The importance of hip strength and lower limb control in knee pain is well documented and researched. Many cases of knee pain have been successfully resolved by strengthening up these key areas and improving control, balance and proprioception to improve lower limb mechanics.
But sometimes this approach just doesn’t work despite valiant efforts from both therapist and client on their recovery.
So what if the problem isn’t lying above at the hips but below at the ankle and foot? What if a lack of mobility in one area is causing compensations up through the body?
How our feet and ankles move is vital to how our knees move on top of them and for our entire kinetic chain, though can often get forgotten during assessment.
The first place to assess is the movement of the first metatarso-phalangeal joint (1st MTP). Extension of this joint is essential to optimize the windlass mechanism during gait¹. Extending this joint shortens the plantar tissue on the sole of the foot, helping to create an arch and a rigid lever to push off from in the propulsive phase of gait (toe off). A minimum of 60 to 65° ² of 1st MTP extension is necessary for normal gait.
If we don’t or can’t move well at this joint the body will compensate a way round it, by changing how the foot moves through the gait cycle to allow us to continue propelling forward. This could look like a foot that rotates outwards, favours the 2-5 toes to push off, or perhaps a leg that swings round in an abductory pattern or twists out of the toe off phase, all good strategies for avoiding the 1st MTP!
A lack of movement at this joint affects the ability of the foot to re-supinate from a pronated foot position into toe off phase which has a big effect on muscle loading.
Just some of the knock on effects up the kinetic chain if the foot cannot re-supinate well mean that the calf muscles (Gastrocnemius/Soleus) cannot work through full range, Tibialis posterior may remain under excessive load and be unable to contract well, the knee may not reach terminal extension,meaning the main knee stabilising muscles (quadriceps) cannot work through full range. The hip extensors (glutes and hamstrings) cannot work effectively to fully extend the hip. The leg may also stay internally rotated throughout the gait cycle, changing the way the knee joint is loaded and predisposing the patient to patello-femoral joint issues and medial knee loading. All these factors can impact the knee joint.
The second key area to assess is ankle range of movement. I have written a blog about this previously looking at the potential compensation strategies we can employ to counteract a lack of available dorsiflexion in the ankle (This is the movement of the knee travelling towards the toes in gait). We need approximately 1o° dorsiflexion³ in the ankle for a normal walking pattern, and more to ascend stairs, run etc. A lack of movement here can increase forces through the knee as the body propels itself forward, especially in activities such as squatting and running. This can be caused by a number of issues but often is either a joint restriction at the talocrural joint (ankle joint) or chronic tightness through the calf muscles.
It is very valuable to assess for chronic tightness of both the calf and hamstring muscles as this can prevent the knee from being able to fully straighten, again increasing load through the knee joint as it remains in constant flexion and the knee extensor muscles are unable to fully extend. This tightness could be caused either by a foot or a hip compensation or in some cases both!
In order for muscles and joints to work optimally they need to work through full range. Restoring this ability is a key part of a treatment programme.
If you find issues at the foot and ankle complex, spend a little time re-educating good movement patterns here to create a lasting effect up the chain.
Gait and movement analysis is incredibly effective at picking up sometimes subtle movement patterns that are difficult to see in static and couch based assessment and can give a different and valuable perspective on how the body works in motion.
For more information please get in contact. www.ellynashat.co.uk
#gaitanalysis #anatomyinmotion #movementisthekey
Brukner and Khan: Clinical Sports Medicine 4th Ed 2012
The Journal of Orthopedic and Sports Physical Therapy 1984 :Vol 5 No. 5. William Boissenault: The Influence of Hallux Extension on the Foot During Ambulation
Loudin Janice: The Clinical Orthopedic Assessment Guide 1998
Tibialis posterior is a very important muscle of the foot and ankle complex, especially in relation to gait (the way we walk). It is very important in controlling and stabilising our foot and ankle on the inside when we walk/run/jump and gives vital support to the arch of our foot.
