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To Alison, 'My
, always WS
For Churchill Ll,,'m�:sw'ne: Editorial Director, Health Professions: Mary Law Project Derek Robertson Design Judith Wright
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The Malalignment Syndrome Implications for Medicine and Sport Wolf Schamberger
MD, FRCP (C), Dip Sports Med
Clinical Associate Professor, Department of Medicine, Division of Physical Medicine and Rehabilitation, and The Allan McGavin Sports Medicine Centre, University of British Columbia, Vancouver, Canada
With contributions by Fredric T. Samorodin RPT BSR MCPA (Chapter 8: Treatment: The Manual Therapy Modes) Cynthia Webster BSR PhD(C) RPT (Chapter 6: Horses, Saddles and Riders)
/�\ �� ::u:
CHURCHILL LIVINGSTONE
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2002
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CHURCHILL LIVINGSTONE An imprint of Elsevier Limited © 2002, Elsevier Limited. All rights re5erved. The right of Wolf Schamberger to be ident.ified as author of this work has been ilsserted by him in accordance with the Copyright, Designs and Patt�l1ts Act 1988. No part of this publication mily be reproduced, stored in a retdevill system, or trClnsmitted in ()ny form or by any means, electTonic, mechanical. photocopying, l't.'Con.ilng or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WIT 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone: (+1) 2152387869, fa:x: (+1) 215 238 2239, e-milil:
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First published 2002 Reprinted 2004 ISBN 0 443 06471 7 British Library Cataloguing in Publication Data A ciltalogue record for this book i� available from the British library Library of Cong-ress Cataloging in Publication Data A cat
-':=��=':::I�
-
;0
0
_ - _
Biceps femoris
�
- Rectus femoris
_
Pelvic obliquity
Figure 2.36 Myofascial contracture and lengthening related to spinal concavity and convexity respectively.
Sacroil iac j o i nt u ps l i p ITB Upslip: occurs considerably less often than rotational malalignment (about 1 0-20% versus 80%) • may coexist with a rotational malalignment (5-10%) o r an outflare/inflare
•
The more obvious ca uses of u pslip include traumatic
.. .�
_
=
anterior force or counternutation from rectus femoris, iliacus and TRJITB complex
upward forces t ransmit ted :
•
through the leg to the acetabu lum, with the knee
straight and the h i p jOint in a relatively neutral
.. ..�
_ _
=
posterior force or nutation from hamstrings (especially biceps femoris) and connections to a tight sacrotuberous ligament.
Figure 2.37 Torquing forces on the in nominate caused by tightness in the attaching muscles or ligaments (see Figs 2.31 B and C for an anterior view) . AS IS, anterior superior iliac spine.
position (Fig. 2.39) so that the leg does not exert a
rotational force on the innomina te, a si tuation that
m ight occur, for example, when:
- the foot is jammed against the floorboa rd s of a
crashing car, bobsled or other vehicle (see Fig. 2.34A) - landing hard on an extended extremity in a fa ll, on a dismowlt or on missing a step (see Fig. 2.348)
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COMMON PRES ENTATIONS AND D IAGNOSTIC TECHNIQUES
39
I I
ill ASIS
Lesser trochanter Figure 2.40 Muscles capable of generating forces (arrows) that can result in an upslip.
Sacro i l iac joint downs l i p Figure 2.39 Upslip caused by a unilateral upward force transmitted to the innominate through the acetab ulum. ASIS, anterior superior iliac spi ne ; GT, greater trochanter; PSIS, posterior superior iliac spine.
Do wnslip occurs rarely a nd i s freq uently m issed .
Typically, there is a history of excessive traction on an extremity. Examples of this mechanism include:
•
•
with the fai l u re of one ski binding to release, or
straight up wards through the innomi n a te itsel f,
the en trapment of one foot in the toe straps of a c ra s h ing bicycle Of the sti rrups while horse-riding
such as on fa lling a n d landing d i rectly on the ischial
tuberosity on one side to cause a shea r injury (see Fig. 2.34 8).
incidents where the ath lete is h u r led forward w h i l e one leg remains tethered, such as occurs
•
trying ra pidly to extract a n extremity that has sunk
i n to a hole, for example a foot suddenly stuck deep
However, more subtle forces relating primarily to an
imbalance of the hip gird le muscles can also cause an
in mud on a boggy running trai l .
Dow nslip i s usually misdiag nosed initially a s a n
upsJip to occur initially and are probably the main cause
u pslip o f the opposite S 1 joint. It is often only when
in tension involving quadratus lu mborum, latissi mus
ed l y fail t h a t the thera pist begins to suspect that the
i n ternal abdominal obliq ues (see Figs 2.248, C) or a
and appropriate treatment is instituted.
for its recurrence. Typical of these is a unilateral in crease dorsi, psoas major/minor (Fig. 2.40), the external and combination of these muscles.
As with rotational mala lignment, an upsl i p causes a
specific pattern of pelvic ring d istortion. Appendix 2
measures ai med at the correction o f the 'upsl ip' repeat
problem is actua l l y a downsl i p on the opposite side,
PELVIC OUT FLARE AND INFLARE
gives the examina tion findings typica lly seen w i th the
'Outfla re' a n d ' i n fl a re' refer to movement of the
detailed below in the d iscussion of 'Establ ishing the
tra nsverse plane (see Figs 2.1 0 an d 2.1 4). Norma l
less common right S I joint u ps l i p; these findings afe d iagnosis of malali gnment'.
innominates outwards and inwa rds respectively i n the
outflare a n d inflare have i nvariably been l i nked to
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40
THE MALALIGNMENT SYNDROME
simultaneous movements of the i nnominates in the sagitta l plane, but there are d ifferent descriptions offered of how and why this should happen: 1 . Gutflare linked to anterior rotation: as previously described (DonTigny 1 990), the anterior widening of the sacrum ca uses the innominates to 'spread on the sacrum' or flare out whenever the i nnominates rotate a n teriorly and downward relative to the sacrum; the same will occur with counternutation of the sacrum. In flare will occur with a posterior rotation of the innominates relative to the sacrum, and with sacral nutation. 2. Gutflare linked to posterior rotation: the posteriorly rotating innominates are described as gliding medially because of the posterior narrowing of the sacrum, causing the pelvis to open anteriorly; the sam e occurs with sacral nuta tion (see Fig. 2.14B). I n flare will occur w ith anterior rotation and with sacral counternutation OS Gerhardt, personal com m unication, 1 999). Other facts to appreciate when considering patho logical outflare and inflare i nclude the following. First, outflare and inflare can actually exist in isolation. Movement in the transverse plane can occur in these d irections, without coexisting rotation or upslip, and excessive movemen t can result in fixation in a n outflare or an i n flare position. For example, reversal o f the convex-concave relationship, w i th a concave ilial and convex sacral surface, allows for i nnominate rota tion medially or laterally a round a vertical axis which could result in i n flare or ou tflare dysfunction, respec tively (Greenman 1 990). Second, when rotational malal ignment is present, an outflare can be seen on the side of the a n terior i nnominate rotation, and a seemingly compensa tory i n flare on the s ide of the posterior rotation. However, the reverse findings of an inflare associated with \ an terior, a nd an ou tflare with posterior, rotation a lso occur. Finally, tightness or adhesions in the surrounding tissues may determine whether an outflare or i n flare occurs w i th rota tion. For example:
The u mb i l icus a nd the glutea l cleft conveniently dem a rcate the a n terior and posterior midline respec tively. If a right outflare a nd left i nflare are prese'nt, the rig h t ASIS will have moved ou twards a nd the left i n wards relative to the umbilicus (see Figs 2.10 Ai & ii; B D ; w hereas the right posterior superior iliac spine (PSIS) will have moved inwards and the left out wards relative to the gluteal cleft (see Figs 2 . 1 0Aii & i i i; CD. Correlation of the PSIS to the gluteal cleft is, however, more likely to be accurate, given that the u mbilicus is frequently 'off centre' pre- and post part u m and as a result of prev ious surgery and vis ceral ad hesions. In addition, the u mbilicus frequently a ppears in the cent re when an outflare/ inflare is actu ally present, probably as a result of having been pulled towards the side of the ou tflare by the trans versus abdomin is muscle being pu t u n d er increased tension (whereas those on the side of the i n flare relax). An even easier, and probably more accurate, way of determ ining outflare and inflare is shown in Box 2.2. The recognition of outflare and inflare is important from a trea tment perspective in that: 1. they can result in specific clinical problems relating
to altered biomechanics, stress being placed particula rly on the SI joints, hip joints and surrounding soft tissues (see Ch. 3) 2. rotational malalignment and upslip may resist treatment efforts lIsing the muscle energy technique u ntil a coexisting outflare or inflare has been corrected (see Ch. 7) 3. correction attempts aimed at the outflare and inflare first are successful in simultaneously correcting a coexisting upsli p and / or rotational malalignment in over 90% of cases. __
Box 2.2
Look for a change in the relative height of: •
.•
•
Adhesions and / or scar tissue formation in the lower posterior pelvic ligaments (around the S3 level) or the long (dorsal) sacroiliac ligament, or involving the posterior hip joint capsule or ligaments, wouJd tend to hold the posterior aspect of the innominate medially and predispose to outflaring on posterior innominate rotation while preventing inflaring on a n terior rotation. I ncreased tension in i liacus or sartorius predisposes to in flaring on anterior rota tion.
Determining inflare and outflare
•
the anterior superior iliac spine in the supine position, down and out with outflare and up and in with inflare; remember, however, that the height will also be affected by rotational malalignment, the anterior superior iliac spine rotating forwards and down with anterior, and backwards and up with posterior rotation the posterior superior iliac spine in the prone position, up and inwards with outflare and down and outwards with inflare; this is a more accurate way of determining outflare/inflare even if rotational malalignment is present.
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COMMON PRESENTATIONS AND DIAGNOSTIC TECHN I QU ES
ESTABLISHING THE DIAGNOSIS OF MALALIGN MENT The ini tial step in the diagnosis of malalignment is to establish whether asymmetry is present a nd, if so, whether it is caused by an anatomical leg length d if ference, a form of pelvic malalignment, vertebral mal rotation or a combination of these. Examination is preferably carried out on a firm, even surface. Sitting or lying on a soft or sagging support, or across a break in the surface, may a ffect the assessment and lead to incorrect conclusions. If the reader is in terested in carrying out manipula tions or mobilization procedures other than the simple tech l� iques presented in this text, a more detailed determi nation of the type of pelvic and spine malalignment present is of the utmost importance. Such a detailed determination is, however, not usually necessary in order to apply the material presented here to the cli n i cal setting. Ad vanced assessment and trea tment tech niques are best learned in a formal teaching setting, ha nds-on workshops and from selected papers, books and videos (e.g. A i tken 1 986, Bernard & Cassidy 1 991 ; DonTigny 1 990, Fowler 1 986, Lee 1 998, 1 999, Lee & Walsh 1 996, Richard 1 986, Vleeming et al 1 997, Wells 1 986b). Box 2.3 outlines the basic questions to be answered by the exa mination.
Box 2.3
Examination for pelvic malalignment
1 . Is the pelvis level or oblique? 2. Are the bony landmarks of the pelvis symmetrical or asymmetrical? 3. What happens on the sitting-lying test (described in detail below)? 4 . Is there any sacral torsion or excessive nutation or counternutation of the sacrum? 5. Is there an obvious curvature of the spine (e.g., a scoliosis) and/or any excessive rotation of isolated vertebrae? 6. Is there any gapping and/or displacement of the symphysis pubis? 7. Is there any increase in tension and/or tenderness localizing to specific muscles and ligaments? 8. What are the findings on sacroiliac joint and pelvic girdle testing for: - function, motion/mobility and stability - form and force closure? 9. Is the basic neurological and vascular examination normal?
41
PELVIC OBLIQUITY The presence or absence of pelvic obliquity may become obvious from what are sometimes very easily apparent d imples of Venus on the buttocks, about 1 cm above the PSIS (Fig. 2.41 A). A more accurate examination relies on a comparison of the relative height of the index and / or middle fingers lying on the la teral iliac crests (Fig. 2.41 B), or the thumbs or index fingers resting on the pubic bones (Fig. 2.41C), or hugging a gainst the lower part of the ASIS (Fig. 2.410), PSIS (Fig. 2.41 B) or of the ischial tuberosities (Fig. 2.41F). Aspects of the sacrum, such as the inferior lateral angle (Fig. 2.41 G) and sacral sulci (see Fig. 2.56), and a comparison of the h ighest point of the ASIS and PSIS in the supine and prone posi tions (see Fig. 2.10A) may also prove helpfu l . I n standing: •
•
If the pelvis is level, this suggests (but d oes not confirm) equal leg length (Fig. 2.41 B and 2.42A). I f the pelvis is oblique, there may be a n a natomical (true) or functional lengthening of the leg on the elevated side (Figs 2.42B and 2.43).
In sitting and lying supine or prone, i f the pelvis is now level, this suggests a n a na to m ica l leg length d i f ference (LLD) as the cause of any obliquity noted i n standing; i f that were so, t h e L L D would still be evident in prone a nd supine lying, but all the pelvic landmarks would be symmetrical (see Fig. 2.42B). I f the pelvic obliquity persists while sitting, with the iliac crest elevated on the same side as in standing, pelvic malalignment is probably presen t (Fig. 2.43A-D; see also Fig. 2.46B); a less likely cause is an actual differ ence in the height of the innominates (see Fig. 3.80 ) . I f the pelvic obliquity persists, but w i th t h e iliac crest now higher on the side opposite to that noted in stand ing, malalignment is even more likely to be present to account for such a change. The pelvis remains level in the presence of a n outflare and i nflare alone.
BONY LAN DMAR KS OF THE PELVIS In practice, assessment using the pelvic landmarks may not be entirely accurate because of muscle imbal ance, congeni tal or acquired side-to-side differences of bony contou rs, o r a u nilateral tendency to pronation or supination when weight-bearing. Attempts to establish the presence or absence of malalignment must never be limited to the assessment of landmarks alone but should be supplemented by the findings on assessment of pelvic obliquity and leg length in various positions.
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42
THE MALALIGNMENT SYN DROME
(A)
Figure 2.41 Landmarks when the pelvis is aligned and the leg length equal. (A) Dimples of Venus, about 1 cm above the inner margin of the posterior superior iliac spine (PSIS). (8) Fingers on the iliac crests, thumbs against the inferior aspect of the PSIS. (C) Superior pubic bl)nes (thumbs resting on the superior aspect). (D) Anterior superior iliac spine (thumbs resting against the inferior aspect). (E) PSIS (thumbs resting against the inner aspect, equidistant from the midli ne). (F) Ischial tuberosities. (G) Inferior lateral angle at the S5 level. (Figs 2 . 4 1 F and G : from Lee & Walsh 1 996, with permission .)
