may be related to the need for increased muscular control owing to thegreaterexternaltorqueforcesonthefemurandthepelvis.

Earl, in 2005, recommended using the “hip hike” exercise, or standing hipabduction,fortheGmed.Inthatstudythefocuswasonusingopenkineticchainexercises in both the side-lying and standing positions.A blue, or extra-heavy,latex rubber resistance TheraBand was used in the side-lying hip abductionexercise, whereas the standing hip abduction was performed on a multi-hipmachine. Two closed kinetic chain exercises, normally performed as part of alowerextremityrehabilitationand/orstrengtheningprogram,werealsoincluded,namely single-leg squats and lateral step-downs. Although not found inrehabilitationorstrengthening literatureforstrengthening theGmedas theyaregenerally regarded as Gmax exercises, these two exercises are often used in aclinicalsetting.

In2010O’Sullivanetal.conductedanEMGstudyofthethreesubdivisionsoftheGmed in a weight-bearing situation. They analyzed three exercises: static wallsquat (WS), pelvic drop (PD), andwall press (WP).A strong relationshipwasfoundbetweenthemusclesubdivisionsoftheGmedandtheexercisetype.Thisstudydemonstrates that the activationof the three subdivisionsof theGmed issignificantly different, depending on which one of the exercises is performed.TheWPexercisegeneratedthehighestEMGamplitudesinallthreesubdivisions,which suggests that it is an effective isometric strengthening exercise for theGmedand,inparticular,theposteriorfibers.

AfewotherstudieswiththeaimoftestingthestrengthoftheGmedhavebeencarriedoutoninjuredsubjectswithanklesprains,ITBpain,orPFPS;however,noneof thesestudiesofferedanysuggestionsforstrengthening theGmed,eventhoughweaknessofthatmusclewasfoundtobeacontributingfactor.

Because of the involvement of the Gmed in dynamic postural control andlocomotionduringgait,cliniciansrecommendstrengtheningthismusclewhenitis found to be in a weakened state. A study by Ogiwara and Sugiura (2001)

suggested the use of progressive resistance exercises (PREs) using a ten-repetition maximum to strengthen the Gmed. PREs have become the mostcommonlyemployedmethodinaclinicalandrehabilitationsettingforregainingGmedstrength.

Thefindingsofotherauthorsaresummarizedasfollows:

•Distefanoetal.(2009):thebestGmedexercises,inorderofeffectiveness,areside-lyinghipabduction,single-legsquat,andsingle-legdeadlift.

•Distefanoetal.(2009):thetopexercises,inorderofeffectiveness,fortheGmaxaresingle-legsquat,single-legdeadlift,andside-lyinghipabduction.

•Ayotteetal.(2007):thebestexercisefortheGmaxistheforwardstep-up.

•Ayotteetal.(2007):thebestexercisefortheGmedistheunilateralwallsquat.

•BolglaandUhl(2005):thetopexercisefortheGmedisthepelvicdrop.

GmedandSide-LyingAbduction

WhentheGmedisdeterminedtobeweakandmisfiring,itisverytemptingtotrytostrengthenitbyliftingthelegintoabductionwhilelyingonthesideasperthetestprocedureinchapter6(figures6.5and6.6).However,ifyouweretoalsotestforthelengthandstrengthoftheadductors,TFL,andQL,itislikelythatthesespecific muscles will turn out to be tight and strong. If this is the case thenunfortunatelytheactivationoftheTFLandQL,ratherthantheGmed,wouldbeprimarily responsible for the abduction movement (think back to the hipabduction firing pattern test). Remember, too, that the short adductors willprobably be “holding” the Gmed weak because of the neurological inhibitionprocess.ThismeansthatthetwomusclesTFLandQLwillbecomestrongerandsubsequently tighter over time, and the Gmed (which you are trying tostrengthen)willactuallybecomeweakerasaconsequence.

The side-lying abduction is a very common exercise, often performed during“legs,bums,andtums”or“buttsandguts”exerciseclasses.IfthegoalduringthistypeofclassistostrengthentheGmed(becauseitisweakandiscontributingto,

forexample,yourpatient’skneeorbackpain),unfortunatelytheGmedwillnot,Irepeatnot,getstrongeruntilthelengthsoftheadductors,TFL,andQLhavebeennormalized.

GmedandtheUseofOrthoses

In 2005 Hertel et al. conducted a study on the effect of foot orthoses onquadricepsandgluteusmediusEMGactivityduring selectedexercises.Variousorthoses (neutral rear foot post, four-degrees lateral rear foot post, and seven-degreesmedialrearfootpost),aswellnoorthosis,wereusedonthreedifferenttypesoffootposition—pesplanus(over-pronated),pescavus(supinated),andpesrectus (neutral).The analysiswas carriedout for the subjects performing threeexercises—lateralstepdown,single-legsquat,andmaximumverticaljump.

Theauthors found that activationof theGmedandvastusmedialiswasgreaterwith the use of all three types of orthosis, regardless of foot position. Theyconcludedthatoff-the-shelforthosescouldbebeneficialintheactivationoftheGmed and vastusmedialis, regardless of the foot position and type of orthosisused, especially if the single-leg squat and lateral step-down exercises wereperformedinaslowandcontrolledmanner.

RehabilitationMethodology

AnyrehabilitationprogramfortheGmaxandGmedshouldincludesomeifnotallofthefollowingexercises.Ihavesplit themintoopenkineticchainexercisesandclosedkineticchainexercises,beginningwitharelativelybasicexerciseandprogressing to ones that are slightly more complex and subsequently morechallenging. I consider the exercises to be like a “ladder” system forrehabilitation.Ifyouthinkofaladderasasteppingsystem,thenrehabilitationisbasically the same concept.We naturally step onto the first rung of the ladderbeforeclimbinguptherest:rehabilitationoftheglutescanbeconsideredtobeasimilarprocess.

Definition:Anopenkinetic chain exercisemeans that thehandor foot isfreetomoveduringtheexercise(forexampleabicepscurlorahamstringcurl).A closed kinetic chain exercisemeans that the handor foot is fixedandcannotmoveduringtheexercise(forexampleapress-uporasquat).

When the Gmax and Gmed are weak or misfiring they are potentially, in myclassification, “clueless” in respect of what functional role they have to play.Glutesthatfirenormallyandareinherentlystrongwillnaturallyknowwhatjobtheyneedtodoandwhentodoit.Stronggluteswillknowexactlywhentoswitchon to hold the pelvis perfectly level, when to act as shock absorbers, when toabductandextendthehip,whentofirecorrectlytokeepthetrunk,hips,andlegsall in correct alignment, and when to contract to propel us forward. Thesemusclesarefunctionallysynergistic tocorestrengthand toahighlyfunctioningposteriorandlateralmyofascialchain.

IhaveincludedthemajorityofspecificexercisesthatIpersonallyfeelwilltargetthemusclesoftheGmaxandGmedsothatyou,thephysicaltherapist,willhaveabetterunderstandingofhowthesemusclesfunctiontoachieveoptimalalignmentand pelvic stability in your patient/athlete. When the following exercises areperformedasIsuggest,Itrulyhopethatanypainordysfunctionthatyourpatientmightbeexperiencingsomewhereintheirbodywillstarttoreduce.

Youareprobablythinkingthattherearemanymoreexerciseswhichcouldhavebeenincludedinthestrengtheningprogram.Ifeltthatdoingso,however,would

havemadethisbookpurelyagluteexercisebook,whereasmygoalinwritingitwas to help the reader understand how to maximize the glutes through otheravenuesofphysicaltherapyaswellasthroughanexerciseprogram.

Someoftheexercisesmentionthetermdominantleg.Toascertainthedominantleg,theathlete/patientisaskedwhichfoottheyconsidertobetheirbetterkickingfootandthat is thenjudgedtobe thedominantside.Eachexercise isgenerallyperformedfirstwiththedominant legandthenrepeatedwiththenon-dominantleg.

RepsandSets

Before embarking on a training program for the glutes, it is important tounderstandthemeaningofthewords“rep”and“set.”Forexample,someonemaycommentthattheydidthreesetsof12repsontheshoulderpressmachine.Thismeansthattheydid12consecutiveshoulderpresses,hadabreak(rest),andthenrepeatedtheprocessafurthertwotimes.

Definition:Arep(orrepetition)isonecompletemotionofanexercise.Asetisagroupofconsecutiverepetitions.

