Therapeutic Exercise Exam 3

forefoot

5 metatarsals and 14 phalanges

meniscal tears

Sometimes "locking" occurs with a meniscal tear, sometimes patients can move just right and it will unlock, or the PT may have to maneuver the leg to get it to unlock-see page 825. After acute symptoms subside following a meniscal tear, exercises should be performed to improve strength and endurance and progress toward functional activities Some pts can live with a small tear with some flare ups If large, may need to be removed or repaired Repair is lengthy recovery (6-8 wks NWB) because of lack of blood supply Avoid deep knee bending if they have a tear esp while loaded (like squatting) and no rotation while flexed

patellofemoral dysfunction

Typically a younger population (Jr high/high school/into 20s) Protection: If so painful they can't do anything, taping or bracing may be the best thing to do for a while to reduce pain to start strengthening Quad sets with or without towel roll for pain free, etc. Tell them to not do the painful activities like reciprocal gait pattern down stairs, they can do step to gait pattern on steps until the pain is diminished Sitting with flexed knee posture for a while will increase pain for this dx Controlled and return: Weakness in abd and ext rotators cause knees to come in when squatting and weight shifting and causes patellofemoral pain or even internal rotation at the foot and ankle causes patellar movement; strengthening these esp the hip can help this - may be motor control, other times just weakness Pt may mmt 5/5 but not have the endurance in the muscle still and may need strengthening

things to consider with each scenario

What are possible diagnosis or pathologies and what are their progressions? What stage in the healing process, or stage of inflammation are they in? What are the impairments, how do we address them, and where do we start? ROM Progression with Manual therapy consideration Modality Consideration (as a side note, not considered ther-ex) Exercise Progression: When to advance mode, intensity, volume, and duration

bones

anatomy review of ankle; tibia, fibula, 7 tarsals, 5 metatarsals, 14 phalanages

hypomobility

at the knee, ROM progression (PROM to AAROM to AROM), exercise mode progression: Isometric/muscle setting This mode can be used when muscle activation is not contraindicated, but motion may still be This mode can be used when you want to begin to facilitate neuromuscular control, proprioceptive feedback, improve circulation when you are still under strict ROM restrictions Usually earlier stages of rehab, but remember you need to do this form of exercise at multiple angles to get the most benefit from it if using it for strengthening in later stages of rehab. DCER Minimal to no resistance at first. Multiple tools to perform exercises Consider concentric and eccentric type exercises Usually began slowly during sub-acute phase if there are no restrictions from surgery Stabilization Exercises- exercises to cause quick activation and deactivation or co-contraction of muscles to cause stabilization of the joint. These usually will begin towards the end of the sub-acute phase or later Functional Exercise Began in later sub-acute or chronic stages of rehab Always need to consider the functional goals of the patient. Plyometric and Sport Specific Not began until later stages of rehab, once ROM is fully re-gained and good quality muscular control achieved When to advance? Once patient can perform easier exercises with good form and control without pain or inflammation you may advance mode, intensity, volume, and duration.

hypomobility

at the knee, this has possible diagnoses of osteoarthritis and post immobilization, common body structure and function impairments: loss of ROM/stiffness, pain, quad inhibition, decreased balance; common activity limitations: pain with WB limits household and community activity (may include ADL), difficulty with sit to stand, stairs, squatting (often use hips and back to avoid squatting all together)

ligament injuries

at the knee; Joint Effusion/Swelling can cause Quad inhibition and should be addressed at the beginning of rehab. Protecting the joint initially by ambulation with crutches WBAT while avoiding pivoting is also important in early stages of rehab ROM exercises within tolerance and quad setting exercises can also begin in early stages of rehab Later stages of rehab should include improving muscle performance, functional status, and cardiopulmonary conditioning 1 minor sprain, 2 moderate, 3 rupture Joint mobility work in controlled motion phase and beyond includes patella mobilizations along with stationary bike, tib/fib mobilizations and as much movement as possible from the patient Protective bracing may be needed to support the healing ligament Strength and endurance should be progressed through many modes/types of exercise An example of the rehab process through all phases of rehab for a ligament Injury is written out on page 808-809. Make sure to read this table