Fig.
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2. 4 1
(Fj & (Gj, see opposite
COMMON PRESENTATIONS AND DIAGNOSTIC TECHNIQUES
Figure 2.41
Continued.
ASIS
PSIS
STANDING
A)
PSIS
(8)
43
t
t
SIDING
SUP I N E
PRONE
ASIS
STANDING
S ID I N G
SUPINE
PRONE
Figure 2.42 Effect of leg length on the aligned pelvis. (A) Aligned: leg length equal. ( 8) Aligned: an anatomically long right leg (the pelvis level sitting and lying). ASIS, anterior superior iliac spine.
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44
THE MALALIG N MENT SYNDROME
PSIS
t
t ASIS
(A)
STANDING
ASIS
t
SITTI NG
SUPINE
SITTI NG
SUPINE
PRONE
t PSIS
STANDING
(8)
PRONE
@ I
� PSIS
(C)
I I
t
STANDING
SITTI NG
SUPINE
PRONE
Figure 2.43 Pelvic obliquity related to malalignment (some typical presentations). (A) Right upslip (all right pelvic landmarks up in all positions) . (8) Left upslip (right pelvis usually up standing and sitting, left up lying). (C) Right anterior rotation (one common presentation). (D) Left anterior rotation (one common presentation). ASIS, anterior superior iliac spine. Fig. 2.43(0), see opposite
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COMMON PRESENTATIONS AND DIAGNOSTIC TECHN IQUES
45
\2 I
rI\ I ASIS
�
t PSIS
Figure 2.43
SITTING
STANDING
(D) Continued.
In alignment and with leg length equal (see
Figs 2.41 and 2.42A) The iliac crests will be level when standing, sitting, and lying prone or supine. The right and left ASIS and PSIS will be level during standing, sitting a nd lying. On a lateral view, the ASIS is positioned upwards relative to the PSIS approxi mately the same a mount on both sides. The right and left superior and inferior pubic rami are level when lying supine or standing (see Fig. 2.41C), the ischial tuberosities level in lying prone or standing (see Fig. 2.41 F) . The right and left ASIS will be level in the transverse plane when stand ing, sitting or lying supine. That is, there is no rotation of the pelvis clockwise or cou nter clockwise that would bring one ASIS forwards a nd the other backwards. I n alignm ent, with an anatom ically long leg
Only in stand ing are a l l landmarks elevated on the side of the long leg, with a uniform obliquity of the pelvic crests and superior pubic rami on clinical exam ination (see Fig. 2.42B). A standing a nteroposterior X-ray of the pelvis shows: •
•
PRONE
SUPINE
a uniform obliquity of the sacrum and superior pubic bones, with no d isplacement of the right and left pubic bones relative to each other a d ifference in the height of the femoral heads, which is the true LLD (Fig. 2.44A).
Sacro iliac joint upslip
There is a simultaneous elevation of all the pelvic land marks on the side of the upslip. One is not, however,
dealing with a simple upward tilt of the pelvis a s occurs with an anatomically long leg, but with an actual upward translation of all the landmarks relative to the other side. Right up�lip. There is a n upward d isplacement of the right AS IS, A I lS, pubic ram i and PSIS (see Fig. 2.43A). The right superior pubic ramus is raised by 3-5 mm relative to the left one; this can be appreciated as a step deformity at the symphysis pubis on palpa tion and on X-ray. The right leg is pulled upwards with the right innomina te, so that i t appears to be shorter than the left leg when the a th lete is lying prone or supine (see Fig. 2.43A). The shortening usua l ly a mounts to some 5-1 0 mm. In stand ing, however, the iliac crest is ele vated on the side of the upslip so that the right leg a ppears to be the longer one in that position. In fact, the elevation of the right iliac crest persists during sitting and lying, and is in part due to the associated rotation of the pelvis in the frontal pla ne. Left upslip. This is most easily appreciated on exam ination in the supine and prone positions, in w hich case the left leg is noted to be shortened a nd the left ASIS, PSIS, pubic bone a nd iliac crest eleva ted relative to the right (see Fig. 2.43B). The pelvis, however, usually appears higher on the right in standing and sitting, possibly because of a shortened left leg (in standing) and a n element of pelv ic rotation in the frontal plane.
7c \
Rotational m alalignm ent
Anterior superior and posterior superior iliac spines. With a nterior rotation of the innominate bone in the sagittal plane, the PSIS moves upward (cephalad) and the ASIS and pubic bone move downwards (caudad).
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46
THE MALALIGNMENT SYNDROME
(A)
(Bi)
(Bii)
Figure 2.44 X-ray of a standing athlete with anatomical (true) leg length difference - right leg long. (A) Posteroanterior view: right femoral head higher than left; note the uniform obliquity of the superior pubic rami and the almost symmetrical appearance of the sacroiliac joints and lesser trochanters. (B) (i) Right and (ii) left oblique views: the facet joints appear to be of uniform width except for right L4-L5, narrowed by what appear to be osteoarthritic changes.
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COMMON PR ESENTATIONS AND DIAGNOSTIC TECHNIQUES
With posterior rotation, the PSIS moves downwards and the ASIS and pubic bone u pwards. The anterior or posterior rotation of one innominate is usua lly compen sated for by the contrary rota tion of the opposite innom inate, which has the effect of amplifying the asymmetry. One can usually make the diagnosis of rotational mal alignment on the basis of this complete asymmetry of the ASIS a n d PSIS (see Figs 2.29, 2.43(, 0 and 2.46). Pubic bones. With right a n terior, left posterior innominate rotation, there wil l be rotation around the symphysis pubis, with the right pubic bone rotating downwards and backwards (posteriorly), and the left upwards and forwards (anteriorly). This creates a dis placement at the symphysis pubis that is usually easily apparent both on clinical examina tion (see Fig. 2.46C) and on an teroposterior X-rays of the pelvis (Fig. 2.45). In other words, as a result of either anterior or posterior rotation of one innominate, all the bony landmarks of the pelvis end up completely asymmetrical in all positions of examination, both on anterior-posterior and side-to-side comparisons.
Gulflare and inflare
Outflare and inflare are unlikely when the right a n d left ASIS are level when viewed i n supine-lying and
Figure 2.45 X-ray: standing anteroposterior view of the pelvis in an athlete with equal leg length and right anterior, left posterior rotational malalignment. Note the equal height of the femoral heads but the obliquity of the pelvic crests, the ap p roximately 3 mm downward displacement of the right superior pubic ramus relative to the left at the symphysis pubis, and the apparent asymmetry of the sacroiliac joints and lesser trochanters (the left appearing larger, the right smaller - compare with Fig. 2.44).
47
the PSIS i n prone-lying. A right ASIS lower and away from centre in the supine position, a nd higher a nd towards the centre when prone, relative to the left ASIS will, however, reflect rotation in the transverse plane, in keeping with a right outflare and left inflare (see Fig. 2 . 1 0 ) . T h e AS IS a n d PSIS and t h e pubic bones rema i n level on viewing t h e pelvis from front or back when the a t hlete is sta n d ing, sitting and lying prone or supine (see Fig. 2 . 1 0) and leg length a lso rema ins unchanged.
SITTING-LYING TEST This test affords those caring for athletes, a nd indeed the athletes themselves, a quick way of establishing whether mala lignment is actually present and, if so, whether it is a rotation, u pslip or possible downslip, in order that appropriate treatmen t can be initiated. Leg length is compa red by noting the level of the med ial malleoli in the 'long-sitting' (legs i n front) a nd 'supine-lying' positions (Figs 2.47 a n d 2.48). Trying to compare the high points of the malleoli is sometimes difficult, especially if the malleoli are u n even i n contour developmentally or a s a result o f injury, not very prominent or quite a distance apart (as occurs, for example, in the athlete with k n ock-knees or genu valgum). I t is much easier, and more accurate, to compare the level of the thumbs placed in the hollow immediately below the med ial malleolus on each side. Point the thumbs straight downwards to make the comparison more accurate. In add ition, take care not to forcefu lly hold on to the a nkles with your hands, or else the free upwards a nd downwards movement of the legs may be impaired . At home, the test is best performed on a firm bed, carpeted floor or even a table: a soft bed could a l ter the movement of the legs by allowing the pelvis to sink into the su rface uneven ly. The heels must be able to slide w ithout hindra nce. If one or other heel gets caught up on the su rface, it will in turn shift the pelvis on that side and make the test invalid . A sheet cover ing the plinth, or a t least a towel placed u nder the heels, will prevent them getting caught up on a vinyl or leather surface; a l ternatel y, the a thletes can just keep their socks on for this test. If a smooth surface i s n o t available a t h o m e or on t h e field, try placing a jacket under the feet, the smooth l i n i ng facing upwards. The athlete initially lies supine and is then asked to sit up. A shift o f the pelvis or other error is less likely if one gives assistance by pulling up on the a th lete's out stretched hands; when carrying this manoeuvre out
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48
THE MALALIGNMENT SYNDROM E
Figu re 2.46 Rotational malalignment: right anterior, left posterior innominate rotation in both athletes. (A) Asymmetry of anterior superior iliac spine (ASIS) (right down, left up). (B) Asymmetry of posterior superior iliac spine (PSIS) and iliac crests (right up, left down) in standing (also in sitting see Fig. 3.79B). (C) Right superior pubic ramus displaced downwards relative to the left. (D) Shift of the right pelvic landmarks relative to their left counterparts: right iliac crest, PSIS and ischial tuberosity move up; right ASIS, anterior inferior iliac spine and pubic ramus move down.
a lone, the athlete can use a belt or rope for the same purpose (Fig. 2 .49). Once the exa miner has established the relative leg length, the athlete is asked to lie down, again taking care not to shift the pelvis in the process, and the comparison is repea ted. The exa miner also observes the d irection of movement of the feet on sitting u p and lying dow n .
Clinical correlation Barring excessive tension or contracture in the pelvic a nd hip·girdle structures (e.g·. u nilaterC)l contracture of quadratus lumborum, or psoas major/ minor pulling up on the ipsilateral innominate; see Fig. 2.40), the more common presentations on the sitting-lying test are those described below.
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COMMON PRESENTATIONS AND DIAGNOSTIC TECHNIQUES
(A)
( 8)
Figure 2.47
(8)
(A) Figure
(A)
Sitting part of the sitting-lying test. (A) Long-sitting. (8) Left leg longer than the right.
2.48
Lying part of the sitting-lying test. (A) Supine-lying. (8) The right leg has lengthened relative to the teft leg.
(8)
Figure 2.49 Sitting-lying test: assisting sitting up to decrease error. (A) Assisted by a second person. (8) Using a strap or rope to pull up on while looki ng for relative leg length difference and any shift of the right versus left foot.
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49
50
THE MALALIG N MENT SYNDROM E
Alig ned, leg length equal (Figs 2.50 and 2.51 )
In supine-lying, the acetabula lie anteriorly and raised (craniad) relative to the ischial tuberosities (Fig. 2.50A). On moving into the long-sitting position, flexion occurs initially in the thoracic and then the lumbar spine, at
which poi n t the pelvis starts to rotate forwards and eventually pivots over the tuberosities as one unit. The acetabula are therefore moved even further anteriorly and also downwards (caudad) so that the legs appear to lengthen to a n equal extent (Fig. 2.50B). On returning to Centrum of acetabulum
ASIS
Femur Ischial tuberosity
/ surtace (A) Vertical axes relative to pivot points
/
.
.
�
�:
. . .
�
. .
Centre of acetabular axis moves anterior and down
Transverse axis of rotation through acetabula axis of ischial tuberosities :--'(8)
/
Pivot points of ischial tuberosities
Sitting-lying test: aligned, leg length equal and all landmarks symmetrical. (After DonTigny 1 997, with permission.) (A) Supine-lying: the acetabula lie anterior and craniad relative to the ischial tuberosities. (8) Moving into long-sitting: the innominates pivot over the ischial tuberosities and the acetabula move forwards and caudad, causing the legs to lengthen equally. ASIS, anterior superior inferior spine; AilS, anterior inferior iliac spine; PIIS, posterior inferior iliac spines. Figure 2.50
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COMMON PRESENTATIONS AND DIAGNOSTIC TECHNIQUES
51
Iliac crest -----..,,,-,,.-----::=--"!'as a unit, in an attempt to stabilize an 51
The activities are
joint
and involve
.. psoas, as a result of facilitation caused by T12, L1 or L2 vertebral malrotation.
with rotational comjumping from one leg
to the other. Because of the competitive element of the game, movements are often almost reflex in nature, with little or no time for
The combined effect of these restrictions
as the athlete throws
of the hip adductors, as well as the individual n()nplr1h, of 3.46, and pectineus (see 4.2 and 4.14), with either a lateral 'slide' or
CYCLING
same structures, at risk of
The legs s hould move
Reference should also be made at this occurrence of a painful as a result of irritation
to the
in the from the crossbar, in
bone in court sports the anterior cutaneous
branches in association with T12/Ll malrotation and the thoracolumbar syndrome (see Fig. 4.21Al, B2; vulnerable
Appendix 9). These branches are
in tennis - and soccer
1995).
rf'f)patpd trunk vres
knees
manoeu-
serving}, as well as excessive or
hip
extension, will put these branches under stretch while narrowing the intervertebral foraminal leans backwards.
injury biomechanics relating to to acute
Box 5.2 Ankle sprains predisposed to by 'alternate' presentations and ups lips .. Left ankle inversion sprains: caused by the tendency
weakness to supination and lateral of the peroneal muscles by internal rotation of the left lower extremity • RighI ankle inversion sprains: probably allribulable 10 a momentary instability as the increase in varus angulation noted in the non-weight-bearing state causes the lateral aspect of the right foot to hit the ground at a more acute angle .. Right ankle eversion sprains: caused by the tendency to pronation and medial weight-bearing, weakness of the ankle invertors, and pre-positioning by external rotation of the right lower extremity
or the
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250
THE MALALIGNMENT SYNDROME
generate a n equal amount of force. The cyclist who presents with malalignment may, however, be aware of an asymmetry of form and strength in that: •
•
leg strength feels different, the leg on one side tending to feel weak in terms of the amount of power it can generate and in having a tendency to fatigue more rapidly the legs appear to move differen tly, movement generally feeling less smooth on the weak side.