Thereisnosimpleanswertothequestionofhowmanyrepsandsetsshouldbeperformed, as thenumberof reps requireddependsonmany factors, includingwhere the patient/athlete is in their current training and what their individualgoals are. Remember, the purpose of this book is to improve the optimumfunctionalityof theglutesso thatyourpatient/athletecanperformtheactivitiesneededforeveryday life,aswellasparticipate inanysports-relatedactivities. Isuggestweaimforbetween10and12repetitionsandbetweenoneandtwosetsofeachexercise,atleasttostartwith.

Pleasealsorememberthat,aswithanytrainingprogram,thework-outswillneedtobeprogressive.Forexample,let’ssaythepatientstartswithfourexercisesthatIhavechosenfromtheopen-chainsectionandtheyperformtwosetsof10repsfor each exercise; when the patient gets to the stage where they find theseexercisestoberelativelyeasy,itisthentimetoprogress.Thismighthappenafteroneweekoritmighttakelonger,perhapsthreeorfourweeks.Theexercisecanbemademoredifficultbysimplychangingthenumberofreps,reducingtherestperiodbetweensets,oradding inanotherexercise.Toprogress in theprogram,

youcould,forexample,askthepatienttoeitherincreasethenumberofreps,i.e.perform two sets of 12 reps (instead of 10 reps), or rest for only 30 seconds(insteadof45seconds)betweenthesets.Ihighlyrecommendthateverythingiswrittendown,asitisveryeasytoforgetwhatwasdoneontheprevioustrainingsession—trust me on this! I can guarantee that within a few weeks thepatient/athletewilleasilybedoingthreesetsof12repsforsixorsevendifferenttypesofglutealexercise.

The followingexercisesdonot specify thenumberof repsand setsnext to theexercise diagram, as I want to demonstrate how to perform the individualexercisescorrectly.Refer to theappendix fora “GmaxandGmedStabilizationExerciseSheet:”theblankboxesallowyoutorecordthenumberofrepsandsetsforyourpatient’srehabilitationprogram.

Important note: Please be aware that some of the following exercises,notably the Side/Front Plank, can cause an increase in pressure in thepatient’s body, especially if they have a tendency to hold their breath. Ifthereisanyhistoryofspinaldiscpathology,orevenbloodpressureissues,extracaremustbetakenwhenattemptinganyofthefollowingexercises.Itis recommended that the patient seek the advice of a medically trainedprofessional before starting any strengthening program, and not justperforminggluteal-specificexercises.

OpenKineticChainExercises

Openkineticchain(OKC)exercisesarerehabilitationtechniquesemployedwherethe hand or foot is not fixed and is free to move during the exercise. Mostphysical therapists and trainers employ OKC exercises, especially in a sportscomplexoraclinicalsetting,tostrengthentheglutes,andinparticulartheGmed.Thesetypesofmovementtendtoisolateasinglemusclegroupandasinglejoint;because of this factor, OKC exercises have also been termed non-functionalexercises.

Generally,theGmedisstrengthenedusingaside-lyingstraightlegraiseasthehipismovedintoabduction.Thisisusuallyperformedagainstanelasticresistanceoran ankle cuff weight, and is very common in some exercise classes. Pilatestrainers advise another type of open-chain exercise for the Gmed—the “openclam,” forwhich the client/patient again adopts a side-lying positionwith theirlegsstackedandaneutralpositionofthelumbarspine,butthistimewiththehipsflexedto45degreesandthekneesflexedto90degrees.

TheopenclamisstillregardedasthekingofallexercisesforstrengtheningtheGmed, especially in a rehabilitation and clinical setting. I think this exercise ismore effective, however, in the early phase of rehabilitation, as the exercise isopenchain,which Iconsider tobeof limitedbenefit for functional stabilityoftheweight-bearingphaseofthegaitcycle.

OpenClamExercise

Level1The patient lies on their non-dominant side, with their hips flexed toapproximately 45 degrees, knees flexed to 90 degrees, and feet together, asshown in figure 12.1(a). While keeping their heels together and maintainingactivationoftheircoremuscles,thepatientisinstructedtoexternallyrotatetheirtoplegtobringthekneesapart,asshowninfigure12.1(b).Thismovementwillinducehipabductionwithanexternalrotation.Thepatientisadvisedtostopthemovementwhentheyfeeltheirpelvispositionchangeanditstartstorotate;thisisnormallyaround45degrees.Thepatientisthenaskedtoholdthispositionfor2 seconds (count of two) before returning to the starting position. Once thepatient iscapableofperforming level1withease, theycanproceedto thenextlevel.

Figure12.1:OpenClam:(a)Level1—startposition;(b)Level1—finishposition.

Level2Maintaining the same position as in level 1 (figure 12.1(a)), the patient isinstructedtokeeptheirkneestogetherwhileinternallyrotatingthetophiptoliftthetopfootawayfromthebottomfootuntiltheyreachapositionofbind(figure12.1(c)),beforereturningtothestartposition.

Note:A restriction or a feeling of bind experienced by the patientwhen

performing the motion of internal rotation can be due to a pathologicalchange in the hip joint, for example capsulitis or even a degenerativeprocessofOA.

Figure12.1:(c)Level2—positionofbind.

Level3Thestartpositionisthesameasinlevel2,butwiththetoplegraisedparalleltothe floor (see figure 12.1(d)). Maintaining the height of the knee, the patientinternallyrotatesatthehipbyliftingtheirfoottowardtheceiling(figure12.1(e))untilabindisfelt,beforereturningtothestartposition.Thepatientisthenaskedtoexternallyrotatethehipuntilabindisfelt(figure12.1(f)),beforeloweringthelegbacktothefloortorest.

Figure12.1:(d)Level3—startposition;(e)Level3—internallyrotatedposition;(f)Level3—externallyrotated

position.

Level4The patient positions themselves as in level 3, but with the hip joint at fullextension(seefigure12.1(g)).As in level3, thepatientmaintains theheightofthekneeandexternallyrotatesatthehipbyturningtheirfoottowardtheceiling(figure12.1(h))untilabindisfelt,beforereturningtothestartposition.

12.1:(g)Level4—hipfullyextended,startposition;(h)Level4—hipfullyextended,externallyrotatedposition.

Side-LyingHipAbduction

Level1Thepatientadoptsaside-lyingpositiononthenon-dominantside.Maintaininganeutralpositionofthehipandlumbarspine,thepatientistheninstructedtoflexthehipandkneeofthesupportside,asshowninfigure12.2(a).Oncethepatienthas adopted this position they are then asked to abduct the dominant leg toapproximately30degreeswhilemaintainingneutralspinewiththetoespointingforward,asshowninfigure12.2(b),beforereturningtothestartposition.

Figure12.2:Side-LyingHipAbduction:(a)Level1—startposition;(b)Level1—finishposition.

Level2The patient adopts a side-lying position as in level 1. The only difference thistime is that the patient is instructed to bring their dominant hip into slightextensionandexternalrotation,sothattheirtoesarepointingslightlytowardtheceiling toactivate theposteriorfibersof theGmed,asshown infigure12.2(c).Once they have adopted this position they are asked to abduct their leg toapproximately30degreeswhilemaintainingthispositionofthehipandtoes,asshowninfigure12.2(d),beforereturningtothestartposition.

Figure12.2:(c)Level2—startposition;(d)Level2—finishposition.

SidePlank

Level1Thepatientadoptsaside-lyingpositionwiththedominantlegup.Keepingtheirshoulders, hips, knees, and ankles in linebilaterally, thepatient is instructed torise into a side plank position, with their hips lifted off the floor to achieveneutral alignment of the trunk, hips, andknees (figure 12.3(a)).Allowing theirupper torso to be used as support, the patient is asked to maintain the plankpositionwhilebalancingontheirelbowsandfeet.

Figure12.3:SidePlank:(a)Level1—neutralalignmentinraisedposition.

Level2Thepatientassumesasideplankpositionasinlevel1,withthedominantlegup(figure12.3(a)).Whilebalancingontheirelbowsandfeet,thepatientraisestheirtoplegintoabductionfor2seconds(onerepetition),asshowninfigure12.3(b).Thepatientisinstructedtomaintaintheplankpositionthroughoutallrepetitions.

Figure12.3:(b)Level2—withabduction.

HipExtensiononAllFours

Level1Thepatientstartsinapositiononallfours(figure12.4(a)).Theyareinstructedtoextendtheirdominantlegatthehip,whilekeepingtheirkneeflexed90degreesas the foot is lifted toward theceiling,as shown in figure12.4 (b).Thefoot isliftedtoachieveneutralhipextension,beforereturningtothestartposition.

Figure12.4:HipExtensiononAllFours:(a)Level1—startposition;(b)Level1—footisliftedtowardthe

ceiling.