kinesthetic training

awareness and control of safe spinal motion, head nodding, pelvic tilts; awareness of neutral spinal position while supine, prone, sitting, standing; awareness of effects of ADLs and extremity motion on the spine

functional training

basic body mechanics with stable spine; log roll supine to prone, prone to supine, transition from supine to sidelying to sitting and return, transition from st to stand and return, walking

aseptic necrosis

bone death taking place at femoral head and neck due to lack of blood supply

flat upper back and neck posture

cervical/thoracic; decreased thoracic curve, decreased cervical lordosis, depressed clavicles, depressed scaps; causes: tight mid/upper back muscles; bad bc: decreased shock absorption of kypholordotic curve, compression on neuromuscular bundle between clavicles and ribs

round back with forward head

cervical/thoracic; increased thoracic kyphosis, rounded shoulders, forward head; causes: slouching, poor ergonomic alignment in work, lengthened back muscles, too many flexion exercises in general ex program; bad bc: stress to ant LL in upper cervical and PLL in lower cervical, facet joint irritation in ext, narrowing of IV foramen

ligamentous injuries

common body structure and function impairments of this in the ankle: pain, excessive motion or instability, impaired balance, edema, decreased ROM at times; activity limitations: restricted ambulation, difficulty walking, running or quick directional changes; most common is inversion ankle sprain; medial (deltoid) is much less common but usually also causes evulsion fracture

hypomobility

common pathologies in ankle of this are degenerative joint disease, post immobilization stiffness, gout (typically only in MTP of the great toe); common body structure and function impairments: decreased ROM, pain, muscle weakness due to deformity and mechanical disadvantage of the tendons, poor balance; common activity limitations: decrease ambulation due to pain and risk of falls, decreased ability to perform household and job related tasks due to inability to weight bear

hip and buttock region

common sources of referred pain where; nerve roots L1-3, S1-2; lumbar intervertebral and SI joints

hip extensors

control flexor moment at initial contact, help to advance body past the limb

hip flexors

control how much hip extension we gain at the end of stance, effect a little at initial swing

congenital deformities

deep acetabulum, thick femoral neck are examples of this

spinal stability

deep muscles for segmental stability, global muscles for general stability

stabilization training

deep segmental muscle activation and sustained contraction: cervical - controlled axial extension with craniocervical flexion and lower cervical/upper thoracic extension; lumbar - drawing in maneuver and multifidus muscle activation techniques; superficial mulitsegmental muscle control with extremity loading; passive support of spinal posture only if needed, progress to active control; coordinate segmental muscle activation with maintenance of a stable spine in neutral spinal position with arm and leg motions

core muscles

deep: closer to axis of motion; attach to each vertebral segment; control segmental motion; greater percentage of type 1 muscle fibers for endurance; lumbar: transverse abdominis, multifidus, quadratus lumborum, deep rotators; cervical: rectus capitis, longus colli

stabilization training

develop awareness of muscle contractions and spinal positions, develop control in simple patterns and exercises while progressing to complex exercises, demonstrate automatic maintenance of spinal stability and control in simple to complex functional activities

spinal soft tissue pathologies

distinguishing impairments/functional limitations: pain and muscle guarding, pain with contraction or stretch of muscle, interference with ADL's, impaired muscle performance, mobility, spinal control/stabilization, postural awareness, and limited IADL's; common sites: cervical - flexion/extension injuries, lumbar - iliac crest, emotional and postural stress

fundamental interventions

exercises or skills that all pts with spinal impairments should learn regardless of their functional level at the time of exam and initial treatment; include basic kinesthetic training, basic spinal stabilization training, basic functional body mechanics; progress to working on abilities and strength at the pt's level