Several laboratory studies have attributed these problems to a mala lig nment-related leg length differ ence (LLD ) . On the side of the 'short' leg, D u n n & Glymph ( 1999) have shown: 1. an up to 5% decrease in the power generated
2. a loss of pedal stroke efficiency, the round and smooth 'electronic motor' type effect being replaced by a piston-like action. Studies were ca rried out using a standard bicycle mounted on a CompuTrainer, which allowed for a measurement of torque applied to each crank arm at every 15 degrees of rotation, as well as of the power split percentage between the righ t and left legs. These studies have documen ted that, on realignment, the cyclist: •
• •
regained a smoother, more rounded stroke on the previous short side, more in keeping with that on the other side could ride for longer at his or her maximum output showed a continuing improvement on repeat studies over time, which was thought to be indicative of the body's continuing adaptation to the newly a ligned position .
The right leg is more likely than the left to feel weak. Given the large percentage of those presenting with right anterior rotation and right upslip (around 80%), the right leg is more often the shorter leg in the sitting position (see 'Sitting-lying test' in Ch. 2) . Foran (1 999) points out that an LLD of more than 3 mm is a sign of 'spastic contracture' (perhaps caused by facilitation) originating at an upper motor neuron level, and that:
The knees end up a variable distance away from the crossbar With right an terior innominate rotation, the right knee comes closer to midline than the left as the foot reaches the lowest point on pushing down on the pedal (Fig. 5.4A). This inward movement reflects the tend ency to ex terna l rotation of the right leg, with a tendency to foot pronation and knee valgus angulation on this side. As the right pedal moves upwards, the right knee flexes and very obviously moves away from the cross bar, a movement again reflecting the fact that the right leg is in exaggerated external rotation (Fig. 5.48). Seen from the front, the right knee a p pears to be moving in a circle in the frontal plane, alternately moving to a nd from the crossbar. In contrast, the left knee moves more straight up and down in the sagittal plane, maintaining a more consistently even distance from the bar. The overall movement of the left leg also appears to be smoother in comparison to that of the right. The cyclist can improve ma tters by adding toe clips in the hope of stabilizing the feet in order to counteract the tendency towards pronation. The right toe clip can be adjusted by rotating it counterclockwise so that the right foot, rather than poi n ting outwards as the malalignment would dictate, now ends up pointing more or less straight ahead or even slightly inwards. Fixing the foot in this position might be expected to counteract the tendency to external rotation of this leg, improving the mechanical advantage of the right leg a nd its ability to generate a force by: •
•
orienting the leg muscles more in the sagitta l plane, so that they are working more in the line of progression increasing right ankle stability by decreasing the tendency to pronation.
Unfortunately, the right leg has really had to be forced into this 'straight' position because, as long as malalignment is present, there will be a force to rotate this leg outwards. If the toe clip now counteracts this tendency to external rotation as the foot forces the pedal down, the rider may start to ex perience pain on either:
The spastic musculature responsible for the functional leg insufficiency remains hypertonic, even while wearing orthotics and heel lifts. This means a torqued pelvis and microtrauma on one side while seated. (p. 12)
1. the medial aspect of the knee, as a result of arrested foot pronation, decreased tibial in ternal rota tion and straining medially on forced femora l external rotation.
Only realignment wil l improve matters.
2. the lateral knee, owing to the increased tension in TFL/lTB and stress on the la teral compartment that results with augmentation of these external rotational forces.
In addition to the above observations regarding form and strength, the following may become obvious to the cyclist or trainer.
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(A)
(8)
Figure 5.4 Relationship of the knees to the midline (crossbar) in a cyclist with an upslip or 'alternate' rotational malalignmenl and typical rotation of legs (right external, left internal). (A) The right knee is moving towards midline on knee extension, with foot pronation and a tendency towards genu valgum; the left knee is relatively neutral, travelling more in the sagittal plane. (8) The right knee is moving away from the midline with external rotation of the leg as the knee flexes. The left knee maintains a relatively neutral position.
One soluhon is to angle the toe clip outwards as far as is needed so that the external rotation of the leg can
•
actually be accommodated, in that way perhaps pro viding some increased stability for the foot while resolving the problems at the knee level. The addition of an orthotic modified to counteract pronation may also be helpful, but the only long-term solution is realignment.
Cycling precipitates back pain In some cyclists, riding with the trunk in a forward flexed position (Fig. 5.5A) precipitates or worsens mal alignment-related back or pelvic pain by: •
increasing the stress on the cervicothoracic junction as the cyclist keeps the head and neck in compens atory extension throughout the ride in order to see the road ahead
•
increasing the tension in already tense and tender paravertebral muscles or posterior pelvic ligaments (particularly the iliolumbar, sacrotuberous and interspinous ligaments) putting direct pressure on tender sites such as the sacrotuberous insertions, hamstring origins and coccyx. One alternative is temporarily to use a stationary bicycle, sitting with trunk straight upright and the arms relaxed at the sides. This m i n i m izes tension on the muscles and ligaments of the back, sacral and coccygeal regions. Weight-bearing is more effectively shifted onto the ischial tuberosities and may in fact spare the coccyx.
An even better option may be to use a recumbent bicycle, which effectively relaxes the back muscles and ligaments by providing support, helping to maintain
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with a groove that accommod a tes the coccyx are also available (Fig. 558).
Seat i n g may be i m pa i red In add ition to the problem of sitting on painful struc tures, d iscussed above, i m paired seating ca n also relate to the uneven weight-bearing c haracteristic of malalignment. With right anterior rotation or upslip, for example, the right ischial tuberosity may be raised by as much as 1 cm relative to the left (see Figs 2.41F, 2.460, 3.69A, 3. 79C and 6.5). The cycl ist may be aware that he or she is bea ring more weight on the left side a nd that the pelvis is shifting to accommodate; alter natively, he or she may try to compensate by filling the gap between the right buttock a nd seat with a thin pillow, or by material stu ffed inside the training pants. Toe cleats, orthotics, cleat s hims and adjustments to the saddle, peddle and crankshaft to accommodate for the short leg may result in some improvement, but realignment remains the only definitive treatment. If cycling repeatedly stirs up coccygeal symptoms or other musculoskeletal pains, this activity is best avoided until the problem has responded to treatment. Finally, those who are cycling and still going out of alignment must make sure that they are not doing so when getting on and off the bicycle. If that is the case, a bicycle without a crossbar is preferable, and making use of a stool or the curb also cuts d own the amount of asymmetrical rota tion through the hip girdle and pelvis that will other wise occur.
(A)
DANCING Figure 5.5 Seating in cycling. (A) The supposedly 'good' position, with the back II at and the head up, may still cause problems when malalignment is present by stressing tense/tender structures (e.g. the paravertebral muscles and posterior pelvic ligaments). ( From Matheny 1 989, with permission.) (B) A bicycle seat with a central depression relieves pressure on the coccyx and concentrates weight bearing on the ischial tuberosities (see also Fig . 7.40).
the l u mbar lordosis and thereby decreasing the tension in these structures. It may also avoid putting pressure d i rectly on tender sites, although this is not always guaranteed. When out on the road, trunk flexion ca n be mi ni mized by raising the h a ndle bars as high as possible. Mountain bikes, rid den o n smooth surfaces, a re preferable; shock absorption can be further increased by usi ng a visco-elastic gel seat or similar cover. Seats
Today's d ancers start training a t a n earlier age and often train longer and h a rder than those in previous d ecades in order to excel. C hronic or overuse-type injuries are more common tha n acute ones, and the lower extremities are inju red more often than other areas in most forms of dance. The biomechanical limit ations imposed by mala lignment probably play a key role in causing these injuries. Take, for example, the turnout of the legs. As Ad rian & Cooper ( 1 986, p. 409) ind icate: the amount of turnout is i n fluenced by bony, liga mentous, and musculotendi nous factors [and] optimum turnout . will result if the dancer has adequate strength in the deep external rotators and a dductor muscles of the h i p joi n t and uses a ppropriate muscle activation pa tterns.
This may be true for the da ncers who are i.n alignment, but those who present with malaJignment are fighting needlessly imposed restrictions on ranges of motion and, in addition, limitations relating to al tered strength
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and activation patterns. The following discussion will refer to the more common upslips and 'alternate' pre sentations of rotational malalignment.
The five basic positions of c l assic dance Dance is a flow of movements based on fu ndamental patterns of al ignment of the head, a rms, trunk, pelvis a nd legs. These movements repeatedly strain the avail able ranges of motion of these various parts of the body to their limit. The five basic positions in classical
ballet, for example, involve a progressively increasing degree of difficul ty in terms of their effect on the ori entation of the lower eXh'emities in relation to the rest of the body (Fig. 5.6). In all five positions:
•
the pelvis remains facing forwards; that is, it is a ligned in the frontal pla n e t h e trunk i s usual ly a l igned i n t h e frontal plane,
•
but it can rotate on the pelvis with some manoeuvres (e.g. ports de bras) the lower extremities a re externally rotated (ell
•
dehors).
1 st position
2 n d position
3rd position
5th position
(A) Figure 5.6
Classical dance. (A) The five basic positions of dance. (6) Narrow and wide fourth position preparations for a (From Laws 1 984, with permission.) Fig. 5. 6 (B). see overleaf
pirouette en dehors.
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254
THE MALALIGNMENT SYNDROME
(8) Fig ure 5.6
Continued
In the first pos ition, the lower extremities are ex terna Uy rotated so that the feet are aligned at an angle of 45 degrees or less relative to the fron tal plane, with the heels touching (Fig. 5.6A, 1st). The second position resem bles the first except that the lower extremities are abducted to an equal extent in the frontal plane and are externally rotated to 90 degrees (Fig. 5.6A, 2nd). in the third, fo urth and fifth positions, the lower extremities are adducted so that the legs are crossed and placed either together (Fig. 5.6A, 3rd and 5th), or with one foot in front of the other (Figs 5.6A, 4th and 5.6B), with the overall orientation of the feet in line with the frontal plane. The stress created in the lower extremities, pelvis and trunk by these five positions is further augmented by progressing from the ii plat (flat) to sur la demi-pointe to sur la pointe (up on the toes) placements of the foot, combined with the various possible positions of the head and arms, and whether the dancer is supported on one or two legs.
The position of the leg en dehors (turned out) is contrary to natu re. The pos ition necessita tes cons ta nt training from a very
P roblems related to the basic positions
after the age of 11 the s h a pe of the femoral neck can no longer be altered through the mou ld ing process of con tinual pressure, such a s lying on the floor with the h i ps abducted
The ranges of motion particularly taxed by these posi tions are external rotation a nd adduction of the lower extremi ties, and to a lesser ex tent pelvic and trunk rotation i n the transverse plane. Nixon (1 983, p. 465) has bluntly sta ted that:
early age and laborious exercise to force it. There is l i ttle wonder . . . tha t musculoskeletal strain becomes man ifes t.
Micheli (1 983), on discussi ng the causa tive factors of back pain in da ncers, indicates that the increased lor dosis noted in a large number of dancers is usua lly acquired; the accompanying extension of the pelvis actua lly a l lows increased external rotation of the lower extremities and would therefore facil itate tu rnout. He also identifies the following as risk factors for overuse inju ries in dancers: 'anatomic malalignment of the lower extremity, including d i fferences in leg length; abnorma lity or rotation of the hips; position of the kneecap; and bow legs, knock-knees, or flat feet' (p. 474). Sammarco ( 1 983) makes the pOint that 'chil dren who begi n classica l ballet training during their juvenile years . . . have the benefit of developing turnout while at the same time developing the femoral neck angle', whereas:
and externally rotated . . . turnout is achieved by stretching the hip capsule. (p. 487)
He points out the common complications that occur around the hip region ( Box 5.3).
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Box 5.3
•
• •
• •
• •
•
•
Effect of malalignment
Hip region complications in dancers
Prolonged forced hip abduction stretches the capsule, whereas strain at turnout puts the medial internal capsule under stretch and compresses the superolateral aspect of the acetabulum; there is eventual capsule scarring and calcification, with osteophyte formation on the acetabular rim and the femoral neck (see Fig. 4.3) Hamstring origin pulls Hamstring tears, in particular of the short head of biceps femoris Strain of the adductor origins or muscle belly Iliacus tendonitis and myositis, often seen bilaterally and in association with the deve/oppe manoeuvre, in which: the hip and leg are brought from the first dance position outward and upward in external rotation [at which point the flexed knee is extended] and the lower extremity returned to the first pOSition again . (Sammarco 1 983; p. 493) Greater trochanteric bursitis A snapping sensation as the tendon of tensor fascia lata moves across the greater trochanter, this being most likely to be visible when the dancer lands from a leap Snapping in the groin region, probably of iliopsoas, when the hip is stili 45 degrees flexed 'as the leg is brought from a flexed, abducted, externally rotated position with the knee extended back to the first position' (Sammarco 1 983; p. 495) in the second half of a deve/oppe Traumatic sciatic neuritis from striking the buttocks against the floor when doing the splits
The above are among the more common injuries seen in dance. Some of them can be related to repetitive movements that place an abnormal stress on a specific structure. On looking a t the structures commonly involved, however, it becomes obvious that these are also in large part the structures that can be put under abnor m a l stress merely by the occurrence of malalignment, even before superimposing the add itional stresses incurred in dancing. The stresses arising from dance manoeuvres and malalignment must be regarded as being capable of augmenting each other and increasing the risk of the dancer becoming symptomatic.
The following is a consideration of how some dance manoeuvres can be affected by the specific stresses asso ciated with malalignment in a dancer afflicted with one of the 'al ternate' presentations. Turnout
The mala lignment-related limita tions that will inter fere with the ability to achieve maximum, symmetrical turnout include: •
In addition to these, there a re the problems related to the Achilles tendon, knee and great toe. Howse (1983) stresses the importance of this toe in allowing the dancer to 'maintain the correct line through the foot', thereby avoiding 'the secondary production of injuries elsewhere in the lower limbs', which could result from 'the difficulty or inability to maintain correct line and weight distribution from the foot up the leg a nd through the trunk' (p. 499) . He notes the following problems in particular: 1. metatarsus primus varus, resulting in secondary hallux valgus 2. a short first ray. forcing the dancer into a ttempts to try to maintain stability by weight-bearing over the second and third toes (commonly known as Morton's toes - see Fig. 3.35A) 3. hallux rigid us, with pain and a progressive loss of dorsiflexion 4. injury to the capsule and ligaments of the first metatarsophalangeal joint, aggravated by a rota tional twist of the toe itself.