[For the gait geeks it works eccentrically to decelerate eversion of the rear foot in strike phase, provides support to the foot and arch in stance phase then contracts to help supinate the rear foot and form part of our rigid lever to push off in propulsion phase].
It attaches to the proximal posterior shafts of the tibia and fibula (shin bones) and runs down the back of the length of the shin bones, travelling under the medial malleolus (inside ankle bone) and inserting into the navicular, bases of all cuneiforms, cuboid and bases of 2-4th metatarsals (bones of the foot).¹
If the muscle/tendon is constantly under increased load due to poor foot mechanics then dysfunction and overload can occur to the tendon. This will often come on gradually and may be triggered and aggravated by increased walking or running or a sudden change in activity. Poor footwear can also be a trigger, e.g. ballet shoes or flip flops, especially if worn for a long time in one go when not used to them. Tightness of the lower leg muscles, especially gastrocnemius and the peroneal muscles can contribute to the dysfunction, affecting the muscle balance of the lower leg which in turn affects foot movement and position.
It can also get injured due to trauma during sports/activities though this blog will focus on the more non traumatic injury.
It will commonly present as an achy pain just under the medial (inside) ankle bone, and may flare with an increase in activity, especially prolonged walking, running or jumping. Pain may occur when rising up on to the toes, especially after a few reps as the foot tires.
Pain may also be present on the outside of the foot/ ankle complex if the poor positioning of the foot is quite pronounced into pronation and rear foot eversion, as the bones may create an impingement on the outside of the foot. (See image).
The aggravating factor must be removed initially, so if this is an increase in a certain activity i.e. increased running, then this needs to be modified to remove excess stress on the tendon.
If the cause of dysfunction/overload is due to poor foot mechanics, this needs to be addressed in order to allow the tendon to recover. The foot will often (though not always) be overpronated, with a rearfoot eversion as in the image. Temporary insoles may be useful in the early stages depending on severity to help improve the foot position and offload an inflamed tendon.
A programme to re-educate the foot and get it moving better is also extremely beneficial. This will create a lasting change and ensure the muscles are able to lengthen and contract as they should. Specific Anatomy in Motion techniques to optimise how the foot moves during gait are very effective for this.
Soft tissue work and stretches can also help lengthen the calf muscles and peroneal muscles as part of a combined treatment.
Gradual increased loading of the tendon is then required to get it back to full strength. A graded rehabilitation programme from your health professional should allow you to resume your normal activities pain free, but be aware that tendon rehabilitation can be a slow process and can take anything from 12 weeks to 3-4 months² depending on severity and compliance.
As with any injury we have to consider the whole body, and address any issues that may be affecting poor movement patterns. Hip strength and lower limb control will be particularly important in this case and should be included in any good rehab programme.
Although a common cause of medial ankle pain, tibialis posterior dysfunction can usually be rectified with a good rehabilitation programme working to optimise foot mechanics, improve strength and control of the lower limb and regain normal muscle balance of the foot and ankle. For more information please get in contact. www.ellynashat.co.uk
A.Biel: The Trail Guide to the Body 3rd Edition
Tendinopathy – rehab progression – part 1: Tom Goom 2013
#Anatomy in Motion #Rehabilitation #Sports Injury Therapy
Climbing represents ultimate movement training for me. It utilises all of our primal movement patterns in a flowing continuous journey across natures gift of rock.
Our primal movement patterns are considered the fundamental movements required to survive. Without these our ancestors would have limited chance of survival, before we all sat behind desks and started ordering takeaways!
These primal patterns consist of:
Gait (walking, jogging, sprinting).
squatting (Chek 2003)
Depending on the type of climbing route all of these movements may be utilised in a variety of ways. Even more so on mountaineering routes that wander through a variety of terrain and changing landscapes. The climber may shift from a pushing mantel move to a high foot and rock over (lunge pattern) in a second, quickly followed by a crimping sequence (pulling)that requires a twist and squat to progress to the next move. What better way to practice and improve our fundamental movements than immersed in the elements, with ever changing challenges and surprises.