Level2Thepatientadoptsthepositiononallfoursasinlevel1(figure12.4(a)).Theyareinstructedtoextendthedominantlegatthehip,butthistimekeeptheirkneeinextension as they lift their heel toward the ceiling (figure 12.4(c)), beforereturningtheirlegtothestartposition.Thefullyextendedpositionoftheleginthisexerciseincreasestheleveragetotheglutes.

Figure12.4:(c)Level2—hipandkneeinextension.

FrontPlank

Level1Thepatient adopts aproneposition, restingon their elbows in aplankpositionwiththeirtrunk,hips,andkneesinneutralalignment,asshowninfigure12.5(a).Thepatientisaskedtomaintainthispositionwhileactivatingtheirinnercoreandglutealmusclesforaspecifiedperiodoftime:forexample,theycouldbeginwith10secondsandworkup to15secondsandsoonuntil theyachieve thedesiredtime.

Figure12.5:FrontPlank:(a)Level1—maintainingtheplankposition.

Level2Startingfromtheplankpositioninlevel1(figure12.5(a)),thepatientisaskedtolifttheirdominantlegoffofthefloorforacountoftwoseconds(figure12.5(b)),beforereturningtothestartposition.

Figure12.5:(b)Level2—withhipextension.

ClosedKineticChainExercises

Closed kinetic chain (CKC) exercises are rehabilitation techniques employedwhere the hand or foot is fixed and cannotmove,whichmeans that either thehandorthefootisincontactwithanimmobilesurface,suchasthefloor.CKCexercises are thought to be more functional in the rehabilitation process, andsome authors state that these exercises are utilized more frequently in therehabilitation setting as they are considered safer.CKC exercises are generallycompound movements that incorporate multi-joint planes of motion: forexample,asquatexercisewillincorporatemotionfromthelumbarspine,pelvis,hip,knee,ankle,andfoot.Anexercisethatincludesallthesespecificareasofthebodyisconsideredtobeafunctionalexercise,sincetheyareinvolvedinnormalday-to-day activities as well as playing a part in a sporting environment. CKCexercises, as explained, will involve more than one joint and simultaneouslyincorporatemorethanonemusclegroup,ratherthanfocusingononlyonejointmotionasinthecaseofOKCexercises.

CKCexercises,whenincorporatedintotherehabilitationprogram,canimposea“compressive”typeofforceonthejoints,whereasOKCexercisescanpotentiallyplace a “shearing” type of force on the joint. Nonetheless, OKC and CKCexercises naturally co-exist in any form of strengthening or rehabilitationprogram.

DissociationPatterninLying

Thefollowingtwoinitiationexercisesarebasicallyopenchain;however,Iliketoaddthesespecificexercisesearlyoninaprogram,asIwantthepatient/athletetobe able to feel the exact area that I wish them to be working, before theyprogress.Thepatientneeds tobeawareofwhichmuscle(s) isbeingworked,aswell as actually feel themuscle working. I find it helpful to teach some basicanatomicalknowledge to thepeople Iam lookingafter, so that theyunderstandthestrengtheningprocess.

GlutealSqueeze(Lying)Thepatientliesprone,withtheirfeetshoulder-widthapartandtheirhandslightlyplacedontheirglutes.Theyarethenaskedtomaximallycontracttheirrightgluteandholdfor2seconds(figure12.6(a)),beforerelaxingandrepeatingontheleftside.Oncethepatientisabletodissociatetheleftglutefromtherightoneatleastfive times in succession, theyare asked tomaximally contractbothglutes.Thecontraction is held for 2 seconds (figure 12.6(b)) and then a rest taken for 2seconds,beforerepeatingforthedesirednumberofreps.

Figure12.6:GlutealSqueeze(Lying):(a)Rightgluteonly;(b)Bilateral.

SqueezeandLiftThepatientliespronewiththeirfeetshoulder-widthapartandtheirhandseitherlightlyplacedontheglutesorrestingbythesideofthehead.Theyareaskedto

maximally contract their right glute (figure 12.6(a)). Once they have thecontractiontheyareinstructedtolifttherightleg2″offthecouch,andholdtheposition for2 seconds, as shown in figure12.6(c).Thepatient then rests for2seconds,beforerepeatingontheleftleg.

Figure12.6:(c)Rightglutewithlift.

Progression1:PelvicTilt

Thepatientassumesasupineposition,withtheirhipsflexedto45degrees,theirkneesbentto90degrees,andtheirspinemaintainedinwhatistermedaneutralposition,asshowninfigure12.7(a).Theyaretheninstructedtotilttheirpelvisinanterior andposteriordirections,whichwill cause the lumbar spine to flexandextend.Perhapsamoredescriptiveinstructionistotellyourpatientto“archthelowerback”andthento“flattentheback.”Thegluteswillberesponsiblefortheflatteningcomponent(posteriorpelvictilt)ofthelumbarspine,soaskthepatienttomaximallycontracttheirgluteswhentheyflattentheirback,asshowninfigure12.7(b).Thispositionisheldfor2secondsandthenrepeatedasnecessary.

Figure12.7:PelvicTilt:(a)Neutralpositionofthelumbarspine;(b)Flatteningtheback.

Progression2:PelvicLift

Thepatientadoptsthesamepositionasdescribedforthepelvictilt,maintaininganeutralpositionof the lumbar spine.For thisprogression, thehands areplacednexttotheglutes(thepatientcanalsobeinstructedtopalpatethegluteslightlyifpreferred,sothattheyareawareoftheactivation)(figure12.8(a)).Thepatientisaskedtolifttheirhipsoffthefloorbyusingonly theirglutes,andistoldnottoactivate their hamstrings. Provided the patient has engaged just the glutes, thehipscanbeliftedafewinchesoffthefloorandthispositionheldfor2seconds,asshowninfigure12.8(b),beforeloweringdowntothestartposition.

Figure12.8:PelvicLift:(a)Startposition;(b)Raisedposition.

Progression3:BridgingonaStableSurface

Thepatientbeginsinthesamepositionasforprogression1(figure12.7(a)).Theyare then instructed to lift their pelvis up into a “bridge position” on both legs.Keeping their feet on the floor, the patient raises their hips to achieve neutralalignmentofthetrunkandhips,whilemaintaining90-degreekneeflexion,for2seconds,asshowninfigure12.9,beforeloweringthebodydowntothefloortothestartposition.

Figure12.9:BridgingonaStableSurface.

Progression4:Single-LegBridgingonaStableSurface

Thepatientbeginsinthesamepositionasforprogression1(figure12.7(a)).Theyaretheninstructedtolifttheirpelvisupintothebridgepositiononbothlegsbykeepingtheirfeetonthefloorandraisingtheirhipstoachieveneutralalignmentof the trunk and hips, whilemaintaining 90-degree knee flexion (figure 12.9).Fromthisposition, thepatient isaskedtoextendthekneeof thenon-dominantlegtofullkneeextensionwhilekeepingbothfemursparallel,asshowninfigure12.10.Thepatientholdsthispositionfor2secondsandreturnsthenon-dominantlegtothebridgeposition.Thefullkneeextensionmovementisrepeatedonthedominantlegside,beforeloweringthebodydowntothefloor.Thepatientshouldbeabletofeelmuscleactivationintheglutesandnotinthehamstrings.

Figure12.10:Single-LegBridgingonaStableSurface.

BalanceStabilization

Balance is generally considered to be a static component of fitness; however,functional balance is a dynamic stabilization process involving multipleneurological components. Gmax and Gmed strength-based training should beincorporatedintoanyformoffunctionaltrainingprogram.

Level1:DissociationPatterninStanding

GlutealSqueeze(Standing)Thisexercise is similar to theGlutealSqueeze(Lying)exercise,except that thepatient now standswith the feet shoulder-width apart.With their hands lightlyplacedontheirglutes,thepatientisthenaskedtomaximallycontracttheirrightgluteandholdfor2seconds(figure12.11(a)),beforerelaxingandrepeatingontheleftside.Oncethepatientisabletodissociatetheleftglutefromtherightoneatleastfivetimesinsuccession,theyareaskedtomaximallycontractbothglutes.Thecontractionisheldfor2seconds(figure12.11(b))andthenaresttakenfor2seconds,beforerepeatingforthedesirednumberofreps.

Figure12.11:GlutealSqueeze(Standing):(a)Rightgluteonly;(b)Bilateral.

Level2:Balance

AlternateStandingonOneLegThepatientstandswiththeirlegsaboutshoulder-widthapart,asshowninfigure12.12(a).Theyareaskedtoengagetheweight-bearingdominant-sideGmedandinstructed to lift the non-dominant leg just off the floor, as shown in figure12.12(b).Thispositionisheldfor5seconds,beforereturningthelegtothestartposition.Thetimeisincreasedfrom5secondsto10secondsandsoon,untilthepatientcanmanage30secondswitheaseusingeitherleg.