•
•
a restriction of left lower extremity external rotation and abduction as a result of asymmetrical orientation of the hip socket the asymmetrical increase in muscle tension around the hip joint, in particular the right h a mstrings and left iliopsoas tightness of left hip abductors and TFL/ 1TB complex.
The dancer may try to force the feet past the amount of left turnout that is readily available. Adrian & Cooper (1 986, p. 409) point out how the dancer may be able to: assume the perfect turned-out position w h i le the lower legs are flexed, and then straighten the legs and attempt to adjust a l ignment from the floor . . . by pronating the feet excessively, by 'screwing (twisting) the knees' and / or by h y perextension of the back - al l of which may cause a myriad of dance inju ries if continued over time
When one of the 'alterna te' presentations or upslips is present, attempts a t such faulty adjustments would be further compromised by: 1. an inability to pronate the left foot as much as the right or, a t worst, not at all because of a tendency towards frank left supination
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cited as a cause of pain in dancers i f left
to ' twist' through the left knee as with a l im i ta ti o n of the a mo u n t of i n terna l rotation o f the left tibia relative to the fem u r, with the r i g h t (see
1 986, Fitt 1 987). The
uncorrected (Adrian &
imbalance is attribu ted to structura l factors and to 'con sistent patterns of misuse or overuse' (Adrian & Cooper
3.74)
3. a ny decrease in l u m ba r
1 986, p. 412). A l though these factors may indeed be
d ec reased flex i b i l i ty of t h e l u m ba r
nnpr�lrn,p
to extend, that c a n res u l t w i t h compensatory
that the
in d ancers, there i s also the
dancer
to carry out these manoeuvres i n a par
l a tera l curvature, the a d d i tion o f vertebral ma lrotation,
ticu lar way for the simple reason that it feels better or is
rotation o f the sacral base (counter-
easier to d o that way, or tha t there just is no choice if the
excessive
involvement and p a i n from stress
n u ta tion), on the junctional
manoeuvre is to be executed at alL
( l u mbosacra l and thoraco-
l u mbar) w i th a reactive increase in tension in the adjacent
m uscles.
Pattern of weight-bearing The typical d a nce shoe o ffers l i t tle, i f any, support. The and
feet a re therefore a t l iberty to movement and t o
on
i n to positions o f med ial and
l a tera l
The left foot tends the
to
a major
stress fractures a n d other a b i l i ty t o absorb shock. A relative i ncrease in
in
the evolu tion
structural chan ges a n d fa u l t y patterns.
pronation u nd er high
with the i mpact on landi ng, res u l ts in
Fai l u re to progress
traction on the abductor h a l l u cis
that
of tibroutines in terms of may a lso occu r from a sustai ned contraction o f tibial is as the dancer
to
excessive
(Kravitz 1 987) . Excessive i n terna l rota tion of the right tibia a n d increased
knee
and grace. The d ancer is at risk point at which the restrictions ment m a ke it advance to the next
to
a n excessive stress on med ia l knee structures a n d compartment
or 'dancer's
3 .33 and 3.74). The risk of ankle the sh ift in weight-bearing and the
DIVING The
associated w i t h
wi II
affect those dives w h ic h h a v e a
a n kl e m u sc les. Increased
a t en try
i n increased stress on the
vertical take-off sa u l t back layout or a somers a u l t pike. The restrictions however, even more rating a tw ist produced
by m a la l i gn m en t are, to affect those dives incorpoby s i m u l ta neous rotation
around two or three axes. A d ive
with a vertical
take-off with an angular
by
reverse somersau l ts a n d 1 5 twists, will rotation around all three axes (Fig. 5.7). If the diver leans
Asymmetry of strength, tension and range of motion
into the twist too soon, it may be d iffi c u l t to initiate the somersau lt. A problem o f a similar nature coul d con-
Musc u l a r imbalance, end urance a n d flexibility in
result because m uscle grou ps, is
i n a 'twisted'
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the
� j •
0"
" ...,
I
I
a
b
j
/
/
/ //
�
� �
c
d
/
�� 1 /
//
// /
��
e
/
/
9
/ � h
Figure 5.7 Reverse 1 '12 somersault with 1 Y2 twists from 1 m height. (From 0' Brien 1 992, with permission.)
Another problem common to diving, particularly with d ives that incorporate a twist, is the recurrence of malalignment. The recurrence can occur either while performing the twist or on entry into the water, espe cially jf the entry is not perfectly symmetrical and/ or there is still a spinning component at the time the body hits the water. Some teams actua lly make sure that someone skilled in the assessment of malalignment examines the diver following each dive and, i f neces sary, carries out immediate rea lignment in an attempt to ensure the quality of a subsequent dive and to decrease the risk of injury. Dives from a springboard may be affected by asym metry in the ability of the a n kles to dorsiflex as the board is depressed, and to plantarflex maximally on pushing off (see Figs 3.68 and 3.77). The ability to gain lift will be affected by the asymmetry i n the strength of the hip and knee extensors, and by the weakness attributable to the tendency towards excessive right pronation and knee valgus angulation. The diver may actually complain of one leg, usually the right, feeling weaker. The coccyx is particularly vulnerable in somersaults, 'lead-ups' and other reverse d ives and tra in i ng drills in which the feet enter the water first and the body leans back. On back dives from the 5 or 10 m board, for example, the body tends to overlean backwards as the feet enter the water, the coccygeal area end ing up
taking the brunt of the blow. The a mount of bu ttock cush ioning may play a protective role here and with some dry-land drills, such as somersaults carried out at floor level or off a low box where the diver actually lands on the mat sitting on his or her b uttocks, with the legs in front. Always suspect the possibility that pelvic floor dysfunction may have developed and is compli cating recovery when coccygeal pain fai.ls to respond to rest, repeated rea lignment and the modification of dives and dry-land dri l l s (see Ch. 3).
FENCING Classical fencing i s a 'unidirectional' sport requiring speed, balance, strength and timing as the body repeatedly lunges forward a nd retreats. The feet are placed a t a right angle to each other; a right-handed fencer will have the righ t foot pointing straight at the opponent (Fig. 5.8A). This stance provides stability in both the frontal and sagittal directions. Stability a lso comes from a proper positioning of the knees: 'the knees should be above the feet to reduce the moments of force and stress at the knee joints' (Adria n & Cooper 1 986, p. 623). Stability is decreased by any deviation of the knees to either side from this ideal position d irectly over the feet (Fig. 5.8B). The lunge i s ini tiated by kicking the front foot towards the opponent and rapidly extending the knee
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(A)
(8)
Figure 5.8 Classical fencing: positioning for speed, strength, balance and timing. (A) Side view of a right handed fencer in the 'on guard' position: the right foot is pointing at the opponent, the left foot is at a right angle and the trunk is turned one-half to three·quarters to the front. (8) Front view of a left-handed fencer (in the 'on guard' position: the left knee is balanced directly over tti e foot. (C) The sabre lunge: note how the left knee is balanced over the left foot, and the feet are at a right angle. ( From Pitman 1 988, with permission.)
(C) of the back leg so that the body moves forwards in as straight a line as possible (Fig. S.8e). There is a simul taneous extension of the back arm and hand from their initial position: held overhead, with the shoulder, eJbow a n d wrist bent to 90 degrees. The knee of the front leg stays flexed and, in order to increase the force of the lu nge, is flexed even further after the lead foot has been planted securely. This knee flexion is con-
trol led by eccentric quadriceps contraction. Forward motion and flexion of the front leg are eventually arrested by a concentric contraction of the quadriceps, hamstrings a n d gluteus maxim us. The motion is then reversed by the combination of the front leg extending, the back leg pulling the weight of the torso backwards, and the back ann resuming the bent pOSition over head.
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The
rota tion
some
forwards a u g
the
(see Fig. 3,40, I n a d d i t ion, t h e d ecrease i n
left h i p a b d u c t i o n range may f u r t h e r decrease the
which the foot can a dvance (as in the swing
in wa l k i ng - see
2.9). I n the
fencer lea d i n g with the
forward
that would
IJU:""lIUle
I f the above l i m i ta tions make i t impossi b l e to have the right foot poi n t d i rectly towards t h e opponent, a nd
coun terc lockwise, trunk is turned one-ha li to
l ine,
move forwards a nd backward s i n a
i n order to m i n i m ize the chest
eX IPo:,ed to
(Pitman 1 988),
the
and force of the otherwise be
the
For m a x i m u m
bala nce w i l l be
d i rectly over the feet at a l l
k nees should be times. T h e right a rm
s a i d to d e v ia te
for
2
every degree t h a t t h e l ea d i ng medially o r
from t h a t
pos i t ion, i ncreas
ing t h e cha nce of m issing t h e
( M , Conyd, per
s o n a l com m u n ica t i on , 1 993).
r i g h t knee m a y
deviate because of: the
innomi n a te a n terior rotation. when the feet a re a t
is
As indicated,
which req u ires tha t both lower extrem-
righ t
of rela t i ve external rotation, The
1
of the
lower extremity towards exter-
nal rotation: beca use
t h e tendency for e x ternal rota-
a
tion of the right
the foot may end u p poi n t i ng o u t
from m i d l i n e (see Figs 3 . 3 B, 3,1 6 B a n d 3 , 17). As k nee flexes to go i nto t h e
the foot tends to
'fhe associa ted """ " "" jO>'="
a n gula tion of the k nee
to a n in ward devia tion of t h e k ne e rela tive decreasing
foot may end up a ngled
cr" ,,,, p n n
plane, d im i n i s h ing stabi l i ty i n
even
planes,
may be achieved by active
clockwise rotation of the pelvis, to ensure the at the oponent a n d amount o f external rotation o f the left w ise rota tion of the in both •
foot
increase the Th i s clock-
internal rota tion of the
2.
rotating the
the fixed foot. On a right forward
l a tera l colla teral
more tension and risks
un der even pai n from the left
trochan ter a n d t h ig h a rea (see
med i u s} w i l l also b e wound up passively and put a t risk. Any
posterior rota tion of the left will res trict the counterclockwise
rota tion of t h e pelvis in the transverse to use
t h e functional weakness
3. weakness
decreas-
coupled with an
actual wasting of the right vastus m e d i a l is, w i ll m a ke t h e eccentric contraction of the less effective i n
m echanism
t h e lunge, T h e knee
more
to collapse i n wa rds (valgus strai n ) a n d t h e
3.37),
Other i n ternal rotators of the left lower
i nnom i n a te
a nd compressing the medial
of the right rectus femoris,
w i th a and t h e TFL/ ITB
h ip,
the knee may
acetabu l u m further backward so
Forced external rota tion on the left s i d e puts t h e join t
using toe
stress o n the l a tera l knee structures
p la n e if t h e tru n k i s
that i t takes more tim e to a d va nce from a nd retreat to t h is
to midline a nd the knee more
d r i ft outward s i n to varus,
coun ter-rota ted the
by
inwards to bring the outwardly-
however, the femur will still want to rotate externally on
m a noeu vres to ensure the
•
the
fencer may try to i ncrease the s ta b i l i ty o f the
As w i t h the
ll1creased exposure of the v u l n erable chest a rea and
the k nee to
the s tresses, will be reversed on
foot
clockwise rota tion o f t he trunk,
a rm moves in the
t h e lateral
recover from t h e l u nge
may help
more
the
and
3.33 and 3.74), The moveme n t pa ttern, and
albeit at the cost of:
resulting i n
tension in
the medial knee structures (e.g, t h e med i a l coll a teral
to track ou twards,
the tension a c ross
and ment. Weakness m a y a lso a ffect t h e subsequent con centric contraction needed to e x tend the knee a n d reverse t h e T h e k n e e i s the m o s t common s i te o f
rota tion to h e l p to a d va nce
Copyrighted Material
(M, Conyd,
in
commu n i ca tion, 1998),
260
THE MALALIGNMENT SYNDROME
Increased valgus angulation at a time when the right knee is under load, coupled w ith a wasting of the right vastus medialis, i ncreases the risk of developing knee injury (Box 54). The fencer can try to overcome the restriction of stride length that results with m a lalignment by lifting the right leg higher, but this unfortunately means coming down harder on the heel, increasing the chance of sustaining a heel bruise. It also increases the amount of shock transmitted upwards to the knee joint, where it can accelerate the degeneration of the menisci a nd cartilaginous surfaces. Perhaps more importa ntly, it a lso raises the centre of gravity a nd decreases stability even further at a moment when the fencer is a lready in a precarious pOSition. The left foot is more likely to supinate, which may i ncrease the tendency towards: •
•
the knee collapsing towards varus angulation a t times when the fencer is i n a more upright position the foot and ankle collapsing towards inversion at push-off, increasing the risk of an inversion spra i n at a time w h e n the trailing l e g is helping to accelerate the body forwards in a lunge.
The fencer with the left a nterior and locked presen tation (see Figs 3.3A and 3.18B) who leads with the right foot will have:
1. a limitation of right external rotation: i t will be more d ifficult to rotate the right leg externally in order to point the right foot directly at the opponent. A Clock wise rotation of the pelvis can compensate for this lim itation. Simultaneous clockwise rotation of the trunk may be inevitable and will make the chest more vul nerable; compensatory active trunk rotation counter clockwise will result in i ncreased rota tional stresses and increased energy output 2. problems related to supination: the tendency is for right foot supination and right knee varus angulation, which increases the risk of a n i nversion sprain. The increased rigidity of the right foot predisposes to injury of the heel and knee at foot plant 3. impaired left leg stability and push-off strength: these will result if the left foot collapses into pronation and the knee buckles into valgus at the time of the lunge. Malalignment affects the classical fencing form in particular, decreasing versatility by limiting the reper toire of actions. It is less likely to affect the modern form, which consists in large part of a 'flash' combin i ng a running motion, jump action and quick recovery. It has, however, a dverse effects on both types, particu larly i n terms of i ncreasing susceptibility to injury by l i m i ting certai n ranges of motion and decreasing stabil ity.