Climbing is also about mass management. How can I keep myself in balance whilst moving forwards and upwards on ever decreasing hand and foot holds. Optimal core strength and stability really comes into play here to help keep one’s centre of gravity where it needs to be, and to hold positions that buy time to work out the next move. But more than static stability we need dynamic stability as the body is never still, ever. We don’t need to train static planks for minutes on end to improve our core stability, we need to be working dynamically whilst integrating our inner core unit. (Transverse abdominus, multifidus, diaphragm, pelvic floor musculature). and outer sling systems. A good example in a gym environment may be cable work or my personal favourites Pilates and TRX training.
Flexibility is an important component in good climbing technique. The ability to reach that foothold that is just a little further away can really help to push the boundaries and make those reaching big moves whilst keeping control. Disciplines such as Yoga are perfect for maximising these skills, whilst also working to integrate mind and body focus and breathing.
Precision of hand and foot placements can make or break a difficult move, requiring good neuro-muscular control, grip strength and attention to detail. The smallest crystal can be your winning hold but only in one specific direction! The are many climbing specific tools available to hone these skills such as fingerboards.
Climbing requires excellent shoulder stability if we are to remain injury free. Good scapulo-thoracic strength gives us a stable base for the shoulder to work from and prevents non optimal movement of the shoulder when pulling hard on holds. The best climbers will often climb with a ‘feet first’ approach, focusing on optimal foot placement rather than pure shoulder strength to move efficiently and conserve power for the moves that really need it.
The mind is perhaps the most important part of our bodies for climbing outdoors. It is a sport that requires constant thinking and decision making, and a confidence that this is the right move and the next hold will be there when you pull through. If we lose focus or suddenly realise the precarious position we are in it can all slide downhill very quickly with a very real risk of injury.
This for many is the hardest thing to master. We can work on strength, stability and flexibility. We can push and pull and work multi directionally through all planes of movement on the ground. Yet keeping control of the mind and not letting it win when things get tough is a constant challenge.
But there is just something magical about climbing outside, with the feeling of rock under your hand, moving in every which way we were designed to move and mastering the sometimes unconquerable devil that is the mind.
Chek Institute: (2003) Primal Movement Patterns: A NeuroDevelopment Approach to Conditioning.
Pilates is gaining in popularity every day, and for good reason. It is a brilliant way to enhance strength, balance, co-ordination and flexibility without building muscle bulk and is invaluable for injury prevention and rehabilitation, which is why I am training to become a Stott Pilates Intructor. Take a look at how it can help us in more detail below.
Muscular endurance and strength
The Pilates repertoire has a focus on building muscular strength and endurance whilst not building bulk. This creates strong muscles, long lean muscular definition, and provides the integral strength to perform sustained activities without losing core and hip control. There is a strong focus on core stability, hip stability and scapular stabilisation in all exercises and emphasis is on working from the core out.
Flexibility is paramount to allow us to move freely and make the most of our bodies. The Pilates method works to increase flexibility under control. It works with eccentric (lengthening under load) exercises to encourage lengthening of muscle groups and promotes movement in all three planes of movement to mobilise and train our muscles three dimensionally.
We require good balance in all of our everyday activities, from walking, bending over and turning, to high level activities such as dancing and athletics. Pilates helps focus our attention to be able to recruit the appropriate muscles to improve our balance and stability, improving our neuromuscular control. This then translates into our every day life, giving us confidence to move freely and is especially important as we get older, with falls being one of the most prevalent causes of injury in the older generation.
Starting from the core (our main stabilising muscles of pelvic floor, transverse abdominus, multifidus) and working out, the exercises challenge co-ordination skills, teaching increasingly challenging patterns of movement whilst maintaining full control and alignment. The helps to build neural control of the body.
Pilates encourages working with the breath during exercises which has a number of physiological and physical benefits and helps increase focus and concentration on the exercise at hand. Often the exhalation is paired with the ‘effort’ part of the exercise to increase intra abdominal stability and core activation, with the ‘recovery’ on the inhale. Working with the breath helps to relieve muscular tension of the upper chest muscles, which is a common pattern in today’s society. Breathing deep into the lungs and allowing three dimensional breathing encourages a better exchange of oxygen and CO2 in the lungs .