slipped epiphysis

femoral head slipping of the neck of the femur, etiology unknown, happens at the growth plate so occurs during adolescence and is more common in males, usually after a large growth spurt

hip abductors

fire to control the pelvis (fire the most when in contralateral limb swing to keep the pelvis up)

post op

for the hip, we must follow these precautions, for ex: after a total hip performed from a posterolateral approach the pt is limited to hip flexion <90, adduction and IR no further than neutral; must follow WB restrictions, must protect healing of soft tissues surrounding surgical procedure; pt will then fall under a hypomobility classification for slow progression of exercise within the restraints of WB and motion precautions

nonstructural scoliosis

functional or postural scoliosis, reversible, can be changed with forward/side bending or positional changes; causes: leg length discrepancy, muscle guarding from a painful stimuli

active control of spinal movement

general management of spine; isolate each body segment and train the pt how to move that segment; use verbal, visual, and tactile reinforcement; exercises: cervical retractions, scapular retractions, pelvic tilt and neutral spine

body mechanics

general management of spine; lift with legs, avoid weighted twisting; avoid stress provoking postures that must be sustained or are repetitive

strengthening

general management of spine; strength train opposite muscle groups equally; stretch opposite muscle groups equally; focus on good posture during exercises

joint, muscle, and connective tissue mobility

general management of spine; stretching - manual and self

muscle relaxation

general management of spine; use these techniques; counteract prolonged muscle contraction with AROM in opposite direction; takes strain off of structures

common faulty positions

head, neck, thorax, lumbar spine, and pelvis are all interrelated; deviation in one will cause compensation in the others; pelvic/lumbar: lordotic, relaxed or slouched posture, flat low back; cervical/thoracic: round back with forward head, flat upper back and neck, scoliosis

protection phase

hypomobility at the knee in this phase includes control pain and protect the joint, maintain soft tissue and joint mobility (ROM, quad sets)

controlled motion and return to function phases

hypomobility at the knee in this phases includes deal with impairments that interfere with functional activities, safe return to function: job, hobbies, etc. getting them back to what they want to do starts here and cont through return to function, educate the pt: HEP, protection

postural dysfunction

impaired posture; adaptive shortening of soft tissue and muscle weakness occurs (contractures/adhesions); stress to shortened structures results in pain

tight weakness

impaired posture; muscles kept in shortened position test strong in only shortened position; test weaker as lengthened; occurs on concave side of structure

stretch weakness

impaired posture; muscles kept in stretch position test weaker due to a shift in the length tension relationship; actin myosin cross bridges are stretched out and have a difficult time contracting; ccurs on convex side of structure

postural pain syndrom

impaired posture; pain that results from mechanical stress caused by prolonged faulty posture; no impairments in functional muscle strength/flexibilty; strength and flexibility imbalances can eventually occur

postural fault

impaired posture; posture that deviates from normal alignment but has no structural impairments

controlled motion and return to function phase

in hypomobility management of ankle, these phases include increase joint play and accessory motions (joint mobilizations and stretching), regain balance in muscle strength, improve balance and proprioception, develop cardiovascular fitness

protection phase

in hypomobility management of ankle, this phase includes educating the pt and provide joint protection (emphasize safe daily ROM, endurance activites, joint protection via good alignement/posture of the foot, and proper footwear, and assistive devices as needed), decrease pain (gentle low grade mobilizations, orthotic devices), maintain joint and soft tissue mobility and muscle integrity (PROM, AAROM, AROM, aquatic therapy, muscle setting)

controlled motion

in ligamentous injuries management in ankle, this phase includes continued protection of injured ligament, continued gentle joint mobilizations, exercises done within tissue tolerance/pain free (NWB AROM, intrinsics, as swelling decreasses progress to strengthening, endurance and stabilization exercises all while protecting healing ligament (brace if needed))