GOLF Box 5.4 •
•
Knee injuries in fencing
Palellofemoral compartment syndrome and chondromalacia patellae: if retropatellar pain is already a problem, the fencer can sometimes avoid the pain by forcing the knee into varus angulation. The i mproved patellar tracking might avoid putting pressure on tender patellar facets or femoral condyles, but it comes at the cost of decreasing stability Injury 10 the medial or lateral meniscus and compartments: varus or valgus angulation under load increases the pressure in the medial or lateral compartment respectively and predisposes to premature degeneration of the joint. Anything that counteracts the increased tendency towards external rotation of the right leg associated with upslips and 'alternate' presentations increases the pressure on the medial compartment. Medial meniscal entrapment is more likely when: - the foot is fixed and does not allow the tibia to rotate externally when the knee extends - the knee quickly moves from a position of flexion and valgus angulation with the tibia in internal rotation to a position of extension and neutral (or even varus) alignment with associated external rotation of the tibia
For the right-handed golfer, the initial action is one of windi ng up the spine by twisting the trunk clockwise and then unwinding to strike the ball and continuing into swi ng-through, effectively winding up counter clockwise. Adrian & Cooper (1986) have described the golf swing as a combination of the arms moving across the body primarily in the fronta l plane while the trunk rotates in the transverse plane. The shift of weight onto the right foot on the backswing, and the left on the forwa rd swing, increases the range of hip rotation. According to their a nalysis, at the height of the back swing 'pelvic action is seen to have rotated the pelvis almost 90 degrees and spinal rotation to have turned the upper torso more' (Adrian & Cooper, 1 986, p. 558). In the right-ha nded golfer presenting with mala lign ment, problems relate to the following.
Asymmetrical /imitation of upper extremity rotation
Asymmetrical limita tion of rotation may become a factor as the right arm rotates externally and the left internally on the backswing, the reverse occurring on swing-through (see Fig. 3 . 1 5A).
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C LIN ICAL CORRELATIONS IN SPORTS
261
Limitation of rotation through the thorax
of cutting down on the number of times he took a
Trunk rotation to one sid e is typically decreased (see Fig, 3.45), This results from a combination of factors including the direction of the thoracic convexity, a n asymmetrical increase in paravertebral m uscle
divot was not well received. The use of graphite clubs should a lso be considered, particularly on the driving range where there is a risk of repeated ly hitting the mat. Unlike traditional steel clubs, these will yield a b i t on impact a nd absorb some
tension, the presence of a ny vertebral malrotation and rib rotation (Lee 1 993),
Limita tion of pelvic rota tion in the trans verse plane
Left posterior i nnominate rotation and left inflare both limit pelvic rotation to the left and will affect the right to-left SWing-through (see Fig, 3.4), With a right poste rior rotation or right infla re, the limitation is to the right and will affect the right backswing, To avoid compromising the backswing or swing-through, the red uced pelvic rotation may be compensated for by increasing rotation primarily through the thoracic segment of the spine a nd the lower extremities, albeit at the cost of increasing the stress on these structures,
Asymmetrical limitation of lower extremity rotation
The golfer with the left anterior and locked presenta tion has a limitation of right external and left internal leg rotation, both of which could affect the right-to-left swing-through, On the other hand, the golfer w ith one of the more common 'alternate' presentations or a n upslip has a restriction o f right internal a nd left exter nal rotation, which could create problems with the left to-right backswing, Problems are more likely to occur i f the feet move inadeq uately or, worse still, remain planted on the ground,
Interference with thoracic rotation
When the golfer d riving from right to left takes a d ivot the wrong way or hits a covered root or rock in the rough, thoracic rotation to the left can be suddenly slowed or even completely stopped, whereas the rota tion of the pelvis continues, This twisting of the pelvis on a fixed trunk can cause an aggravation of problems relating to malalignment (e,g, if there is a lread y a lim itation of pelvic rotation cou nterclockwise) or actually a recurrence of the malalignment, The author is reminded of the golfer who goes out of alignment each and every time he 'takes a d ivot' , He has solved this problem by lying d ow n on the links in order to carry out an immediate correction using a muscle energy technique. This allows him to get on with the game until he takes the next d ivot. The sug gestion of having someone assess his style in the hope
of the shock, Increased stress on the thoracolumbar junction
Restrictions imposed by limitations of pelvic and lower extremity rotation require a compensatory increase in rotation more proximally. the resulting stress being maximal at the thoracolumbar junction or mid-back region.
A typical history is that of the golfer who presents fit and unaware of any problems a t the start but develops back pain over the first half of the course, The pain typically increases as the game progresses, sometimes forcing him or her to abandon play before reaching the 1 8th hole, The pain is often limited to the mid-back region or may be maximal i n this area. Other parts o f t h e back m a y eventually become a pro b l e m a s i mpaired rotation a nd pain result in protective muscle spasm and a faulty technique, An irritation of the T12 a n d L1 cutaneous fibres can trigger a full-blown thora columbar syndrome,
Posterior pelvic ligament stress
Malalignment results in increased stress on these liga ments so that some or all of them are often already tender or outright painful (see Fig, 2.3), They a re more likely to become a problem with golf, particularly when working out on the driving range, To drive the ball, the trunk is slightly flexed on the pelvis, further increasing the tension in these ligaments. Maintaining this stance while repeated ly adding a twisting insult can eventu ally precipitate or worsen pain from these ligaments, The results of treatment can be most gratifying, with repeated reports tha t realignment finally a llowed a completion of the 1 8 holes without pain being 'par for the course', The biggest problem in most cases is one of convincing the golfer not to play for a while to ensure that treatment attempts will be successfu l. Unfortunately, few a re willing to stop for the 3-4 months sometimes required to get to the poin t of maintaining the realignment a n d tolerating the rota tional stresses inherent to playing golf without trigger ing a recurrence of the malalignment.
Copyrighted Material
GYMNASTICS
u la tion. Back
may be d iv id e d into fl oor exercises and t h o se carried o u t o n
Some
be overshadowed
u n i la tera l or
tightening or the
development of a 'sciatic scol iosis'.
back and knee Sll'onrivliO(]Anic back pain
Back pain
This is often a
Tsa i & Wre d m a rk ( 1 993) have
exclusion of the above three r"'rpo'Or1
that the
increased incidence of back pain in
based on the
a t u mo u r or infecti ous process,
the commonly n o ted increased Micheli for back
and ruling out
the stress on both the d iscs and
pars i n terarticula ris, and
increases
the cha nce of the
t h e above
In t h e gymnast a li g n me n t, manoeuvres that call for a m a x i m u m movement o f the vertebrae i n a l l three
Pars interarticularis fracture or spondylolysis
on a
can sometimes be a ttributed to
These t ra u ma o r to a
of
of
lordosis a n d / o r repeated and extreme
compresses the left L5-S 1 facet
and
on the left
w i l l a u tomatica l l y i ncrease the stress
whenever a movement involving extension, left
for some rou t i nes, Stinson (1 993) c i tes stud ies a lso
mov i ng
M a l ro ta t i on of the L5 vertebra to the right,
It is,
however, more often felt to be related to t h e i ncreased
are
t h a t is
flexion or clockwise rotation o f the trunk is super heredity
and the combination of lordoti c stress on a neural a rch
rn r.n"" (1
(see
2.35B), As stated by Ciullo & Jackson
(1 985, p . 97), the
fa i l ' when
weakened because of a n in heri ted defect i n the model-
to
H e n o tes, h owever, that the
l i ng of the
i n certain a t h l e tic d iscipl ines footba l l ,
can cause or
and
i n the ath lete i n s o m e
all of these
stresses. The compensatory l u m ba r convexIty to right
is u s u a l l y one o f an insid ious onset of l o w
bnnging the facet concave side cl oser together
w i t h or w i th o u t rad iation t o o n e o r b o t h buttocks, 'often first noted w hen the
enta i l s a rotation of Ll -LA i nto the
o r left, for
' ... .', IJeuo>
5 1 9) , It may o cc u r u n i laterally o r
d oes a back
or back-walkover' (p. 86).
of the l umba r
surfaces on the red ucing the overall (see
4.6, 4.22 and 4.28), The
2.29, 2.65,
w i l l be even worse
w i th the add i tion o f a ma l rotation o f one o r m o re i ndi vidual vertebrae (see above and Fig. 2.658).
Vertebral body fracture
i n c rease
M icheli (1 985) ci tes fracture of the vertebral end as another cause of back
in young a t h l etes.
Fractures are noted particu larly at the anterior and tra uma
m icro-
to b e u s ua l l y the result of most proba b l y
flexion . . , and can
resu l t in frank vertebral wedgi n g'
89). He goes o n
to s a y t h a t 'in the gymnast, these occur at the thorac o l u mb a r junction and may i nvolve three or more vertebra l
a l t h o ugh one or two
levels o f i nv o l vement a re more common' a t h letes
may
be
label led
in
sacral
n u t a t i on
would accentuate the l u mbar lord osis and further
89). The as
Scheuermann's d i sease,
increase the pressure o n these facet joi nt s u rfaces, as would a n y side-flexion from ret1ex contraction o f psoas,
Micheli ( 1 985) that vertebral body frac tures i n
involve t h e anterior
of
only one or two vertebrae in the thoraco lu mbar junction the
a rea could be a
at this s i te, with a
t1exion stresses
from a lordosis to from extension to
If, however, these fractures
a re indeed rela ted to increased or
flexion
stresses, the flexion stress caused by the
would
be
UI�;co'ae,mc back
l u m b orum o r t h e
m u scles o n one side.
to be least at the thoracolumbar junction
and max i ma l at the apex of the thoracic
In
i nc i d e nce of
addition, because of the orientation of the facet joint sur
this condition i n the athletica l l y active adolescent pop-
faces, most flexion and extension movement occurs i n
Mich e l i (1 979) has reported an
Copyrighted Material
to lesser extent at the thoraco
transverse
and least in the thoracic segment (see
Problems relate to the
that occur with limitations of thoracic spine and pelvic rotation. These
can offer a more probable explana tion vertebral fractures at the thoracolumbar
to d o somersaults and twists as
affect the
routines carried ou t on the
of
parallel bars, the side
is the torsional a nd lateral flexion
horse and the balance beam o r in the course of vaulting.
strain on the discs a ttributable to the reversal o f the
A limi tation of rotation of the pelvis in the transverse
junction.
into the side of the
lumbar a nd thoracic convexities, L1 being rotated one
innominate rotation
d i rection (see Fig. 3.120 . way and T1 2 in the In vertebral malrotation T12 o r L1
or inflare may become a problem, particularly when the
i n conjunction
with manoeuvres on the pommel horse
is very common, with a rotational
o f the pelvis. All these
decreases the a b ility to rotate through
increased resistance or
and therefore increases the rotational
the stiffness dimin-
the thoracolumbar, lumbosacral and
stiffness at the level of the the
(Fig. 5.9D). Holding on this
or the
resu l t in a loss o f the normal joint play or so tha t there is,
with both hands,
on to the
the SI and hip joints.
of this a rea to yield to stresses o f any 5.1). a
flexion
stress
more
read i ly
increases the load on the anterior disc and adjoining vertebral
to fracture. The fact a nd transverse
tha t pain elicited by pressure on the
processes often localizes to the
thoracolumbar a nd l umbosacral ju nction a reas is indicative of the increased stress o n these sites a ttrib (see
utable to the
Even though tenderness can often be elicited from either site on examination of the until
a thlete,
have no actual
tha t athlete may,
more
occurs a nd
structures. If the pelvis and
spine cannot accommod a te because of a malalignment directions, the
related limitation o f rotation in
result ca n be awkward ness, a decreased ability - or
such a s a tear of the annulu s fibrosus
or an end plate
The restriction i n c reases the rota tional stresses
3.12 and 4.18).
these
even
of the
to carry out these rou
tines, and The u l timate test of any limita tion of the hip, pelvic
areas to his o r her a ttention.
o r thoracic
of motion must occur while carrying
out h ig h
Knee
circles on the
legs in one d irection across the
of the horse while a lternately b y each
the rest of the a rm holding on to one
horse
the closely appl ied
(Fig. 5,98). This
the handles, rotates in the
opposite d i rection. The
to rotate t he upper trunk to either righ t
or left while in the
(iron cross)
the rings will be tions of the thoracic twist into one d i rection Asymmetry of lower extremity muscle strength, a feeling of weakness in one leg and a p roblem with balance. These may
demands of the individual
d ifficu lties
beam, especially those
a twist of the
t ru n k relative to the pelvis o r a round the
Apparatus
the by
Malalignment those routines
on
d ismount and with routines carried out o n the bala nce
Dismount stability is further the various asymmetries
extremities, the right one being more
are
requiring rotation around the vertical axis a nd in the
problem (see eh. 3).
Copyrighted Material
(A)
(8)
(C) Figure 5.9 Gymnastic ma noeuvres. (A) Front support turn on the parallel bars. (8) Double·leg circle on the pommel horse. (C) Single-leg circle with scissor-action. (D) Straight-body cross-hang (iron cross) position on the rings. (From Loken & Willoughby 1 977, with permission.)
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INTERCEPT IONS IN T EAM SPOR T S Interceptions result in a n unexpected turn-over of the ball or puck to the opposition; they are mentioned here because they are an important part of a number of athletic activities. The opposition player usually cannot plan for the event, that is, prepare the body for any asso ciated impact, excessive rotation or loss of stability. The athlete can easily end up a t increased risk of: • • •
exceeding a restriction of range of motion losing equilibrium having to twist the pelviS a nd spi ne, sometimes in opposite directions and sometimes with the addition of acute trunk flexion or extension.
I n terceptions a re therefore more likely to resu l t i n i nj ury, especially i n the ath lete a l ready presenting with m a la lignment. They must a lso be considered a s a possible cause of a n i nitial malalignment or of recurrence.
JUMPING SPORTS Limitations relating to malalignment a ffect primarily the following aspects: ( D)
1.
Figure 5.9
Rotation : most jumps have a rotational compo
nent, for example, after the take-off in a high jump using the Fosbury flop (Fig. 5 . 1 0), or on ascending and when reaching the top in the pole vault.
Continued.
Floor exercises Floor exercises require the ultimate in flexibility and balance flS the gymnast carries out tumbles, springs and double flnd triple twists in quick succession, Iflnding on either one or both feet or in the split position. As the difficulty of the routines increases, so does the chance that the asymmetries associated with malalignment will become a limjting factor or a cause of injury. The ath lete may appreciate asymmetries in push-off strength, stiffness or limita tions of movement, as well as a feeling of insecurity or imbalance on trying to come to a controlled stop a t the end of a routine. Athletes probably tailor their routines, consciously or subconsciously, in order to avoid these problems, for example, by repeatedly land ing on the more stable leg, putting more weight on that leg when landing on both or repeatedly carrying out a manoeuvre in the direc tion tha t avoids a restriction of range. This repetition predisposes to overuse problems, whereas an inadvertent deviation from these routines puts the gymnast at risk of injury.