Pilates has a strong focus on alignment and posture, always aiming for optimal alignment during activities to ensure proper muscular engagement. Working in this way heightens our awareness of our posture and highlights areas of weakness or overuse that may be being perpetuated by our work or play habits. Working with a qualified teacher in a small group can really help with this as it allows hands on adjustment and cueing to help achieve good alignment and an understanding to the client of where they should be, providing proprioceptive feedback.
Incorporating the above skills into our sporting activities has a positive impact on control and stability and is therefore great for injury prevention. Working in a controlled and focused way through the muscle groups helps to identify areas of weakness or overuse in the body and increases our body awareness. This can prevent overuse injuries occurring due to poor muscular strength and control. Working on flexibility also helps with injury prevention, ensuring we have optimal range through our joints to allow free movement.
As a result of pain or dysfunction in the back our deep spinal stabilising muscles can become inhibited, meaning they fail to provide intersegmental stability required for optimal spine health. Long term this can create over use of larger mobilising muscles, creating muscular imbalance, and means the spine is not adequately stabilised at a segmental level.
This can perpetuate back pain even after the initial injury phase has passed, and can lead to fear of movement, which in itself can be a causative effect of long term back pain.
As discussed Pilates focuses on activation of our deep core muscles to perform controlled movements of the body, building strength and stamina within these muscles and increasing neuromuscular efficiency and recruitment. Carefully selected and executed exercises from the Pilates repertoire effectively targets these muscles and improves automatic recruitment. We need to be able to use these muscles in an anticipatory way, so they automatically fire just before movement, giving us a strong base of support to move from.
Being guided by a qualified teacher can give you confidence to move and disperse fears that may have built up through prolonged periods of pain.
Pilates is also excellent for rehabilitation of injury caused by lack of pelvic stability which is very prominent and is a common precursor to lower limb injury.
I combine my skills as sports and remedial massage therapist with Pilates to offer a complete package of care, looking at the body holistically to find solutions to pain and dysfunction and providing long term results.
I run 1-1 and small group Pilates sessions from various locations in Bristol. Like my facebook page https://www.facebook.com/elly.nashat/ to get information on venues and times as they come online.
Here is a useful article from Physio Answers on the best and worst squat positions and the effect on the lumbar spine. Take home messages are
Though I am not one for heavy weight lifting, preferring body weight training as strength work, it is useful to be aware of the difference in stresses for those that do.
There is lots of information on workplace set up available, but I wanted to put the main points of consideration in one place for easy reference for my clients.
Staying in any position for a prolonged length of time is not good for our bodies and especially our muscles, tendons and ligaments.
Stuart McGill found that remaining in a sustained position of 20 mins or more of sustained or cyclical loading causes ‘creep’ which refers to the gradual overloading and lengthening of soft tissue structures.
[Creep: a physical property of materials that results in progressive deformation when a constant load is applied over time; it allows soft tissues to tolerate applied loads by lengthening. (1)]
‘McGill and Brown, (2) showed that after 20 mins of creep followed by 20 min of rest, muscle activity recovered only 50% of its pre-creep magnitude’. Suggesting muscle activity is reduced with sustained loading and these forces are transmitted to the ligaments, discs and joint capsules of the spine. This can have a negative effect on the spine.
Below is a check list of important factors to consider at your workstation.
Don’t be afraid to ask your employers for a workplace assessment, they are required to provide this for you and could save you a whole host of pain and discomfort.
1: Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003)
2:McGill SM, Brown S. Creep response of the lumbar spine to prolonged full flexion. Clin Biomech.1992;7:43–46. [PubMed]
3: Kapandji, Physiology of Joints, Vol. 3.
One important factor to look at when looking at gait is whether the client has enough dorsi flexion to easily move through the gait cycle without compensating elsewhere.