protection phase

in ligamentous injuries management in ankle, this phase includes minimize swelling and protect injured ligament, gentle mobilization for pain and maintenance of ROM, educate pt about RICE, partial WB if needed, isometrics and active toe exercises to maintain muscle integrity and circulation

return to function

in ligamentous injuries management in ankle, this phase includes progress strengthening, progress stabilization and balance training including agility and controlled twisting, turning and lateral mvmts, when returning to sport, tape, or brace, and proper shoes to prevent reinjury

controlled motion and return to function phase

in overuse and repetitive trauma syndrome management in ankle, this phase includes educate the pt and provide HEP (prevention - warm up, proper footwear, recovery from intense workouts), self stretching (calf, PF), improve muscle performance (normal progression from isometric to DCER, open and closed chain, foot intrinsics, endurance, and eccentric exersices

protection phase

in overuse and repetitive trauma syndrome management in ankle, this phase includes rest, modalities, possible immobilization (bracing/taping), gentle muscle setting, pain free ROM exercises, education to avoid painful activities

functional activities

includes basic body mechanics of rolling, supine to sit, sit to stand, walking, and reversing (coordinate with kinesthetic training and core muscle activation and stabilization)

cardiopulmonary endurance

initiated as soon as pt tolerates repetitive activity without exacerbating symptoms, aerobic training

muscle performance

involves strength, power, endurance, and stability

structural scoliosis

irreversible lateral curve with fixed rotation, rib hump produced with forward bending; causes: neuromuscular diseases, osteopathic disorders, idopathic unknown causes; bad bc: nerve root irritation and joint irritation on concave side, muscular fatigue and ligamentous strain on convex side

functional exercise

knee hypermobility; Began in later sub-acute or chronic stages of rehab Always need to consider the functional goals of the patient.

ROM progression

knee hypermobility; Depends on if patient was immobilized Maintain normal range -avoiding motions that cause apprehension (uneasiness of patient as if something may dislocate) No stretching or joint mobilization

plyometric and sport specific

knee hypermobility; Not began until later stages of rehab, once good quality muscular control and stabilization achieved

advance

knee hypermobility; Once patient can perform easier exercises with good form and control without pain or inflammation, or apprehension you may advance mode, intensity, volume, and duration

isometrics

knee hypermobility; be careful of which direction your muscle contraction is pulling- remember that things change in a closed chain. Submaximal in early stages- acute phase

stabilization

knee hypermobility; biggest part of rehab with hypermobility Perform open and closed chain stabalization Can be started in controlled motion/ sub-acute phase Must be done in a single limb stance with perturbation or similar

DCER

knee hypermobility; usually in sub-acute phase/ controlled motion Slow progression, start with smaller ranges of motion then progress from there

functional exercise

knee hypomobility; Began in later sub-acute or chronic stages of rehab Always need to consider the functional goals of the patient.

DCER

knee hypomobility; Minimal to no resistance at first. Multiple tools to perform exercises Consider concentric and eccentric type exercises Usually began slowly during sub-acute phase if there are no restrictions from surgery

plyometric and sport specific

knee hypomobility; Not began until later stages of rehab, once ROM is fully re-gained and good quality muscular control achieved

advance

knee hypomobility; Once patient can perform easier exercises with good form and control without pain or inflammation you may do what to mode, intensity, volume, and duration

ROM progression

knee hypomobility; PROM (May add joint mobilizations and stretching with PROM as long as you don't risk damage to healing tissue) to AAROM to AROM

isometric muscle setting

knee hypomobility; This mode can be used when muscle activation is not contraindicated, but motion may still be This mode can be used when you want to begin to facilitate neuromuscular control, proprioceptive feedback, improve circulation when you are still under strict ROM restrictions Usually earlier stages of rehab, but remember you need to do this form of exercise at multiple angles to get the most benefit from it if using it for strengthening in later stages of rehab.