2. Hip extension and flexion : righ t a n terior, left pos terior rotation restricts right hip flexion a nd left hip extension, the reverse occurring with the left a nterior, right posterior presentation (see Figs 2.72 and 3.65). These changes will a ffect the stride length required for clearance (hurdles and steeplechase), the extent of reach (the long and triple jumps) and push-off (pole vault and high jump). The final upward thrust in the vault and high jump, for example, comes from simul taneously kicking one leg up in the a i r (hip flexion) and extending the opposite hip and knee a fter initial flexion. Stride length can also be affected by a n asym metry of pelvic rotation in the transverse plane, for example, by a limita tion into the side of a posteriorly rotated innominate or an inflare (see Fig. 3.4). The jumper may be able to change style to adapt to the limitations imposed by malaligrunent. Leading off with the left leg in steeplechase and hurdle events might, for example, get round any restriction of right hip flexion caused by right anterior rotation, right outflare or increased tension in the right hamstrings (see Fjgs 3.64-3.66). For the same reason, the pole vaulter might fare better swinging up the left leg and pushing
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266
THE MALALIGNMENT SYNDROME
off with the right, provided that functional weakness affecting the right hip extensors is not a major problem. T he way in which an athlete finally executes a particular manoeuvre is probably arrived at by trial and error, largely i n fluenced by the l im i tations i mposed by malaLignment. Take, for example, the high-jumper with one of the 'alternate' presentations and right anterior, left posterior rotation who i ntends to execute a Fosbury flop by approaching the bar in one of the following ways.
•
•
From the right side (Fig. 5 . 1 0) T he jumper will ru n towards the bar in a curved approach ( 1 ) . After planting the left foot, lift-off is com bined with simulta neous counterclockwise rotation of the pelvis and trunk, forcing the left leg into external rotation (2). Lift-off comes through initially flexing the left leg and then simulta neously fully extending that leg while kicking the right leg (closest to the bar) up in the air (2). Once a irborne (3), the thorax and pelvis continue to twist, hopefully to allow clearance of the bar with the buttocks while sailing backwards with the extended back 'draped' across the bar (4). In other words, acceleration is converted into a ver tical force by the kicking action of the right leg with simulta neous left leg extension, initiating a counter clockwise rotation of the trunk and then peJvis, and final back extension (Paish 1 976, Worth 1 990). T he malalignment may a ffect the factors listed in Box 5.5.
Figure 5.10
Box 5.5 Factors aHected by malalignment in a right side Fosbury flop approach
•
•
•
The ability to drive the right thigh upwards (hip flexion) may be limited by: - the mechanical restriction of the femur that occurs with anteroinferior rotation of the superior rim of the acetabulum (see Figs 3.64-3.66). - tightening of the hamstring/sacrotuberous complex by a change in the length-to-tension ratio and complicating facilitation of the hamstrings (see Figs 3.38 and 3.39) A decreased ability to externally rotate the weight bearing left leg, external rotation being restricted on this side An increased risk of a left ankle inversion sprain, given the weakness in the left peroneus longus and a tendency to supination on this side (see Figs 1 . 1 , 3 . 1 8A and 3.498) A torsional stress on the spine, especially thoracolumbar junction, if there is a restriction of counterclockwise rotation of the thorax (see Fig. 3.45) Stress on the already 'ill-fitting' thoracolumbar junction - especially the facet joints - by hyperextension of the back (see Fig. 3.1 2)
From the left side Accelera tion is converted into a vertical force by simul taneous extension of the flexed right leg and kicking up the left leg, which is followed by clockwise rotation of
Fosbury flop: approaching the bar from the right. (After Worth 1 990, with permission.)
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CLINICAL CORRELATIONS IN SPORTS
the trunk and then the pelvis. The malalignment may lead to the following: •
•
•
stability of the push-off foot and strength of the right leg is decreased, given the asymmetrical functional weakness that typically affects the right hip flexors and extensors, tibialis anterior and posterior, extensor haUucis longus and other toe extensors, so that the right leg may feel weak compared with the Left (see Figs 3.49-3.53) a decreased ability to plantarflex the right foot (see Fig. 3.77) torsional strain on the spine and thoracolumbar junction (see Figs 3.1 2 and 3.45).
Depending on the type of malalignment present, and which pattern of restriction is dominant, the jumper may find that it 'feels easier' to approach the bar from one side than the other, with better results. In that respect, the malalignment may be thought of as provid ing a 'biomechanical' advantage to the a thlete. I f malalignment does indeed appear to result i n improved performance in an 'established' jumper, there may be no point in attemptillg realignment, provided that the athlete is asymptomatic.
This karateka is at increased risk of a sprain or strain o f the tight right hip extensors and left hip flexors when advancing the right foot in front stance or lunging, especially with the 'lunge punch', a particularly deep lunge required to deliver a low blow (Fig. 5.11 D). The karateka ca n compensate for a decreased stride length by moving closer to the opponent in order to 'connect', at the increased risk of being hit and injured. Second, the reach of the rig h t leg is usually decreased a n d the high kicking action hampered, making this leg a less form idable striking weapon. Reach could be increased by pla n tar flexing the right foot, but this motion is already restricted on this side (see Fig. 3.778) The restrictions affecting counterclockwise rotation of the pelviS, and internal rotation of the right and external rotation of the left leg, may become a limiting factor for any rotational manoeuvre of the trunk carried out while supported on one or both feet. These restrictions could, for example, impair those manoeuvres in which the body quickly rotates through 1 80 degrees to face alter nately to right a nd left while both feet remain on the ground. These restrictions could also interfere with assuming a specific stance, such as: •
MARTIAL ARTS: KA RATE Karate involves fighting with the hands and feet, punching and kicking being the two most common forms of attack. The intent is to deliver as forceful a blow with as small a surface area as quickly as possi ble, while at the same time maintaining balance. When advancing to deliver a punch or kick the athlete - or karateka - moves forward in a straight line in order to minimize the displacement of the centre of gravity and to shorten the time required to reach the opponent. I ncreased mobility occurs at the expense of stability: the 'one-a nd-a-hal f-footed' cat stance (Fig. s.11 A), for example, provides mobility but is less stable than the wide-based 'two-footed' horse stance (Fig. 5.11 B) or back stance (Fig. s . 1 1 C) . Increasing the distance through which an extremity moves increases the amount of force generated, but this again comes at the expense of stability. The karateka with one of the 'alternate' presentations and right anterior irulominate rotation has limitations that may decrease effectiveness and increase the risk of injury, as described below. First, stride length is decreased as a result of a restriction of: • •
counterclockwise rota tion of the pelvis right hip flexion and left hip extension.
267
•
•
the horse stance, in which both feet point forwards or out and the knees are flexed, externally rotating both legs (Fig. 5.11 B) the back stance, the feet being placed at a right a ngle to each other (Fig. 5.11 C) the straddle stance, i n which the feet are rotated outwards at the start, simultaneous knee flexion then accentuating this external rotation.
The force that can be generated with either leg may be decreased because of decreased strength and/ or the decreased range through which the leg can now be moved, with a decrease in the length of the resulting lever arm: 1. The weakness o f the right hip flexors and the decrease in right hip flexion can result in a decreased strength and range of kicks with a flexion component (e.g. the high right forward kick - Fig. s . 1 2A). 2. The weakness of left hip abductors and the decrease in left hip extension can result i n a decreased strength a nd range of kicks with an abduction and extension component (e.g. the left backward round house kick - Fig. 5.1 28). The ability to abduct the lower extremity is usua lly less on the left than the right. This could decrease the effectiveness of a left forward roundhouse kick because the kick might end up bein g delivered low. The karateka can compensate by side-bending to the right to
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268
THE MALALIGNM ENT SYNDROME
..
'
.,
---- ----j-- ----
Foot Position
----+---
---l
Foot Position
(B)
1
(A)
Figure 5.11 Karate: typical positions and movements. (A) Cat stance, (B) Horse stance, (C) Back stance. (D) The 'lunge punch' from the front stance position. (From Queen 1 993, with permission,)
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CLINICAL CORR E LATIONS IN SPORTS
269
Foot Position
(C) Figure 5. 1 1
(0) Continued.
elevate the left thigh further, but this will be a t the expense of stability as the centre of gravity is displaced to the right of the midline (Fig. 5.1 20. An impaired ability to externally rotate the left lower extremity may interfere with the ability to 'close the . gap' properly in the roundhouse kick, which requires that the left foot rotate outwards 90 degrees from its starting position (Hobusch & McClella n 1990) . Limitations of ranges of motion can decrease the effectiveness of the impact of a kick:
• In side-kicking, there may be difficulty stri king the opponent with a smail surface area, such as the lateral edge of the foot, because of a limitation of i n ternal or extern a l rotation of the leg a n d variations
i n the varus /valgus a ngulation of the n on-weig ht bearing foot (see Fig. 3.22). The blow is more likely to be delivered with the sole of the foot, which is less effective because the force is dissipa ted over a l a rger area. There is a lso a n i ncreased risk of fracturing t h e toes.
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(8 )
Figure 5.1 2 Typical karate kicks. (A) Right ( 1 ) and left sided (2) 'crescent' kick incorporating hip flexion (limited on the right side). (8) Right 'spinning back' o r 'roundhouse' kick. (C) Left forward roundhouse kick. (From Queen 1 993, with permission .)
(A)
• A direct kick to the body should impact at the baLl of the foot; that is, the foot is in maximal active dorsi flexion and may be passively pushed into further dorsiflexion on contact. With the roundhouse kick, impact with the dorsum of the foot requires maximum active plantar flexion, and the foot is forced into further plantar flexion passively on contact. The malalignment related limitation of plantar flexion on one side, and dorsiflexion on the other, may decrease the effectiveness
of these kicks and increase the risk of injury by pas sively forcing the foot past a physiological or even anatomical barrier (see Figs 3.77 and 3.78). Instability when standing on one leg alone may be more noticeable on kicking, particularly when using a forward or reverse roundhouse kick, in which the kicking action is combined with rotation to increase the force of the bl ow. The right single-leg stance is more
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the leading foot so that the rear foot can be q uickly used for sweeping and for other attacks' (p. 629). In the presence of malalignment, the stability of the lead leg will be decreased by the same factors discussed above for fencing a nd karate. Impa ired bala nce is a factor to consider when weight is borne on one leg only. In addition, the ability to use the sweeping leg effec tively may be decreased by limitations of rotation. Right anterior innominate rotation, for example, l im its the ability of the righ t leg to sweep behi nd the oppo nent from right to left by: 1 . decreasing the ability to internally rotate the right leg 2. limiting the ability of the pelvis to rotate counterclockwise in the transverse plane, which would normally a l low the right hip and leg to swing forward to gain extra length for the sweep (see Fig. 3.4C). The torquing forces used to throw the opponent in judo increase the chance of injury by inadvertently forcing the thorax, pelvis or legs into the direction of a restriction.
ROWING, SCULLING, KAYAKING A N D CANOEING These sports differ primarily in the a mount and sym metry of trunk rotation, flexion and extension that occur from the 'catch' through the 'drive' a nd eventual recovery phase (Dal Monte & Komor 1 989).
(C) Figure
5.1 2
Continued.
often a problem, which may become evident with the kinetic rotational (Gillet) test (see Figs 2.88 a nd 2.89). The karateka requires a stable base when advancing and when delivering punches. As in fencing, advancing rapidly requires a quick forwards movement of the foot and flexion of the knee on one side, combined with extension of the other hip and knee (see Fig. S.8C). Maximum stability in the sagittal plane is achieved by having the right and left knees end up directly over their respective feet (see Figs 5.8 and 5 . 1 1 D). Instability resuJts with deviation of the knee to either side because of the inward or outward rota tion of the leg, and valgus or varus a ngulation of t he knee with a tendency towards pronation or supination respectively. InstabiJity attributable to these factors is even more likely with leaping movements, both forwards and backwards, along the sagittal plane.
Sculling The rowing action for single, double a n d quadruple sculls is symmetrical, a similar action occurring when the athlete uses a rowing ergometer. The force gener ated by the extending legs and tru nk is transferred to the arms a n d finally the oar. At the 'catch', the scapu lothoracic muscles, in particular serratus a nterior, a re maximally contracted, which helps to stabilize the scapula against the t horax . The 'drive' p hase i n volves extension of the lower extremities, extension of the trunk and flexion of the upper extremities. Style is determined primarily by the timing and the degree of initia l trunk flexion and final extension. M a l a l ignment will increase the possibility of devel oping back pain a nd restricting ranges of motion by: •
increasing tension in tense, and often tender, thoracic (a nd sometimes l u mbar) paravertebral muscles a nd posterior pelvic ligaments, thus restricting forward flexion
MART IAL ARTS: JUDO The intent is to throw the opponent off balance without losing one's own. A drian & Cooper (1 986) have pointed out that 'the weight is often maintained over
•
increasing the amount of stress on the now asymmetrical facet joints, sacrum a nd SI joints, restricting extension a nd flexion.
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272
THE MALALIGNMENT SYNDROME
There are other complicating factors relating to malalignment: L There is a functional inequality of leg length and strength. 2. Forward flexion can provoke pain by further increasing tension in other tender and/ or tight muscles (e.g. the right hamstrings, which very often already show an i ncrease in tension - see Figs 3.38 and 3.39). 3. Tender structures subjected to direct pressure will lim it sitting time. Seat comfort varies with body propor tions and seat design. Appropriate cut-outs on the seat help to avoid direct pressure on the ischial tuberosities and coccyx but may not spare a tender piriformis,
gluteus maximus muscle or sacrotuberous ligament. The peroneal and tibial components of the sciatic nerve are also vulnerable to pressure on the posterior thigh region. 4. Asymmetry of the ribs and of the associated rib rotation increases the chances that the bellows-type effect on the chest cage will result in irritation of the costochondral, costotrans verse, costovertebral and clavicular joints (see Figs 2.62-2 .64). S weep-rowing
The significant asymmetry involved in sweep-rowing results in specific inj u ry patte rns not seen in sculling as there is considerable forwards flexion combined with repetitive rotation to the side of the boat.
Complications with malalignment relate in particular to limitations of range in these directions because of tender or asymmetrically tight soft tissue structures and an impaired rotational ability of the pelvis and the various segments of the spine, with or without com plicating vertebral malrota tion. The compensatory curves and changes i n muscle tension resulting from mala lign ment can, for example, eaSily limit tru n k rota tion i n to either the port or starboard side by 5-1 5 degrees (see Fig. 3.45B). Sweep-rowing also results in unbalanced muscle development and strength, particularly involving latissimus dorsi and quad riceps on the side of the rigger frame; this asymmetrical development could welJ predispose to a recurrence of malalignment.