As always if we cannot make a movement at one joint this movement will be made elsewhere up the chain to enable us to keep moving. This could cause excess movement in other areas within the hip/knee/low back right up to the shoulder.
We ideally have >10 Degrees of ankle dorsiflexion during gait, and there are a number of common compensation patterns that are seen when ankle rocker (dorsiflexion during gait) is lacking.
It is worth looking at available dorsiflexion when assessing for any ankle/knee/hip and low back pathology as a potential contributor of symptoms. Considerations for causes of reduced dorsiflexion can be posterior calf tightness, tibio-talar joint restriction, weak anterior, lateral or medial calf muscles. All can be treated by manual therapy and rehabilitation techniques to achieve greater freedom of movement and range.
References: The Gait Guys
Clients may present with either one sided or bilateral shoulder pain that does not seem to resolve with postural re-education and soft tissue work. Often they will report a dull, aching feeling in the shoulder region that is persistent .One factor that may be contributing to this is 1st rib dysfunction.
Clients with poor posture, respiratory conditions, or those who suffer with anxiety and nervousness often have a faulty breathing pattern and overuse their accessory breathing muscles rather than including their abdomen and expanding their lower rib cage.
An ideal breathing pattern sees the abdomen expand, coupled with a lateral expansion of the lower ribs and a small rise in the upper chest. If a client tends to breathe into the upper chest as a preference with little or no abdominal involvement this may indicate a faulty breathing pattern.
Over time this can cause shortening of these accessory muscles which may lead the 1st rib to become elevated. The anterior and middle scalenes are often the most likely soft tissue restriction causing this elevation and the rib becomes ‘locked in inhalation’ (Chaitow 2014)
1st rib may also be implicated in conditions of thoracic outlet syndrome, causing a narrowing of the thoracic outlet when elevated, and would need to be assessed alongside other potential contributors.
The 1st rib will feel very tender to palpate and the surrounding muscle tissues of trapezius, scalenes and sternocleidomastoid will present as tight. Range of movement of the neck will likely be restricted. As the client inhales and exhales deeply an asymmetry may be felt between the two sides on palpation. Both may be locked however there will likely be a more affected side, which would be treated first.
Soft tissue work to address these structures along with muscle energy techniques to release the first rib are very effective at normalising this problem, and coupled with education on optimal breathing patterns can prevent re-occurrence. Poor sleeping positions which encourage shortening of the affected side will need to be changed. Good posture is also key to prevention especially in tasks which may encourage a classic ‘forward head posture’ and rounded shoulders such as computer work.
A full assessment and treatment by a qualified soft tissue therapist will identify and successfully resolve this common problem.
References: Chaitow L 2014: Recognizing and Treating Breathing Disorders
I have had a recent influx of clients who heavily supinate on one or both of their feet.
Supination is a tri-planar movement of the ankle which occurs during gait and consists of plantar flexion, adduction and inversion of the ankle joint. It is a natural part of the gait cycle, and the foot moves between pronation and supination to allow us to walk and run. However ‘over’ supination can cause problems, especially for runners and walkers. You will usually have quite high arches and place a lot of pressure on the outside edge of the foot in both standing and walking/running.
The pronation element of gait, which sees the foot roll inwards slightly during ‘foot flat’ phase allows forces to be absorbed by the ankle which is important for shock absorption. If you are an over supinator you will lack flexibility and spring within the medial arch of the foot, meaning this pronation movement cannot take place as effectively.
This can affect the lower limb in a multitude of ways as these forces are transferred straight up the leg rather than being absorbed by the foot and ankle, and potentially create an external rotation on the limb. This can increase the chance of shin splints, stress fractures and ankle sprains and the likely hood of soft tissue injuries such as calf strain, achilles problems and plantar fasciitis.
You may also lack dorsiflexion in the ankle, which is the ability to bring the top of the foot towards the shin, or more importantly, functionally this means you may lack range of movement in the ankle, increasing the chance of compensation patterns to occur elsewhere through the lower limb and hips.