Figure12.12:AlternateStandingonOneLeg:(a)Startposition;(b)Legraisedoffthefloor.

AsthepatientperformstheAlternateStandingonOneLegexercise,thetherapistshouldlookoutforthefollowingprincipalfaults:1.Excessivelateralshifttotheweight-bearingleg.2.Dippingofthepelvistothecontralateralside(whichmightindicatea

Trendelenburgpatternofgait).3.Instabilityoftheweight-bearingleg(aproprioceptionissuewiththeankle

complex,oraweaknessoftheglutes).4.Medialorlateralkneedrift.

4.Medialorlateralkneedrift.

If any of these four dysfunctional patterns are observed, a potential weaknesswithintheGmedcouldbeindicated.

Progression1:SagittalPlaneOne-LegSwing

The patient stands on their dominant leg and maintains a balanced position(figure 12.12(b)). They are instructed to slowly bring their non-dominant legforward and backward, as shown in figures 12.13(a) and (b). This flexion andextensionmovementofthehipjointwillchallengetheGmedinthesagittalplaneofmotion.Theexerciseisinitiallyperformedfor3reps,beforeswappinglegstoworkthenon-dominantside.Oncethisiscomfortable,thepatientmovesonto5reps,andgraduallyworksupto10.

Figure12.13:SagittalPlaneOne-LegSwing:(a)Flexion;(b)Extension.

Progression2:FrontalPlaneOne-LegSwing

The patient stands on their dominant leg and maintains a balanced position(figure12.12(b)).Theyareinstructedtoslowlyswingtheirnon-dominant legtothe side, away from the body and back toward the body, as shown in figures12.14(a) and (b).This abduction and adductionmovementof thehip jointwillchallengetheGmedinthefrontalplaneofmotion.Theexerciseisperformedfor3reps,beforeswappinglegstoworkthenon-dominantside.

Figure12.14:FrontalPlaneOne-LegSwing:(a)Abduction;(b)Adduction.

Progression3:TransversePlaneOne-LegRotation

The patient stands on their dominant leg and maintains a balanced position(figure12.12(b)).Theyareaskedtoslowlylifttheirnon-dominanthipandkneeto 90 degrees, as shown in figure 12.5(a). From this position, the patient isinstructedtorotatetheirnon-dominanthiptotherightandthenbacktotheleft,as shown in figures 12.15(b) and (c).This rotationalmovement of the hipwillchallengetheGmedinthetransverseplaneofmotion.Theexerciseisperformedfor3reps,beforeswappinglegstoworkthenon-dominantside.

Figure12.15:TransversePlaneOne-LegRotation:(a)Startposition;(b)Rotationleft;(c)Rotationright.

Progression4:HipCirclesonaStableSurface

The patient stands on their dominant leg and maintains a balanced position(figure 12.12(b)). They are asked to place the toes of the non-dominant leglaterallyoveranimaginarypointonthefloor(startingposition).Slightlybendingthekneeofthedominantlegtomaintainbalancecontrol,thepatientisthenaskedto trace the toes of the non-dominant leg around an imaginary circle for onerevolution,asshowninfigure12.16,untilthefootisbackatthestartingposition.

Figure12.16:HipCirclesonaStableSurface.

Level3:BalancewithCoordination

Toprogressively rehabilitate the gluteswe need to add exercises that aremorechallenging, since the patient is consciously controlling the activation of theGmedwhentheyareaskedtostandononeleg.Ifweaddinmovementsthataremorecomplex,thepatientwillcontrolthemotionof,forexample,thearmsbyaconsciousaction,whereasthegluteswillnowstabilizethepelvicpositionthroughasubconsciousaction.

Single-LegStancewithIpsilateralArminTwoPlanesThepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloor,asshowninfigure12.17(a).Oncethispositionismaintained,thepatientisinstructed to lift their ipsilateralarmintoflexion(sagittalplanemovement)andabduction(frontalplanemovement)for10reps,asshowninfigures12.17(b)and(c).Theipsilateralarmliftmeansthatthepatientliftsthearmonthesamesideastheweight-bearingleg(dominantside).

Figure12.17:Single-LegStancewithIpsilateralArm:(a)Startposition;(b)Sagittalplane(flexion);(c)Frontal

plane(abduction).

Progression1:Single-LegStancewithContralateralArminTwoPlanes

Thepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloor(figure12.17(a)).Oncethispositionismaintained,thepatientisinstructedto lift their contralateral arm into flexion (sagittal plane movement) andabduction(frontalplanemovement)for10reps,asshowninfigures12.18(a)and(b).Thecontralateralarmliftmeansthatthepatientliftsthearmontheoppositeside to theweight-bearing leg (dominant side),whichmakes the exercisemorechallengingfortheGmed.

Figure12.18:Single-LegStancewithContralateralArm:(a)Sagittalplane(flexion);(b)Frontalplane

(abduction).

Progression2:Single-LegStancewithIpsilateral/ContralateralArminTwoPlanes—withWeight

Thepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloor while holding a weight, as shown figure 12.19(a). Once this position ismaintained,thepatientisinstructedtolifttheiripsilateralarmintoabductionandflexion for10 reps, as shown in figures12.19(b)and (c).This is then repeatedwith the contralateral arm, as shown in figures 12.19(d) and (e). Lifting thecontralateralarm(thearmoppositetotheweight-bearingleg)makestheexercisemorechallengingfortheGmed.

Figure12.19:Single-LegStancewithWeight:(a)Startposition;(b)Ipsilateralarm—frontalplane(abduction);

(c)Ipsilateralarm—sagittalplane(flexion);(d)Contralateralarm—frontalplane(abduction);(e)

Contralateralarm—sagittalplane(flexion).

Progression3:Single-LegStancewithIpsilateral/ContralateralArm—BicepsCurltoShoulderPress

This exercise is a variation of the progression 2 exercise.When designing andimplementingstrength-trainingprograms,weneedtohaveabitofimaginationtokeep challenging the glutes. I could just keep adding pictures of variousexercises,butthatmightdefeattheobjectofwhatIamtryingtodemonstrate.

Thepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloorwhileholdingaweight,as shown in figure12.20(a).Once thisposition ismaintained, the patient is instructed to flex the elbow of their ipsilateral arm(easierexercise)ortheircontralateralarm(harderexercise)toperformabicepscurlandtocontinueintoashoulderpress,asshowninfigures12.20(b)and(c).

Figure12.20:Single-LegStancewithBicepsCurltoShoulderPress:(a)Startposition;(b)Bicepscurl;(c)

Shoulderpress.

Progression4:Single-LegStancewithContralateralCross-OverArmAbduction

Thepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloor.Theyareaskedtoplacetheirhandonthefrontofthehipoftheirdominantleg,asshowninfigure12.21(a).Oncethispositionismaintained, thepatient isinstructed to lift theircontralateralarm,startingfromthedominant leg tocrossoverthebodyandfinishinabduction(remaininginthefrontalplane)for10reps,asshowninfigure12.21(b).

Figure12.21:Single-LegStancewithContralateralCross-OverArmAbduction:(a)Startposition;(b)Frontal

plane(abduction).

Progression5:Single-LegKneeBendwithContralateralCross-OverArmAbduction

Thepatientstandsonthedominantlegandliftstheotherlegafewinchesoffthefloor(figure2.17(a)).Fromthispositionofsustainedbalance,thepatientbendsthedominantkneeto30degrees,asshowninfigure12.22(a).Oncethispositionismaintained,thepatientisinstructedtolifttheircontralateralarm,startingfromthedominantlegtocrossoverthebodyandfinishinabduction,whiletheyextendtheirknee to full extension at the same time, as shown in figure12.22(b).Thepatientisaskedtoperform10reps.

Figure12.22:Single-LegKneeBendwithContralateralCross-OverArmAbduction:(a)Startposition;(b)

Frontalplane(abduction);(c)Withweight.

Progression6:Single-LegKneeBendwithContralateralCross-OverArmAbduction—withWeight

Thepatient performs the same exercise as in progression5, but nowholding alightweight(figure12.22(c)).

CoreBallSquatAcoreballisplacedagainstthewallandthepatientpositionsthemselvessothatthecoreballislocatedneartheirlowerback,asshowninfigure12.23(a).Fromthisposition, thepatient steps forward slightly,with theirknees shoulder-widthapart. The patient is then asked to activate the inner core and slowly squat(eccentric phase) as shown in figure 12.23(b) until they reach a position ofapproximately90degrees,asshowninfigure12.23(c).Thetherapistmakessurethat the tracking of the patella is toward the patient’s second toe and that thepatelladoesnotpassbeyondthe levelof the toes,as indicatedby thearrows infigure 12.23(c). The patient is then instructed to stand up on the return(concentricphase) foracountof two.Theyarealso instructed to squeeze theirglutesjustbeforetheendphaseofthesquat.