Kayaking In the typical recrea tional kayak, the double-bladed paddle allows for stroking on alternate sides in a cycli cal fashion. The legs and pelvis are essentially fixed because of the low seating position and the fact that each foot may be stabilized on a foot pedal for rudder
control, and the knees braced against the sides of the boat. In a flat-water kayak used for competition on lakes, there is no rudder and the knees are not b raced when racing, so that the trunk is subjected to more in trinsic forces, whereas in whitewater kayaking racing down a canyon or other natura.! challenge - the body is subjected to more extrinsic forces. The cyclical paddling action in aU events is primar ily one of forward flexion, combined with alternate side flexion, and clockwise or coun terclockwise rota tion of the trunk in the transverse plane. Most of this rotation occurs through the thoracic segment, which, in the presence of m a lalignment, usually shows restriction into one side (see Fig. 3.458). The maximum stress will be through the transitional region for facet orientation : the thoracolumbar region (see Figs 3.8 and 3.12). Back pain is therefore more likely to develop in the mid-back region. Low back pain a l so occurs because there is some rotation of the lumbar segment as a whole once thoracic rotation reaches i ts l imit, com pounding the stress already imposed on the lumbo sacral junction by the malalignment. The increased demands for trunk rotation associated with whitewater kayaking might be expected to pre cipitate back symptoms more readily tha n flat-water kayaking, but the repetitive nature of the action, and the genera lly increased duration of ocean and river kayaking, may make these outings just as devastating. Factors tha t prove complicating in any situations include: •
•
the pressure exerted on tender sites (e.g. coccyx a nd ischial tuberosities, the s i te of sacrotuberous insertion and hamstring origin) increased tension forces on structures that are already tender (e.g. the posterior pelvic ligaments and muscles such as piriformis and quadratus lum borum), exerted by prolonged or repetitive forward flexion a n d / or the repetitive rotation .
Canoeing A stroke on the left side is initiated by reaching for wards and out to the left with the paddle, that is, by simultaneous forward flexion and left side flexion. There follows a counterclockwise rotation of the trunk and pelvis, and progreSSive trunk and hip extension as the blade is driven backwards. The positioning and combination of movements ma kes the stroke the most asymmetrical of the ones described and therefore probably more vulnerable to the effects of malalignment. Left posterior innominate rotation, for exam ple, limits both left hip extension
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CLI N I CAL CORRELATIONS IN SPORTS
and left pelvic rota tion in the transve rse plane. There is often also a complicating increase in tension in the left hip flexors, reflecting a change in the length-to-tension ratio
and
sometimes
fa cilita tion,
w h ich
fu rther
Box 5.6
the boat at the same time lor support while stepping in or out (Fig. 5. 1 3A)
changes could create problems for the canoeist who •
on the left knee, left hip in neutral or slight extension, and weight-bearing on the right foot with the right hjp and knee flexed to 90 degrees (see Fig.
5.2). Problems
•
include: •
when driving
the left blade backwards:
increased
rotational stress on the thoracic segment because of a limitation of left pelvic rotation; i ncreased stress o n
When getting up from or down onto the seat: have someone steady the boat and hang on to both sides (Fig. 5 . 1 3B) When getting in or out of the boat: il at all possible, avoid leading with one leg (which usually requires excessive hip abduction, flexion or extension, rotation or a combination of these), but try instead to move the legs together while sitting on the dock or side of the boat
•
tight left h i p flexors a s t h e trunk a n d left hip extend •
in the right semi-squa t position (right hip a nd knee
flexed) :
i ncreased stress on the right sacrotuberous
l i gament and the glu teus maximus and hamstrings,
use the dock or side
01 the boat to sit on, or hang on to both sides 01
restricts left hip extension (see Fig. 3.64A). These drives the blade backwards on the left wh ile kneeling
Techniques to try to preserve symmetry
Slide in and out of the boa t :
•
273
•
a ugmented whenever the pelvis rotates cou n ter clockwise.
When alone and carrying the boat to and from the water: with the boat lying parallel to the water's
edge, face the boat and pick it up with both hands as symmetrically as possible (Fig. 5. 1 4A); preferable would be a two-person low carry (Fig. 5.1 4B) When having to lift the boat: try to get someone to help by simultaneously lifting the boat up on the other side or end in order to avoid as much torsional strain as possible (Fig. 5. 1 4B, C)
Even though sculling a nd kayaking may be sym metrical, these activities, along with sweep-rowing a nd canoeing, a re a l l associa ted with an increased risk of having the athlete go out of alignment when:
1. getting in and out of the boat
2. getting the boat i n to and out of the water or on
Appendix 5 lists some of the typical problems encoun tered by ru n ners with one of the 'alterna te' presentations.
and off a transport vehicle.
SKAT ING
The risk of losing alignment on these occasions can
The skater has to defy gravity while at the same time
be decreased by having the athlete try to preserve symmetry as much as possible ( Box
5.6).
I f malalignment recurs as a result of being unable to
trying to balance the weight of the body over a thin blade. In the presence of malalignment, these chal lenges may become highly problematic.
heed these precautions, or even when activity is limited to symmetrical sculling or recrea tional kayak ing, the athlete should avoid these activities u ntiJ
Edges
rea lignment is being ma i n tained.
There are basically four edges - inside and outside,
RUNNING
lean of the body, the 'deeper' the edge and the less
forward and backward - and the ska ter has to be able to switch from one to another quickly. The more the
Problems relating to ru nning have been d iscussed
support available from the blade.
throughout the previous cha pters, particu larly with regard to problems resulting from: •
an asymmetry of weight-bearing, pronation and supination (see Figs 3.18, 3.33, 3.74 and 7.1 )
•
contrary rotation of the legs (e.g. a whipping action of either heel, or 'clipping' of the opposite side - see
Edging is aHected by any tendency to pronation or supination, the tendency to go either way being in turn augmented by the lack of a supporting base, any angulation and/or oH-setting of the way in which the blade is fixed to the boot, and the fact that the foot is elevated by the boot.
Fig. 3 . 1 7) •
functional leg weakness, fatiguing and instability
These factors can make for a very insecure foot i n
•
a tendency of the pelvis to rotate towards the side of
terms o f weight-bearing support a n d pu sh-off stabili ty.
a n outfla re, with a l imitation of stride length i n the opposite direction.
Falling inwards or 'losing the edge' on the side of the pronating foot appears to be a more common complaint
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(A)
(8) Figure 5.1 3 Suggestions for steadying the boat and decreasing torsional stresses for getting (A) into or (8) out of the boat. ( From Harrison 1 98 1 , with permission.) than toppling outwards probably because the supinat ing foot is a more rigid foot, better suited for supporting the skater, for push-off and for 'holding the edge'. Any medial or la teral deviation of the knee from a position directly over the foot will furtber decrease stability (as for judo and karate; see above and Figs 5.88, C and 5.11D). The combination of custom-made skates with medial or lateral reinforcement, and possibly longitudinal arch supports with or without posting, may increase the sta-
bility at the ankle a nd mi nimize such deviations of the knee. If, however, the tendency towards excessive and asymmetrical pronation or supination is attributable to malalignment, only realignment can be expected to resolve the problem completely, by: •
•
putting the feet into a more secure and symmetrical position for weight-bearing removing any resistance to controlled shifting on to the inner or outer edge.
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(Bi)
(A) (Bii )
Figure 5.1 4 Safe carrying and lifting techniques. (A) One person carry over a short distance (minimal torquing), (B) Two-person (i) low and (ii) high carry (minimal torquing), (C) One-person assisted lift (no torquing), (0) One-person unassisted lift (with considerable torquing), (From Harrison 1 981 , with permission,)
(C)
Figure 5, 1 4 (0), see overleaf
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(Oi)
(Oii)
(Oiii) Figure 5 . 1 4
(Oiv)
Continued.
Execut i n g turns Turning is accomplished b y shifting t h e weight on to the appropriate inner or outer edge (see Fig. 5.1 6A, B). To make a left turn, for example, the skater can simply lean on to the left outer and /or right inner edge. Malalignment, by affecting the ease with which the skater can sh ift on to a pa rticular edge, will make it easier to make a turn in one direction. Whether this is
to right or left may be predictable from the presenta tion of the malalignment. 'Alternate' presentations and ups/ips
The tendency to supinate on the left and pronate on the right facilitates turning to the left; the skater is already predisposed to leaning on to the left outer and right imler edge. By the same token, the same skater may find
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it harder to execute a turn to the right because of the increased difficulty of shifting weight on to the left inner and right outer edges. Biomechanicaliy, making a left turn is Eke 'going with the flow', whereas on a ttempting a turn to the right, the skater is 'going against the current'. The right foot and ankle may, however, tend to feel 'sloppy', collapse inward s and fa tigue more easily than the left because . of the weakness o f tibia l is a nterior and posteri or, and the collapse of the medial longitudinal a rch, so tha t the skater may prefer to put more · weight on the more stable left foot and ankle. If the same skater attempts to skate circles of a small diameter, such as figure-ska ting or comp u lsory figures, the following might occur. It might again be easier to go counterclockwise. Counterclockwise circling requires a l ternately trans ferring the weight on to the left ou ter a nd right inner edges and back. The transfer from left to right is achieved by adducting the right leg to cross it in front of the left. This manoeuvre again requires getting on to the skater' s preferred edges. It also ca lls for adduc tion with the right leg, which ha ppens to have a greater passive adduction range than the left in nea rly 1 00% of those presenting with mala lignment (see Figs 3.40 and 3.70). The 'a lternate' presentations wiIl a lso favour the speed-skater going coun terclockwise around the track, especially when the right leg has to adduct to cross in front of the left leg while lea ning to the left into a curve (Fig. 5 . 1 5). It will be relatively more difficult to go clockwise. Attempts to transfer weight to the right outer and left inner edge nll1 counter to the tendencies usually imposed by malalignment. In addition, there is the restriction of left hip adduction relative to the right. The skater may try facilitating getting onto the left inner, right outer edge by lea ning towards the ice more on the right side, but this comes at increased risk o f fa lling. An exception to the above is an attempt to go counter clockwise su pported only on the right outer edge. This is required, for example, on the 'back or backward outside eight' part of a figu re-of-eight or as part of another configuration (Fig. S . 1 6B). Here, the skater with an 'al ternate' presentation or upslip is at risk of 'losing the edge'; that is, attempts to stay on the right outer edge may eventually fail a s the foot fa l ls inwprds. An astute 'pro' may notice that the right knee also falls inwards the moment that the edge is lost. I f both edges o n the righ t skate end up contacting t h e ice, this constitutes a 'flat', which, in competition, resu lts in loss of points.
Figure 5. 1 5 Speed-skating: leaning inwards to help push oH from the right inner and left outer edge while adducting the right and left leg simultaneously.
Left anterior and locked presentation
This skater tends to pronate on the left and supinate on the right and may therefore find it easier to execute circles clockwise rather than counterclockwise. The speed-skater with this presentation would be at a d is ad vantage when racing in the usual counterclockwise direction.
Balance and recovery The skater with an 'alternate' presentation or upslip may feel insecure when landing on the right leg, for example, on completion of an Axel-Paulsen loop jump (Fig. S . 1 6A). The skater in the illustration takes off from the left outer edge, does a full rotation counterclockwise and lands on the right outer edge. On land ing, there may be extraneous movements of the arms, trunk and left leg in an attempt to maintain balance because sta bility is decreased by the combination of: • •
losing the outer edge as the right foot tends to pronate the right knee collapsing inwards into valgus, a way from its more stable position directly over the foot.
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Rbo
(A)
(B) Figure 5.1 6 Edging and weighting during typical ice·dancing routines. (A) Axel-Paulsen jump; note the weighting of specific edges (Lto, left forward outside; Rbo, right backward outside) and the landing on the right leg afler the jump. (B) A 'camel spin' (which incorporates the 'spiral') carried out weight-bearing on the right leg. ( From Worth 1 990, with permission .)
The biomechanical limitations imposed by malalign ment can become blatantly obvious with some of the routines. The 'spiral', for example, calls for flexion of the trunk to horizontal, a rms out to the side, gliding along supported on only one skate with the other leg extended in a ·horizontal position, in line with the trun.!< (Fig. 5.1 6B) . The ska ter with right a n terior, left posterior innom inate rotation doing the spira l : 1 . will be able to raise the right leg further up i n the air while supported on the left leg than he or she could raise the left leg while supported on the right. This is consistent with the increased amount of hip extension possible on the side of the anterior rota tion. When attempting the spiral supported on the right leg, the left posterior innominate rotation may interfere with the ability to bring the left leg to horizontal or higher by: - creating a mechanical block to extension (see Figs. 3.64 and 3.65) - tightening up the left iliacus a nd rectus femoris by separating their origin and insertion even further (see Fig. 3.38) - limiting compensa tory counterclockwise rotation of the pelvis i n the transverse plane (see Fig. 3.4C). 2. Will find it easier to flex the tru n k to a horizontal position when supported on the left leg than on the
right. The right a n terior rotation tightens the right gluteus maximus, the hamstrings and the sacrotuber ous ligament, t hereby limiting right h ip flexion. Balance is also more likely to be a problem with right Single-leg support. Balance becomes progressively more precarious with routines that combine single-leg support, trunk flexion a nd cutting a circle. For example, the addition of a turn to the spiral (Fig. 5.1 6B), known as a camel spin, caUs for staying on a specific edge. For a 'back inner edge', for example, the skater in the spiral position supported on the left leg would place the weight on the left inner edge. Because of the tendency towards supination on the left, those with one of the 'alternate' presentations may lose that inner edge more easily and end up with a flat or even move on to the outer edge of the left skate. This results in a simulta neous increase in varus stress on the knee. If the knee ends up no longer posi tioned directly over the foot, the stability of the left lower extremity will be decreased. Malalignment can only compound the difficulty of mastering the progressively more demanding routines,
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such as the
axle or quadruple toe loop, or combi lp-trll"1/p toe loop. It will a lso when increase the chance of a these routines, particularly given most in most oI1 ··lnm sites of curve pelvic """i o'w� 1 malrotation
rotate the
the muscle contracts further to
but that movement i s suddenly blocked \It
the muscle is
to an i n crease i n tension
rotate to the
or a combination of
in the
crease.
a manoe u v re that results in i n t e r n a l rota tion,
range of motion can i n terfere w i th i n c rease the risk of injury. The a reas l isted in Box 5] vulnerable. are particularly at risk of trunk, pelvis or extremities moved
vu lnerable when the leg is d i rections (see
their into d i rec-
tions of restriction a n d past anatomical barriers on colli-
3.64 a n d 3.71 B)
sion with other
the boards and
posts.