stabilization exercises

knee hypomobility; exercises to cause quick activation and deactivation or co-contraction of muscles to cause stabilization of the joint. These usually will begin towards the end of the sub-acute phase or later.

impaired posture

little muscle activity is required for upright posture; activity helps to keep curves at appropriate level; relaxation causes exaggeration of curves leads to postural impairment and muscle strength and flexibility imbalances

relaxed or slouched posture

lumbar/pelvic; anterior shift of pelvic unit (results in hip extension, increased lordosis of lumbar spine, kyphosis of thoracic spine, and forward head); causes: attitudinal, fatigue, muscle weakness, stretched lower abs, hip flexors, and extensors of lower thoracic region; bad bc: narrowing of IV foramen in lower lumbar, stress on facet joints, stress to ant LL of lower lumbar spine, PLL of upper lumbar and thoracic; sway back

flat low back

lumbar/pelvic; decreased lumbosacral angle, decreased lumbar lordosis, hip extension, posterior tilt; causes: cont slouching, flexion in sitting, overemphasis on flexion exercises in general ex program; bad bc: reduced shock absorption, stress to PLL, increased in posterior disc space (can lead to post disc protrusion)

lordotic posture

lumbar/pelvic; increase in lumbar lordosis/anterior pelvic tilt/lumbosacral angle; resultant increased thoracic kyphosis; stretched abs and shortened erector spinae; causes: pregnancy, obesity, weak abs, sustained faulty posture; bad bc: can narrow posterior disc space and IV foramen, compressing vessels and nerve roots, facet joint irritation due to increased weight bearing

leg

made up of tibia and fibula

sciatic nerve

major nerves subject to injury or entrapment at hip and pelvis; through piriformis

obturator nerve

major nerves subject to injury or entrapment at hip and pelvis; typically seen after giving birth, rare

femoral nerve

major nerves subject to injury or entrapment at hip and pelvis; usually from a fracture of femur or pelvis where scar tissue impedes the nerve

functional

most pts begin to follow the same progression after early stages; ther ex still very specific to what goals; most pts fit into basic categories; progression of mode of exercise should also include working on strength, power, and endurance as discussed earlier; endurance and strength will come before power type training

midfoot

navicular, cuboid, three cunieforms

patient education

need active participation to identify desired outcomes, learn limits at each stage of healing, understand prevention (safe ways to exercise, proper body mechanics for high intensity activities, modify work/home environment, minimize stresses)

posterior tibial nerve

nerve subject to pressure and trauma; entrapment may occur in the tarsal tunnel just posterior to the medial malleoli

common peroneal nerve

nerve subject to pressure and trauma; pressure may occur as it courses laterally around the fibular neck and passes through the opening in the peroneus longus muscle

plantar and calcaneal nerves

nerve subject to pressure and trauma;branches of the post tib nerve that can become entrapped as they pass under the medial aspect of the foot and pass through an opening the in abductor hallucis muscle

knee

nerves subject to injury here: common peroneal nerve, saphenous (sensory skin nerve, medial leg and knee); common referred pain: L3 ant knee, S1-S2 posterior knee, hip joint ant thigh and knee

spinal instability

neutral zone - point in range where no stress is placed on passive structures; instability - associated with an increase in the neutral zone; common causes: disc degeneration, spondylolisthesis, ligament laxity, poor neuromuscular control

controlled motion and return to function phases

non operative management of hypomobility at the hip in these phases includes progressively increasing joint play and soft tissue mobility (joint mobilization techniques, passive stretching, neuromuscular inhibition, and self stretching techniques), improving joint tracking and pain free motion (increasing internal rotation, flexion, extension, extension during WB activities), improving muscle performance in supporting muscles (neuromuscular faciliation with muscle setting and strengthening exercises progressing to functional activiites and balance then low impact exercise program), pt education