Figure12.23:CoreBallSquat:(a)Startposition;(b)Half-squatposition;(c)Full-squatposition.

Progression1:CoreBallSquatwithBicepsCurl

TheCoreBallSquatexerciseisperformedasexplainedabove,exceptthepatientnow holds a light weight in each hand as shown in the start position in figure12.24(a).Duringtheconcentricphaseofthesquat,thepatientperformsabicepscurl,asshowninfigure12.24(b).Thefinishpositionisshowninfigure12.24(c).

Figure12.24:CoreBallSquatwithBicepsCurl:(a)Startposition;(b)Concentricphaseofsquatwhilecurling

theweight;(c)Finishposition.

Progression2:CoreBallSquatwithShoulderPress

TheCoreBallSquatexerciseisperformedasexplainedabove,exceptthepatientnowholdsa lightweight ineachhand inashoulderpressposition,asshowninfigure12.25(a).Duringtheconcentricphaseofthesquat,thepatientperformsashoulderpress,asshowninfigure12.25(b).Thefinishpositionisshowninfigure12.25(c).

Figure12.25:CoreBallSquatwithShoulderPress:(a)Startposition;(b)Concentricphaseofsquatwhile

pressingtheweight;(c)Finishposition.

Progression3:CoreBallIsometricSquatwithForwardRaise

Thepatientassumesthesquatpositionshowninfigure12.23(c),holdingalightweight in each hand. While maintaining this isometric (static) position, thepatientisinstructedtolifttherightarmuntilitisparallelwiththefloorwhiletheleft arm is resting, as shown in figure 12.26(a). The right arm is then broughtbacktothestartposition,andtheleftarmlifted,asshowninfigure12.26(b).Thewholeprocessisrepeatedforthedesirednumberofreps.Thereisnoeccentricorconcentric squatting motion during this exercise so the glutes are workingisometricallytomaintainthesquatposition.

Figure12.26:CoreBallIsometricSquatwithForwardRaise:(a)Rightarmislifted;(b)Leftarmislifted.

Progression4:CoreBallSquatwithTheraBand

Thisprogression is similar to theCoreBall Squat exercise, theonlydifferencebeingthataTheraBandisplacedaroundtheoutsideofthepatient’skneejoints,as shown infigure12.27(a).Thepatient isencouraged toabductandexternallyrotate thehip joint into theTheraBandandhold this isometricpositionas theyperform the squat,as shown in figures12.27(b)and (c).Useof theTheraBandemphasizes the abduction and external rotation component of the Gmax andGmed; there will also be a reciprocal inhibition of the adductors (switch ofmechanism).

Figure12.27:CoreBallSquatwithTheraBand:(a)Startposition;(b)Midwayposition;(c)Finishposition.

Progression5:CoreBallSquatwithTheraBandandBicepsCurl

Thisexercise isexactly thesameas thesquatwithacoreballandaTheraBandplacedaroundthepatient’sknees,exceptthepatientnowholdsalightweightineachhand, as shown in figure12.28(a).Theyare instructed toperforma squatfrom the 90-degree position to the finish position (concentric phase) whileperformingabicepscurlwiththeweightandapplyingresistanceisometricallytothe TheraBand, as shown in figure 12.28(b). The finish position is shown infigure12.28(c).

Figure12.28:CoreBallSquatwithTheraBandandBicepsCurl:(a)Startposition;(b)Concentricphaseof

squatwhilecurlingtheweight;(c)Finishposition.

Progression6:CoreBallSquatwithTheraBandandShoulderPress

Asavariationofprogression5, thepatientholdsa lightweight ineachhandintheshoulderpressposition,asshowninfigure12.29(a).Thepatientisthenaskedto perform a concentric squat movement from the 90-degree position whileperformingashoulderpresswiththeweightandapplyingresistanceisometricallyto theTheraBand, as shown in figure12.29(b).The finishposition is shown infigure12.29(c).

Figure12.29:CoreBallSquatwithTheraBandandShoulderPress:(a)Startposition;(b)Concentricphaseof

squatwhilepressingtheweight;(c)Finishposition.

Progression7:Single-LegCoreBallSquat

ThisprogressionissimplytheCoreBallSquatexerciseperformedononeleg.Acoreball isplacedagainst thewall and thepatientadoptsaposition so that theballislocatedneartheirlowerbackasintheaboveexercises.Fromthisposition,thepatientstepsforwardslightly,withtheirkneesshoulder-widthapart,andliftstheirnon-dominant lega few inchesoff the floor, as shown in figure12.30(a).Theyare instructed toslowlysquat to45degrees,progressing to90degrees,asshowninfigure12.30(b).

Figure12.30:Single-LegCoreBallSquat:(a)Startposition;(b)90-degreesquatposition.

LateralWalkwithTheraBandThepatient standswith their feet flat, their legsshoulder-widthapart,and theirbackinaneutralposition.ATheraBandisthenplacedaroundtheirmid-thigh,asshowninfigure12.31(a).Thepatientisaskedtolift theirnon-dominantleg(sothattheyarebalancingonthedominantleg)andtosteptotheside,asshowninfigure12.31(b).Theyare then instructed to return this leg to the startposition,beforerepeatingthesamesteppingmovementwiththeotherleg,asshownfigure12.31(c).Insteadofthesteptotheside,asmalllungecanbeaddedlateron.

Figure12.31:LateralWalkwithTheraBand:(a)Startposition;(b)Dominantlegfixed;(c)Non-dominantleg

fixed.

Single-LegSquatThepatient standswith their feet flat, their legsshoulder-widthapart,and theirbackfacingachair.Theyareaskedtolifttheirnon-dominantleg,sothattheyarebalancing on the dominant leg. The patient is then instructed to slowly lowerthemselvesdownbyperformingasquat,asshowninfigure12.32.Theycontinuetothepointwheretheirbuttocksareinlightcontactwiththechair,beforeslowlyextendingthehipstoreturntothestartposition.

Figure12.32:Single-LegSquatintoaChair.

StepandLungeWalkThis exercise combines theGmax andGmed—if I am honest, it is one ofmyfavoriteexercises.

Phase1:Step

The patient stands with their legs shoulder-width apart, as shown in figure12.33(a),andstepsforwardusingthenon-dominantleg,sothattheirfootisflatandincontactwiththefloor.Thedominantlegisnowpositionedinsuchawaythat thepatient’sbalance ismaintainedbythe toesof thedominantfoot(figure12.33(b)).

Figure12.33:StepandLungeWalk:(a):Phase1—startposition;(b)Phase1—forwardstep.

Phase2:Lunge

Fromthebalancedpositioninfigure12.33(b),thepatientistoldtoimaginethattheyarenowholdingineachhandabucketofwaterwhichisfulltothetop.Thepatientisaskedtolowertheimaginarybucketstothefloorwithoutspillinganyofthewater.Thetherapistmakessurethatthepatient’skneedoesnotpassthelevelof their toesand that itdoesnotdriftmediallyor laterally (figure12.33(c)). Iftheyareable, thepatientrepeats this loweringmovement,beforeprogressingtophase3oftheexercise.

Figure12.33:(c)Phase2—lunge.

Phase3:Hold

After the second repetition, the patient is instructed to rise from the loweredposition (concentric phase) until the weight-bearing dominant leg is at fullextensionandthepatientisinastateofcontrolledbalanceusingthetoesofthenon-weight-bearingnon-dominantleg(figure12.33(d)).

Figure12.33:(d):Phase3—hold.

Phase4:Steptorepeat

Thestepand lungeactionsarenowrepeatedwith theopposite leg,asshown infigure12.33(e).

Figure12.33:(e):Phase4—stepwithoppositeleg.

Progression1:ThoracicRotation

OncethepatienthasmasteredtheStepandLungeWalkexercise,andtheyhavegood techniqueperforming the specificmovements,wecanchallenge thebodyby including some additional actions. This will start to activate and focus thebrain on another exercise component and therefore take some of the emphasisawayfrom thepatientalwayshaving toconsciously thinkaboutactivating theirglutes all the timewhile they exercise.The glutealmuscle group, once trained,shouldautomaticallycontractasandwhenitisrequiredtodoso,ratherthantheconsciousmindbeingforcedtotelltheglutestoswitchon.