You can sometimes tell whether you are an over supinator by the wear on your shoes. An uneven pattern of wear, on the outer edge of your trainer suggests that you load this area more heavily when standing and moving.
There are some great soft tissue and physical therapy techniques that can help improve this, focusing on addressing the tight structures contributing to the problem which will include the calf complex , tibialis anterior and the deep compartment muscles of tibialis posterior, flexor hallucis longus and flexor digitorum longus, which all work to plantar flex the foot and invert it, or bring it to towards the midline. Gentle mobilisation techniques can also be very beneficial in improving movement.
Whilst not as common as over pronation, which can be corrected with insoles, soft tissue work or/and orthotics, there is still lots that can be done to help correct ‘over’ supination and improve movement.
Summer is coming, the weather is picking up and more of you will be taking to the roads to get some exercise. The most common injury we see with cyclists is knee pain. Below is a brief summary of some potential causes. This list is by no means exhaustive, but is intended to cover a few things you can change or work on to improve your symptoms.
Having your seat height too high often causes rocking of the hips. This can cause hamstring injuries as the leg is extending further than the optimal amount at the bottom of the downward stroke. If we think about how many revolutions the legs make on a 50 mile ride this is can prove to be problematic. This can present as pain behind the knee on either the medial or lateral side, although can present anywhere up the posterior thigh.
Equally, having your seat too low or cranks that are too long can cause excessive flexion at the hip and knee. Over time this can affect your hip flexors which are working in a shortened position and not able to extend out. This can cause tightness through the quads, specifically rectus femoris which can cause problems with the anterior knee and the quad tendon just below the patella, and TFL, which directly influences the IT band and therefore the lateral knee.
Lower limb stability
Weakness in the lower limb can cause inefficient cycling, and often presents as the knee dropping toward the top tube on the downward stroke as pressure is applied through the leg. Weakness in the glute medius muscle is a contributor to this as one of its roles is to stabilise the pelvis under load. In addition, this may be coupled with a weakness through the medial quad (VMO) further allowing the knee to drop inwards, as VMO is a medial stabiliser of the knee. Weakness through the glute medius may also be coupled with an over dominant TFL muscle, which feeds into the iliotibial tract (along with glute max), therefore affecting the lateral knee.
Both of these scenarios can cause patella tracking issues which can create pain anywhere around or beneath the patella as it cannot track correctly in its groove due to poor alignment. A trip to your local sports injury therapist is the best advice in this case to provide a full assessment, manual therapy and rehabilitation to regain balance in the muscles.
Cleat positioning, in my opinion, is the most difficult element of a bike set up. A few millimetres out and the knee can be forced to move in an unnatural way, thus causing pain in the patella area or causing a pulling or rotation during the stroke as the leg tries to find a better position. This may also affect the medial and collateral ligaments of the knee.
Some cleats allow for a degree of rotational ‘float’ which allows the foot to rotate medially or laterally a little once clipped in, this is often between 4-6 degrees. It is worth trying to look at how you walk and how your feet sit naturally before trying to set up your cleats. Are your feet naturally externally rotated or ‘duck footed’? or are you internally rotated or ‘pigeon toed’?. A tip is to sit on a chair or sideboard that allows your feet to be off the ground and see how your feet hang down. Try to get your hip and knee at roughly 90 degrees and sit far back on the chair. Ideally you would re-create this position on the bike to get the best position of comfort. You can also go for a ride without cleats and keep an eye on what your feet like to do when not clipped in.
Another element of cleat positioning that needs to be considered is whether they need to be moved in towards the bike or out towards the edge of the pedal. Commonly, if pain is presenting in the medial leg as a result of cleat positioning you may need to move the cleat to the inside of the shoe, therefore putting your foot further out towards the edge of the pedal. Conversely if you are experiencing pain on the lateral knee due to cleat positioning you may wish to try moving the cleat to the outside of the shoes, putting the foot closer to the bike. If in doubt it is worth consulting a bike fit specialist who can watch you ride and set up your cleats for you.
The good news is that most knee pain can be rectified with the right bike set up and a little help from a sports injury therapist.