protection phase

non operative management of hypomobility at the hip in this phase includes decreasing pain at rest (low grade joint mobilizations), decreasing pain during weight bearing activities (use assistive device to reduce stress on joint, adapt seating surfaces as needed), decreasing effects of stiffness and maintain available motion (ROM exercises, aquatic therapy and nonimpact activities)

hypomobility

non-op management in hip and pelvis; related pathologies and etiology of symptoms: osteoarthritis (degenerative joint disease), other joint pathologies can lead to degenerative changes in the hip (aseptic necrosis, slipped epiphysis, dislocations, congenital deformities), post immobilization; common impairments of body structure and function: pain in groin and anterior thigh to knee, stiffness after rest, limited motion with a firm end feel, antalgic gait, limited hip extension causing possible LBP and gait defects, impaired balance and postural control; common activity/functional limitations and participation restrictions/disabilities: early - pain with WB activities such as meal prep, cleaning, shopping esp at end of day/progressive degeneration - difficulty rising from chair, climbing stairs, squatting, bathing, dressing

red flags

pain that awakens at night or is extreme, spinal cord symptoms, when fracture has not been ruled out; other considerations: neuro symptoms, psychological distress, pain patterns

protection phase

painful hip syndrome/overuse syndromes nonoperative management in this phase includes controlling inflammation and promoting healing, developing support in related areas; light stretching, muscle setting, all without pain

controlled motion phase

painful hip syndrome/overuse syndromes nonoperative management in this phase includes developing a strong mobile scar and regain flexibility, developing a balance in length and strength of the hip muscles, developing stability and closed chain function, developing muscle and cardiopulm endurance, pt education on balance, HEP

return to function phase

painful hip syndrome/overuse syndromes nonoperative management in this phase includes progressing strength and functional control, returning to function; load pt in closed chain, acceleration, deceleration, plyometrics if needed

spinal stability

passive - bones and ligaments; active - muscular control (global/superficial, core/deep); neural control via nervous system activating trunk muscles in anticipation of limb mvmt to stabilize the spine; transverse abdominis and other core muscles fire anticipatory control in prep for voluntary mvmts; pts with back pain lose this preparatory stability

protection phase

patellofemoral dysfunction management in this phase includes treating acute symptoms: modalities, rest, gentle motion, muscle setting in pain free positions

controlled motion and return to function phases

patellofemoral dysfunction management in this phase includes when signs of inflammation no longer present, correct or modify biomechanical forces causing impairments

disc

pathology of these; common body structure and function impairments related to these protrusions in the lumbar spine: pain and muscle guarding, flexed posture and deviated away from the symptomatic side (lateral shift), neuro symptoms along a dermatome and maybe a myotome, peripheralization of symptoms with flexed posture, coughing, sneezing and straining

facets

pathology of these; common etiologies: sprain, degeneration (OA, DJD, spondylosis), impingement; pain: acute pain includes muscle guarding with all motions, when subacute and chronic is related to periods of immobility or excessive activity; impaired mobility: usually hypomobility and decreased joint play in affected joints, may be hypermobilty or instability during early stages; impaired posture; impaired spinal extension: ext may cause or increase neuro symptoms due to stenosis so may be unable to sustain or perform repetitive ext activities w/o exacerbating symptoms; any activity that requires flexibility or prolonged repetition of trunk motions may exacerbate symptoms in the arthritic spine

anterior pelvic tilt

pelvic motion and muscle function; tight muscles: back extensors, hip flexors; over stretched muscles: hamstrings, abdominals

posterior pelvic tilt

pelvic motion and muscle function; tight muscles: hamstrings, abdominals; over stretched muscles: back extensors, hip flexors

postural alignment

plumb line typically used for reference; COG: head, trunk, hip, knee, ankle

posture

position or attitude of the body, the relative arrangement of body parts for a specific activity, or a characteristic manner of bearing one' body; alignment of body parts; position of joints and body segments; balance between muscles crossing the joint