In thisprogression, theonlydifference to theStepandLungeWalkexercise isthatwhenthepatientstepsforwardinphase2,theyareinstructedtorotatetheirthoracicspinebyusingtheirarms,asshowninfigure12.34(a).Whenthepatientmoveson toperformphase4, they rotate to theother side, as shown in figure12.34(b).

Figure12.34:StepandLungeWalkwithThoracicRotation:(a)Rotationtotheleft;(b)Rotationtotheright.

Progression2:WithWeight

InthisprogressionoftheStepandLungeWalkexercise,thedifferenceistheuseof weights, for example dumbbells. The exercise is the same as before, butholdingaweightineachhand:thepatientstepsforwardandperformsthelunge,withthedominantlegleading,asshowninfigure12.35(a).Theexerciseisthenrepeatedusingthenon-dominantleg,asshowninfigure12.35(b).

Figure12.35:StepandLungeWalkwithWeights:(a)Dominantlegleading;(b)Non-dominantlegleading.

Double-LegBoundThepatientstandsonalinemarkedonthefloorandslowlyflexesatthehipintoasquatposition,as shown infigure12.36(a).Keeping their spine inneutral, theyareaskedtoboundorjumpto thenextmarked linebyextendingat thehip,sothatbothfeetareoffthefloor,asshowninfigure12.36(b).Thetherapistmakessurethatwhenthepatientlandsonthesecondline,theirkneesarenotallowedtodriftmediallyorlaterally,asthismightindicateglutealweakness.Itmustalsobeensured that the patient’s knees do not pass beyond the level of their toes, asshowninfigure12.36(c).

Figure12.36:Double-LegBound:(a)Startposition;(b)Mid-airposition;(c)Finishposition.

Single-LegDeadLiftThepatientstandsontheirdominant legandisaskedto lift theirnon-dominantlegoffthefloorandintoextension,asshowninfigure12.37(a).Theyareaskedto slowly flex at the hip, keeping the back straight, in order to touch the floorwith the opposite hand for a count of two, as shown in figure 12.37(b). Thepatientistheninstructedtoextendatthehiptothestandingpositionforacountoftwo.Thelegiskeptstraight,butitispermissibleforittobeslightlybentinacasewherehamstringtightnesslimitstheabilitytotouchthefloor.

Figure12.37:Single-LegDeadLift:(a)Startposition;(b)Flooristouchedwithoppositehand.

PelvicDropThepatientstandsontheedgeofa4″(10cm)stepwith theirdominant leg,asshowninfigure12.38(a).Theyareaskedtodiptheirpelvisinordertolowertheheelof thenon-dominant leg,so that thefoot touches thefloorwithoutbearingweight, as shown in figure 12.38(b). While keeping their hips and kneesextended,thepatientisinstructedtoreturntheirfoottoapositionslightlyhigherthantheheightof thestep,asshowninfigure12.38(c), inorder toactivate theGmed.

Figure12.38:PelvicDrop:(a)Startposition;(b)Pelvisisdipped;(c)Finishposition.

ForwardStep-UpThepatient stands facinga6–8″ (15–20cm)step,as shown in figure12.39(a).Theyareinstructedtostepforwardontothestepwiththeirdominantlegleading(figure 12.39(b)) and then step forward and up with their non-dominant leg(figure 12.39(c)). The patient lowers their non-dominant leg back to the floor,followedbytheirdominantleg,andtheprocessisrepeated.

Figure12.39:ForwardStep-Up:(a)Startposition;(b)Stepwithdominantleg;(c)Stepwithnon-dominantleg.

LateralStep-Down-UpThis exercise is similar to the forward step-up, but this time the patient standssideways on top of a 6–8″ (15–20 cm) step, as shown in figure 12.40(a). Thepatientisinstructedtolifttheirdominantlegandputthatfootonthefloor(figure12.40(b)).Aftercontactingthefloor,thelegisliftedandplacedbackonthestepinthestartpositionbythecontractionofthegluteofthenon-dominantleg.Thestepmovementisthenrepeatedontheoppositeside,asshowninfigure12.40(c).

Figure12.40:LateralStep-Down-Up:(a)Startposition;(b)Stepwithdominantleg;(c)Stepwithnon-dominant

leg.

Progression:LateralStep-Down-UpwithLunge

Thisexerciseissimilartothepreviousone,theonlydifferencebeingthatalungeisnowincluded.Thepatientisaskedtolifttheirdominantlegandplacethatfootonto the floor. When the foot contacts the floor, the patient is instructed toperformalunge(figure12.41(a)).Thelegisthenliftedoffthefloorandplacedbackinthestartpositionbythecontractionoftheglutesofthenon-dominantleg.Thestepandlungemovementisthenrepeatedontheoppositeside,asshowninfigure12.41(b).

Figure12.41:LateralStep-Down-UpwithLunge:(a)Dominantleg;(b)Non-dominantleg.

Appendix:GmaxandGmedStabilizationExerciseSheet

The following exercises can be used in the physical therapist’s own clinicalsetting.Foreachexercise there isablankspace inwhichapatient’s repetitionsandsetscanberecorded.

OpenKineticChain

—ToDownloadthisPDF,clickhere.

ClosedKineticChain

—ToDownloadthisPDF,clickhere.

Bibliography

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Index

A&E.seeAccidentandemergency(A&E)Accidentandemergency(A&E)ACJ.seeAcromioclavicularjoint(ACJ)Acromioclavicularjoint(ACJ)Activerangeofmotiontests(AROMtests)Adductors,8.1.seealsoAntagonisticmuscles;action,8.2;assessmentof,8.3;hip

abductiontest,8.4,8.5;insertion,8.6;METtreatmentof,8.7;nerve,8.8;origin,8.9;shortadductor,8.10

AHC.seeAnteriorhorncell(AHC)Alternatestandingononeleg,12.1.seealsoBalancestabilization;frontalplane

one-legswing,12.2;hipcircling,12.3;principalfaults,12.4,12.5;sagittalplaneone-legswing,12.6;transverseplaneone-legrotation,12.7

Ankle,9.1;andfootposition,4.1,4.2;inheel-strike,3.1;joint,9.2;over-pronationsyndrome,4.3,4.4;sprains,9.3

AnnulusfibrosusAntagonisticmuscles,8.1,11.1.seealsoAdductors;Gluteusmaximus(Gmax);

Gluteusmedius(Gmed);Iliopsoas;RectusfemorisAnteriorhorncell(AHC),seealsoMuscleenergytechnique(MET)Anteriorsuperioriliacspine(ASIS)Anteriortalofibularligament(ATFL)AROMtests.seeActiverangeofmotiontests(AROMtests)ASIS.seeAnteriorsuperioriliacspine(ASIS)ATFL.seeAnteriortalofibularligament(ATFL)

Backpain.seealsoGluteusmaximus(Gmax);Gluteusmedius(Gmed);causesandreason,11.1;dermatome,11.2;L5/S1disc,11.3;lowerbackpain,11.4;myotome,11.5;reciprocalinhibition,10.1;relationshiptoglutes,10.2

Balance,12.1,12.2;withcoordination,12.3Balancestabilization,12.1.seealsoAlternatestandingononeleg;Coreballsquat;

Lateralstep-down-up;Single-legstance;Stabilizationexercises;Stepandlunge

walk;dissociationpatterninstanding,12.2;double-legbound,12.3;forwardstep-up,12.4;glutealsqueeze,12.5;lateralwalkwiththeraband,12.6,12.7;pelvicdrop,12.8;single-legdeadlift,12.9;single-legsquat,12.10

Basicreflexarc,seealsoMuscleenergytechnique(MET)Bulgingdiscs.seeHerniateddisc

Calcaneofibularligament(CFL)Centerofgravity(COG)CFL.seeCalcaneofibularligament(CFL)CKCexercises.seeClosedkineticchainexercises(CKCexercises)Closedkineticchainexercises(CKCexercises),12.1,12.2.seealsoOpenkineticchainexercises(OKCexercises);Squeezeandlift;Stabilizationexercises;dissociationpatterninlying,12.3

COG.seeCenterofgravity(COG)Coreballsquat,12.1.seealsoBalancestabilization;withbicepscurl,12.2;isometricsquatwithforwardraise,12.3;withshoulderpress,12.4;single-leg,12.5;withtheraband,12.6,12.7;withtherabandandbicepscurl,12.8;withtherabandandshoulderpress,12.9

Coremusclerelationships,2.1.seealsoMuscleimbalance;Myofascialsling;forceclosure,2.2;forceclosureligaments,2.3;forcecouple,2.4;formclosure,2.5;form/forceclosureandsacroiliacstability,2.6;sacralcounternutation,2.7;sacralnutation,2.8,2.9;sacroiliacstability,2.10

Counterrotation

DDD.seeDegenerativediscdisease(DDD)Degenerativediscdisease(DDD),seealsoGluteusmaximus(Gmax);Gluteusmedius(Gmed)

Dermatome,1.1,11.1Discherniation.seeHerniateddiscDiscprotrusion,11.1,11.2Double-legbound,seealsoBalancestabilizationDysfunctionalglutes

Electromyography(EMG)EMG.seeElectromyography(EMG)

Facetjointsyndrome/disease,seealsoGluteusmaximus(Gmax);Gluteusmedius(Gmed)

FacetjointsFiletmignon.seePsoasmajorFlat-backposture,seealsoPoorpostureForce;closure,1.1;couple,2.1.seealsoCoremusclerelationshipsFormclosureForwardstep-up,seealsoBalancestabilizationFrontplank,12.1.seealsoOpenkineticchainexercises;level1,12.2;level2,12.3

Functionalbalance

Gaitcycle,3.1.seealsoLeglengthdiscrepancy(LLD);Myofascialsling;Trendelenburggait;heelstrike,3.2,3.3;myofasciallink,3.4;pelvismotion,3.5;sacralrotationandlumbarcounterrotation,3.6

GlobalmusclesGlutealsqueeze,12.1,12.2.seealsoBalancestabilization;Closedkineticchainexercises

Glutes.seealsoBackpain;Gluteusmaximus(Gmax);Gluteusmedius(Gmed);andbackpain,10.1,10.2;reciprocalinhibition,10.3;weaknessinhibitiondiagnosis,11.1

Gluteusmaximus(Gmax),1.1,1.2,5.1,5.2,6.1,8.1.seealsoAntagonisticmuscles;Backpain;Degenerativediscdisease(DDD);Facetjointsyndrome/disease;Gluteusmaximusanatomycasestudy;Gluteusmedius(Gmed);Herniateddisc;Iliotibialbandfrictionsyndrome(ITBFS);Knee;Lumbarspineanatomy;Patellofemoralpainsyndrome(PFPS);Stabilizationexercises;action,5.3;anatomy,5.4;anklesprains,9.1,9.2;antagonistsof,8.2;assessmentof,5.5;discprotrusion,11.1,11.2;fibers,2.1;functionof,5.6;hipextensionfiringpatterntest,5.7;iliotibialbandfrictionsyndromeby,9.3;insertion,5.8;lumbarspinepainby,10.1;nerve,5.9;neurologicalinhibition,5.10;origin,5.11;posteriorobliqueslingandconnectionwithlatissimusdorsi,5.12;S1myotome,11.3,11.4;testingAchillesreflex,11.5;thoracolumbarfascia10.2

Gluteusmaximusanatomycasestudy,5.1.seealsoGluteusmaximus(Gmax);onexamination,5.2,5.3;exercisehistory,5.4;firingpatternassessment,5.5;hyperlordoticposition,5.6;innominateposteriortilt,5.7;treatment,5.8

Gluteusmedius(Gmed),3.1,6.1,6.2,8.1.seealsoGluteusmaximus(Gmax);action,6.3;anatomy,6.4;anklesprains,9.1,9.2;antagonistsof,8.2;anterior/posteriorfibersstrengthtest,6.5;assessmentof,6.6;compensatory

trendelenburggait,6.7;fiberstrengthtest,6.8,6.9;functionof,6.10;hipabductionfiringpatterntest,6.11,6.12;iliotibialbandfrictionsyndromeby,9.3;insertion,6.13;L4/5myotome,11.1;lateralsling,6.14;lumbarspinepainby,10.1;MCLpainandmeniscalpainby,9.4,9.5;nerve,6.15;origin,6.16;andorthoses,12.1;patellofemoralpainsyndromeby,9.6;portions,6.17;andside-lyingabduction,12.2;testingpatellarreflex,11.2;trendelenburggait,6.18;weaknessof,3.2,6.19,6.20,11.3

Gluteusminimus(Gmin)Gmax.seeGluteusmaximus(Gmax)Gmed.seeGluteusmedius(Gmed)Gmin.seeGluteusminimus(Gmin)Golgitendonorgan(GTO)GTO.seeGolgitendonorgan(GTO)

HamstringmusclesHerniateddisc,10.1,10.2.seealsoGluteusmaximus(Gmax);Gluteusmedius

(Gmed)Hip.seealsoGluteusmedius(Gmed);abductionfiringpatterntest,6.1,6.2;

abductiontest,8.1,8.2;capsulitis,11.1,11.2Hipextensionfiringpatterntest,5.1,5.2;sequence1,5.3;sequence2,5.4,5.5Hipextensiononallfours,12.1.seealsoOpenkineticchainexercises;level1,

12.2;level2,12.3Hipjointcapsule,11.1;andassociatedstructures,11.2Hydraulicamplifier,2.1,2.2.seealsoInnercoreunit

ILA.seeInferiorlateralangle(ILA)Iliofemoralligament,11.1,11.2Iliopsoas,1.1,8.1.seealsoAntagonisticmuscles;Muscleimbalance;Myofascial

sling;Psoasmajor;action,8.2;assessmentof,8.3,8.4;insertion,8.5;METtreatmentof,8.6;modifiedThomastest,8.7;muscle,2.1;nerve,8.8;normallengthof,8.9;origin,8.10;restrictedhipabduction,8.11;tightright,8.12

Iliotibialband(ITB)Iliotibialbandfrictionsyndrome(ITBFS),9.1,9.2,9.3.seealsoGluteusmaximus

(Gmax);Gluteusmedius(Gmed)Inferiorlateralangle(ILA)Innercoreunit,2.1.seealsoMuscleimbalance;Myofascialsling;hydraulic

amplifier,2.2,2.3;multifidus,2.4;transversusabdominis,2.5

IntegratedMyofascialSlingSystem,2.1,2.2,2.3IntervertebraldiscIntervertebralforamenITB.seeIliotibialband(ITB)ITBFS.seeIliotibialbandfrictionsyndrome(ITBFS)

Knee,9.1.seealsoGluteusmaximus(Gmax);Gluteusmedius(Gmed);anatomy,9.2;commonkneeinjuries,9.3,9.4;drift,9.5;jointandsofttissue,9.6;meniscusandMCL,9.7

Kyphotic/lordoticposture,seealsoPoorposture

L5/S1discLateralstep-down-up,12.1.seealsoBalancestabilization;withlunge,12.2Lateralwalkwiththeraband,12.1,12.2.seealsoBalancestabilizationLeglengthdiscrepancy(LLD),4.1.seealsoOver-pronationsyndrome;assessment,4.2,4.3;balancetest,4.4,4.5;compensationstoiliopsoas,4.6;compensationstosacrumandlumbarspine,4.7;footandankleposition,4.8;functionalscoliosiscompensation,4.9;andgaitcycle,4.10;andglutes,4.11;innominatecompensation,4.12;leftlonglegsyndromevs.rightshortlegsyndrome,4.13;lengthmeasurement,4.14,4.15,4.16;L-on-Lsacraltorsion,4.17;measurementsfromASIS,4.18;over-pronatedfoot,4.19;andpelvis,4.20;trendelenburggait,4.21,4.22;tri-planarmotion,4.23;trunk,headand,4.24;typesof,4.25

Leglengthmeasurement,4.1,4.2.seealsoLeglengthdiscrepancy(LLD);apparent,4.3;fromASIS,4.4

LigamentumpatellaeLLD.seeLeglengthdiscrepancy(LLD)LockingtechniqueLordosisLumbarspineanatomy,10.1.seealsoBackpain;Gluteusmaximus(Gmax);Gluteusmedius(Gmed);lordosis,11.1

Magneticresonanceimaging(MRI)Mammillaryprocess,seealsoInnercoreunitMaximalvoluntaryisometriccontraction(MVIC)Maximusbackintogluteusmaximus,1.1;approach,1.2;assessment,1.3,1.4;casestudy,1.5;diagnosis,1.6;Gmaxfunction,1.7;posteriorobliquesling,1.8;

prognosis,1.9;treatment,1.10MCL.seeMedialcollateralligament(MCL)Medialcollateralligament(MCL),9.1,9.2.seealsoKnee;Gmedcausingpain,