guidelines for stabilization training

principles and progression; begin training awareness of safe spinal motions and the neutral spine position or bias, have pt learn to activate the deep core stabilizing muscles while in the neutral position, add extremity motions to load the superficial global muscles while maintaining a stable neutral spine position (dynamic stabilization), increase reps to improve holding capacity (endurance) in the stabilizing muscles, increase load (change lever arm or add resistance) to improve strength while maintaining stability, use alternating isometric contractions and rhythmic stabilization techniques to enhance stabilization and balance with fluctuating loads, progress to mvmt from one position to another in conjunction with extremity motions while maintaining a stable neutral spine (transitional stabilization), use unstable surfaces to improve the stabilizing response and improve balance

kinesthetic awareness

proprioception training of safe mvmt and postures

core muscles

reasons to work on what: activate and develop neuromuscular control of core and global spinal stabilizing muscles to support the spine against external loading, develop endurance and strength in the muscles of the axial skeleton for functional activities, develop control of balance in stable and unstable situations, proximal stability for distal mobility, primary functions of the muscles of the trunk (keep upright posture against a variety of forces, provide stable base so extremities can execute function)

overuse and repetitive trauma syndromes

related pathologies of this in the ankle are tendinitis and tenosynovitis, plantar fascitis, shin splints; common impairments/disabilities: pain with palpation and repetitive activity, pain with weight bearing, muscle length and strength imbalances, abnormal foot posture, decrease ability to stand, decreased cadence of gait and restriction of sport or recreational activities

acute

spinal management in this stage (less than 4 weeks); modalities and manipulations (decrease symptoms), education as to not exacerbate symptoms, start core activation techniques

subacute

spinal management in this stage; when pain is no longer constant: educate (self management, relaxation, safe body mechanics), progress in spinal control practice, soft tissue mobility (manipulations, mobilizations, stretching), cardiopulm endurance

chronic

spinal management in this stage; when there are minimal impairments: educate (reemphasize previous techniques and principles), soft tissue mobility (manipulations, mobilizations, stretching), cardiopulm endurance

mobility/flexibility

stretching and flexibility exercises to increase mobility; move, stretch, manipulate restricting tissues

stability

structure is stable when line of gravity is within BOS; increased stability when lower COG or increase BOS; structures supporting body against gravity and other external forces (inert - osseus and ligamentous structures; dynamic - muscles)

global muscles

superficial: farther from axis of motion; cross multiple vertebral segments; produce motion; compressive loading with strong contractions; lumbar: rectus abdominis, external and internal obliques, quadratus luborum, erector spinae, iliopsoas; cervical: SCM, scalene, levator scapulae, upper traps, erector spinae

hindfoot

talus and calcaneus

referred pain

terminal point for L4, L5, S1 via the terminal branches of the peroneal and tibial nerves; these or sensory changes may occur from irritation or damage to these nerve roots

dislocations

these cause fractures and other damage typically

pathomechanics

these in the hip region: decreased flexibility, asymmetrical leg length (unilateral short leg, coxa valga and vara, anteversion and retroversion), hip muscle imbalances and their effects

foot

this is first to contact the ground in gait; its position and ability to do its job effects the entire kinetic chain ; even in static stance, the position effects the knee, hip, and lumbosacral regions

painful hip syndromes and overuse syndromes

this non op managment problem with the hips; related pathologies and etiology of symptoms: tendonitis or muscle strain, trochanteric bursitis (lateral pain), psoas bursitis (repetitive flexion, anterior/groin pain), ischiogluteal bursitis (tailors or weavers bottom, painful sitting); body structure/function impairments and activity limitations and participation restrictions: pain, gait deviations, imbalance in muscle flexibility and strength, decreased muscular endurance

rehab process

this of pts with spinal problems; activation of deep core back muscles/coordination with superficial back muscles to reinforcing stabilizing musculature function with muscular endurance and strengthening exercises to functional activities