9.3,9.4MET.seeMuscleenergytechnique(MET)ModifiedThomastest,8.1;iliopsoas,8.2;rectusfemoris,8.3,8.4MRI.seeMagneticresonanceimaging(MRI)Multifidus,2.1.seealsoInnercoreunit;contract,2.2;relaxedmuscle,2.3Muscle.seealsoMuscleimbalance;Myofascialsling;classification,2.1;and

stretching,2.2Muscleenergytechnique(MET),2.1,7.1;acuteandchronicconditions,7.2;

basicreflexarc,7.3;benefitsof,7.4;jointmobilityimprovement,7.5;methodofapplication,7.6;musclepreparationforstretching,7.7;normaltonerestoration,7.8;physiologicaleffectsof,7.9,7.10;PIRexample,7.11,7.12;PIRvs.RI,7.13,7.14;pointofbindorrestrictionbarrier,7.15,7.16;refractoryperiod,7.17;stretchreflexarc,7.18;treatmentobjective,7.19;weakmusclestrengthening,7.20

Muscleimbalance,2.1.seealsoCoremusclerelationships;Innercoreunit;Myofascialsling;Muscle;Phasicmuscles;Poorposture;Posturalmuscles;Posture;effectsof,2.2,2.3;iliopsoasmuscle,2.4;musculoskeletaldeterioration,2.5

MVIC.seeMaximalvoluntaryisometriccontraction(MVIC)Myofascialsling,2.1,2.2,3.1.seealsoCoremusclerelationships;Gaitcycle;

Innercoreunit;IntegratedMyofascialSlingSystem;Muscle;Muscleimbalance;Phasicmuscles;Poorposture;Posturalmuscles;Posture;anteriorslingmuscles,3.1;counterrotation,3.2;Gmaxactivation,3.3;lateralslingmuscles,3.4;posteriorlongitudinalsling,3.5

Myotome

NationalHealthService(NHS)NHS.seeNationalHealthService(NHS)Non-functionalexercises.seeOpenkineticchainexercises(OKCexercises)Nucleuspulposus

OA.seeOsteoarthritis(OA)OKCexercises.seeOpenkineticchainexercises(OKCexercises)Openclamexercise,12.1.seealsoOpenkineticchainexercises;level1,12.2;

level2,12.3;level3,12.4;level4,12.5Openkineticchainexercises(OKCexercises),12.1,12.2.seealsoClosedkinetic

chainexercises(CKCexercises);Stabilizationexercises;frontplank,12.3,12.4;hipextensiononallfours,12.5,12.6;openclamexercise,12.7;sideplank,12.8;side-lyinghipabduction,12.9,12.10

OrthosesOsteoarthritis(OA)Osteoarticular-ligamentoussystemOsteophytesOver-pronatedfootOver-pronationsyndrome,4.1,4.2,4.3.seealsoLeglengthdiscrepancy(LLD)

Passiverangeofmotiontests(PROMtests)PatellaPatellartendonPatellofemoralpainsyndrome(PFPS),9.1,9.2.seealsoGluteusmaximus

(Gmax);Gluteusmedius(Gmed)PD.seePelvicdrop(PD)Pelvicdrop(PD),12.1,12.2.seealsoBalancestabilizationPFPS.seePatellofemoralpainsyndrome(PFPS)Phasicmuscles,2.1,2.2.seealsoMuscleimbalance;Myofascialsling;

characteristics,2.3;lengtheningandshorteningof,2.4;predominantly,2.5PHC.seePosteriorhorncell(PHC)PhysicaltherapistsPIR.seePost-isometricrelaxation(PIR)PLS.seePosteriorlongitudinalsling(PLS)Poorposture,2.1.seealsoMuscleimbalance;Myofascialsling;flat-backposture,

2.2;kyphotic/lordoticposture,2.3;painspasmcycle,2.4;sagittalposturaldeviations,2.5;sourceofpain,2.6;sway-backposture,2.7

Posteriorhorncell(PHC),seealsoMuscleenergytechnique(MET)Posteriorlongitudinalsling(PLS)Posteriorobliquesling,1.1;myofascialsling,2.1Post-isometricrelaxation(PIR),7.1,7.2.seealsoMuscleenergytechnique

(MET);example,7.3,7.4;vs.RI,7.5,7.6Posturalmuscles,2.1,2.2.seealsoMuscleimbalance;Myofascialsling;

characteristics,2.3;lengtheningandshorteningof,2.4;predominantly,2.5Posture,2.1,2.2.seealsoPosturalmuscles

PREs.seeProgressiveresistanceexercises(PREs)Progressiveresistanceexercises(PREs)Prolapseddiscs.seeHerniateddiscPROMtests.seePassiverangeofmotiontests(PROMtests)Psoasmajor,8.1.seealsoIliopsoas;location,8.2,8.3;lockingtechnique,8.4;myofascialtreatmentof,8.5;palpationof,8.6;startposition,8.7;startingtechnique,8.8;techniquevariations,8.9

QL.seeQuadratuslumborum(QL)Quadratuslumborum(QL)

Rangeofmotiontests(ROMtests)Reciprocalinhibition(RI),7.1,7.2,10.1.seealsoMuscleenergytechnique(MET)

Rectusfemoris,8.1.seealsoAntagonisticmuscles;action,8.2;alternativeMETtreatmentof,8.3,8.4;assessmentof,8.5;insertion,8.6;METtreatmentof,8.7;modifiedThomastest,8.8,8.9;nerve,8.10;origin,8.11

Refractoryperiod,seealsoMuscleenergytechnique(MET)RepsRetinaculaeRI.seeReciprocalinhibition(RI)ROMtests.seeRangeofmotiontests(ROMtests)Runner’sknee,seealsoIliotibialbandfrictionsyndrome(ITBFS)

Sacralcounternutation,seealsoCoremusclerelationshipsSacralnutation,2.1,2.2.seealsoCoremusclerelationshipsSacroiliacjoint(SIJ)SacrotuberousligamentSCJ.seeSternoclavicularjoint(SCJ)SCM.seeSternocleidomastoid(SCM)SetsSherrington’slawofreciprocalinhibitionShortadductorSideplank,seealsoOpenkineticchainexercisesSide-lyingabductionSide-lyinghipabduction,12.1.seealsoOpenkineticchainexercises;level1,12.2;level2,12.3

SIJ.seeSacroiliacjoint(SIJ)Single-leg.seealsoBalancestabilization;bridgingonstablesurface,12.1;deadlift,12.2;squat,12.3

Single-legstance,12.1.seealsoBalancestabilization;bicepscurltoshoulderpress,12.2;withcontralateralarm,12.3;withcontralateralcross-overarmabduction,12.4;withipsilateralarm,12.5;single-legkneebend,12.6,12.7;withweight,12.8,12.9

Slippeddiscs.seeHerniateddiscSqueezeandlift,12.1.seealsoClosedkineticchainexercises;bridgingonstablesurface,12.2,12.3;lumbarspineposition,12.4;pelviclift,12.5,12.6;pelvictilt,12.7;rightglutewithlift,12.8

Stabilizationexercises,12.1.seealsoClosedkineticchainexercises;Gluteusmaximus(Gmax);Gluteusmedius(Gmed);Openkineticchainexercises;literaturereview,12.2;rehabilitationmethodology,12.3;repsandsets,12.4

Standingbalancetest,4.1,4.2.seealsoLeglengthdiscrepancy(LLD)StartingtechniqueStaticstability,seealsoInnercoreunitStepandlungewalk,12.1.seealsoBalancestabilization;hold,12.2;lunge,12.3,12.4;step,12.5;steptorepeat,12.6;thoracicrotation,12.7,12.8;withweight,12.9

Sternoclavicularjoint(SCJ)Sternocleidomastoid(SCM)STJ.seeSubtalarjoint(STJ)Stretchreflexarc,seealsoMuscleenergytechnique(MET)Subtalarjoint(STJ)SupinationSway-backposture,seealsoPoorposture

Temporomandibularjoint(TMJ)Tensorfasciaelatae(TFL)TFL.seeTensorfasciaelatae(TFL)Thoracolumbarfascia(TLF),2.1,3.1,5.1.seealsoGluteusmaximus(Gmax);Gluteusmedius(Gmed);relationshiptoGmax,10.1

THR.seeTotalhipreplacement(THR)TibialisanteriorTLF.seeThoracolumbarfascia(TLF)TMJ.seeTemporomandibularjoint(TMJ)

Tonicmuscles.seePosturalmusclesTotalhipreplacement(THR)Transversusabdominis(TVA),2.1.seealsoInnercoreunit;contraction,2.2Trendelenburggait,4.1,4.2.seealsoGait;Leglengthdiscrepancy(LLD)Tri-planarmotionTrochleargrooveTVA.seeTransversusabdominis(TVA)

Vastusmedialis(VM)Vastusmedialisoblique(VMO)VertebralendplateVM.seeVastusmedialis(VM)VMO.seeVastusmedialisoblique(VMO)

Wallpress(WP)Wallsquat(WS)WP.seeWallpress(WP)WS.seeWallsquat(WS)