I ncreased tension i n the gluteus maximus, hamstrings a nd sacrotuberous
o n the side of the anterior these structures at risk in by
the
the h i p o n this side.
stra ight out,
increased tension
in
rectus femoris o n the side of the
rotation
these structures at risk when
left
the
straight back, thus hyperextending the hip. A split would
site sides
these structures o n oppoand the ability to nprt{)rm
these movements would also be affected
Given the increased
potential for collisions and / or falls, skaters are also at increased risk of
out of alignment in the first place when trying to maintain
and correction.
S KI ING : ALPINE OR DOWNHILL Alpine
Pelvis, trunk, shoulders and neck
has to be pytrprnp lv
can result in SI
micro-
faUs onto one buttock
facilitation
increased tension in any o f these muscles.
A
A single incident of shear inju ry, or trauma, from a
is one of the athletic activi ties that maxstresses the ability o f a l l body parts to move the full available ranges of motion. As so
i n order to move to a nother, or to
described
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et al ( 1 992, p, 572):
The movement problems encountered by the alpine skier revolve around changing d irections and maintaining balance a t high speeds while undergoing a variety of horizont il l and vertical disturbances.
Executi n g a normal turn Turns are in itia ted primarily by a rotation of body parts, un weighting and transferring the weight to the appropriate edges. Almost any body part ca n be used to initiate a turn, but the feet and arms tend to be the least effective because they are the farthest away from the centre of gravity. In addition, as ind icated by Adrian & Cooper ( 1 986, p. 672): Arm and trunk rotations, initiated by movements at the shoul der, hip and spinal column will cause the skis to turn i f the action i s forceful enough. This necessity for force, ilcceleration, ilnd la rge motions is a source of 'overturning' and loss of control.
Rotation of the pel vis in the transverse plane thus proves most effective for initiating a turn, given the proximity of the pelvis to the centre of gravity and the need for only a minima l displacement of this part o f the body (see Fig. 3.85). An intermediate skier travelling to the right and per pend icular to the fall line is gliding on the inner edge o f the downhiU (left) and outer edge o f the uphill (right)
ski while putting more load on the downhill tha n the uphill ski (Fig. 5 . 1 7). The edging is facilitated by leaning with the hips a nd knees into the mountain while the trunk is maintained in a vertical position or leans down hill, creating a varus stress (outer soft tissues and medial compartment) on the right knee, and valgus stress (inner soft tissues and lateral compartment) on the left one (see Figs 3.33 and 3.74). In order to execute a left (downhiU) turn, the skier: 1 . transfers weight to the inner edge of the uphi ll (right) a n d o u ter edge of the downhill (left) ski; this transfer is aided by lea ning the body downhill, the combined effect being to: - u nload the downhill ski while at the same time loading the u phill one - create a force towards valgus angulation of the
uphill (right) and varus angulation of the downhill (left) knee 2. rotates the pelvis coun terclockwise in the trans verse plane, which helps to i nitiate the turn by adva nc ing the uphill leg a nd increasing the abiIity to weight the inside edge of that ski 3. progressively pivots through the turn, the uph i l l (right) leg pivoting from externa l t o internal rotation, the d o w n h i l l (left) leg pivoting in the o pposite d irection.
Figure 5.1 7 The basic 'stem turn' i n skiing: proceeding initially perpendicularly to the fall line and then down the fall line and on around the turn. ( From Parker 1 988, with permission.)
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of the turn has been When the first half, or 90 the skier will be facing downh ill with the dislegs and trunk in a lignment and the tributed on both skis. If the skier decided at this to head straight down the mountain, the rotate clockwise back to neutral, order to continue the turn to a full 180 the skier has to: .. mainta i n the forward rotation of the s i de of the .. help the inside of the right (now downhill) and of the left (now uphill) ski. the knees This weight transfer is aided and into, and the body away from, the h i l l, the Jeft varus, right anguthereby lation stra in on the knees.
Effect of m a l a l i g n ment on execut i n g a turn Adrian & Cooper (1986) rightly observe that 'human a tend to be asymmetric, that is, i n one d i rection than i n the turn more go o n t o state that dominance with determines the to balance t u rning direction' 674) While dominance with to balance' may be involved, the chief deter factors in this author's relate to the presence of mala l ignment th at
other ' .
with l imitation into the rotation or an in Hare
.. rotation in the transverse
side of a ..
reverse when the left anterior and locked is Those presenting with a left
rotation wi l l find i t easier to execute a turn to the those with a right rotation, a turn to the left. The to right or left pronation and supination does not to be as influential as the l imitation side of rotation. by that four d i fferent preLet us look a t the sentations of create for skiers attempta turn.
(uphill) ski, unless the skier is one of those athletes who has that on the kinetic rotational or Gillet test - see The is transferred more to the outside of the l eft and inside of the right ski, which should favour a left turn. However, some athletes with an 'alternate' presentation report how the right , how it is difficul t to 'get an inner foot feels side and how the addition of a medial longitu d i n a l a rch increases the of that foot and ankle and a llows them to dig in A weakness of the that more ankle in vertors, combined with external rota tion to right pronation, of the right leg and a foot and ankle may account for this instabi l i ty. Pelvic rotation in the transverse is restricted to the left. The side-to-side d ifference can be 10-25 degrees i s not unusual (see Fig. 3,4). the restriction of left rotation increases as the of left posterior innominate rotation increases, and can actua l ly progress to the pOint at which i t the turn. The skier becomes ineffective for the turn by: may then a l l the on to the left ski and 'hiking the right h i p, in order to clear the right ski and allow the skier to rotate the right and a ttached ski interna lly m uscle action, in combination with .. left trunk rotation to for the pelvic rota tion . •
at a time when the skier is Al l the above is the left ski and to be the right. Needless to say, having to unweight the forfeits the ski to effect a left turn on to its inner Trunk rotation i n the transverse plane is typically restricted to the left, restriction to the a lso occu r (see 3.45). Left l imitation will uc'u e,,,c, the to use trunk rotation to the left to help to ini a left turn, even though this tia te or carry would be corlsldier€�C1
the skier may resort to using the to initiate and control turning; this
rmnnl'm:."IA
Right anterior, left
"/"I" I" ,,,/"I r
When attempting a left turn, there should be no nrc)hl,pm unweighting the left (downhiU) and weighting the
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CLINICAL CORRELATIONS IN SPORTS
Left anterior, right posterior innominate rotation; right sacroiliac joint locked
The main problem with this 'alternate' presentation is the restriction of clockwise rotation of the pelvis, which is likely to make it harder to use the pelvis to initiate a turn to the right and easier to initiate a turn to the left. Left anterior and locked
The tendency for the left foot to prona te, and the right to supinate, should be of help in digging in the appro priate edges to initiate a right turn. However, the asso ciated limitations of lower extremity rotation - with a limitation of left internal and right external rotation and the decrease of clockwise rotation of the pelvis in the transverse plane all become a hindrance to initiat ing and carrying out a right turn. Right outflare, left inflare
The pelvis tends to rotate clockwise and the left swing/ right stance stride is increased, facilitating a turn to the right. The reverse will occur with left outflare, right inflare.
Tu rning problems related to deg ree of mala l i g n ment As indicated, the difficulty with turning into the side of the posterior innominate rotation appears to be directly related to the degree of posterior rotation. The abi l i ty to turn in one direction can certainly worsen from one day to another, or may even deteriorate a s the day progresses, perhaps because t h e amount o f posterior rotation h a s increased. Aggravating factors include the following. Tightness in the muscles attaching to the innominate, which can exert a pull. This can occur: •
•
in a posterior direction (e.g. from the gluteus maximus, hams trings a nd externa l abdomi n a l oblique - see Figs 2.248 a n d 2.37), which increases the tendency towards posterior rotation of the ipsilateral innomina te in an an terior direction on one side (e.g. from the rectus femoris, iliacus, TFL, quadratus lumborum a n d i n ternal oblique) which could worsen a n a n terior rotation a n d thereby aggra v a te a compensatory posterior rotation of the contralateral innominate (see Figs 2.24C, 2.31 and 2.37).
Unskilled turns initiated by excessive trunk rotation. Excessive trunk rotation at a time when the lower
283
extremities are fixed can exert a rotational effect on the innominates: 1. di re c t ly : by way of the a ttachments of muscles (e.g. quadratus lumborum, latissimus dorsi and the abdominal obliques) and ligaments (e.g. the iliolumbar - see Fig. 2.35A) 2. indirectly: by exerting a rota tiona l force down through the lumbar spine, straining the lumbosacral junction and compressing the facet joint on one side to cause torsion of the sacrum (see Fig. 2.358). Im pact to the innominate bone. The direction of rota tion that results from a direct blow to the innominate as a result of a fall or collision depends on whether the impact has come from an a nterior or posterior direc tion, and whether the force was applied above or below the transverse axis of rotation (see Figs. 2.33 and 2.34). Leverage effect on the innominate. A fal l or col lision can easily turn the lower extremities i n to levers capable of effecting innominate rota tion: anterior with inadvertent hyperextension of the hip, posterior with forced hip flexion (see Fig. 2.32). Simu ltaneous inflare on the side of the posterior rota tion. The skier with marked left posterior rotation will often note that turns to the right can be carried o u t w i t h increased ease a nd speed, a nd a t a more acute angle, if necessa ry. In contrast, turns to the left are harder to execu te, tend to take more time and are less acute. At worst, the skier literally lifts the right leg a n d twists the body into the d irection of the turn. Whenever these limitations become apparent, he or she should carry out one of the self-treatment tech niques intended to correct innomina te rotation (see Chs 7 and 8) in the hope of being immedia tely able to return to unh indered skiing. Alternatively, a trip to the therapist at the foot of the slope might prove worth while. Correction will certainly make for a better day of skiing in that it should again allow turns to be carried out with equal ease, speed and angulation to either side, as well as decrease the risk of injury.
Problems : 'gett i n g a good ed ge' Skiers are acutely aware of side-to-side diHerences in the ability to fit comfortably into a boot and to dig in the inner or outer edge, and they often make modifications on their own through trial and error. The following comments apply also to Nordic a n d cross-country skiing a n d telema rking. One common com plaint is that of feeling a weakness of the a n kle, with a n inward collapse of the foot. Skiers
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may use terms such as 'pronation', this condition being coun tered using either a medial arch support or a build-up under the binding. Skiers who supinate bilat era l l y may feel an improved ability to get onto the inner edge by adding a l a teral raise under the binding. For those with one of the 'alternate' presentations or an upslip, the tendency towards supination is likely to be accentuated on the left, so that they may end up witb a left lateral raise only, or one on the left that is higher than the one on the right side.
The binding on one side is often rotated outwards in an a ttempt to accommodate for an increased tendency towards external rotation of that leg, typica lly o n the right side in those with an 'a lternate' presentation or upslip (Fig. 5.18A). Provided that the amount by which the binding is rotated ou twards exactly ma tches the external rotation of the leg: •
it will help to m ini mize stresses at the ankle and knee that would otherwise result from a mismatch
t
(L)
---+- malalignment-related forces - - - . neutral settings
(8) Figure 5.1 8
(iL) accommodating for the malalignment (A)
---+- new settings
Typical manifestations of a malalignment-related tendency to right external, left internal rotation in skiing. (A) The ski bindings have been offset outwards from the midline on the right and inwards on the left in (ii) to accommodate for the increased stress exerted on the right lateral and left medial foot in (i) as the legs attempt to rotate within the boot. (8) When riding the lift: malalignment is probably present in the skier sitting in the left seat (appearance from below), where right ski (leg) is turned outwards relative to the left. The skier in the right seat is probably in alignment, with both skis pointing in the same direction.
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•
the foot, a n kl e and knee may feel more stable, a n d
•
There w i l l be a res i d u a l varus stress o n the knee as
there m a y be a relief o f t h e d iscomfort previously
the fem u r
felt on the l a teral aspect of the foot and knee; this i s
'fixed' tibia. The skier may
who has rotated the
n o t u n l i k e the case o f the
t o rotate i nw a rd s relative t o the o f sy mptoms
related to stress o n l a teral soft tissues and the medial compa rtme n t .
toe clip outwards and a b i l i ty to above) little else to counter the stresses (e.g. on the
and spine).
I f the binding i s maintai ned in a neutral plane), so t h a t the boot points
and
wards (Fig. 5 . 1 8A i ), o r if the amount
so t h e biome
to match the
is offset outwards fails external rotation o f the
lower l i m b o r i e n t a t i o n m a y
and to
for the
fixed in the boot, the persistent rotate outwards will:
modifications may, i f they are left i n
now be completely
a t e . In fact, these modifica tions could now actually
to external rotation o f
1. accentuate the
stress
t h e femur relative t o the 'fixed' tibia,
on the medial structures (e.g. Mel), pressure o n the l a teral joint
excessive
a n d tension in TFL/ITB (see
3.33 a n d 2.
aspect o f t h e foot,
genu varulTl w i th a
the
as i t tries to rotate outward s but i s restra ined by the boot this pressure sensation may be
by the
towards pronation: by raising the media l longitudinal laterally and
encourages a further extern a l rotation of tha t the pressure exerted by the boot the lateral edge of the foot
towards supi na tion, o r
external or internal rotation o f Fo l l o w i n g 3.29 )
whether or not the skier is in may be helped by
the orientat i o n of the
skies on the next ride u p on the lift: a re both pointing forwards or outwards by the same a m o u n t, or is one rotated o u twards ( u sually the 5 . 1 88)? If
an orthotic w i th a l a teral raise o f the forefoot may
rela tive t o the is suspected, the
is to confirm this and establish the
relieve the pressure on the o u tside o f the foot but will
of
before proceed ing with any
knee
accentuate the forces tend i n g towards
lo·wer extremity).
these factors h a v e to b e
reassessed a n d accommodated f o r a s i n dicated (see
add i tion o f an orthotic made to counteract the tendency arch, the orthotic shi fts
w ith compensa tory
genu
resu l t in a pressure feeling
or
of the lower extremities
valgus and lateral tracking o f the The initial temptation is often to offset both usua l ly to the same d egree. In someone w i th one of the 'al ternate' whose left leg has
Difficulty weight-bearing on one lower extremity
or an rotated i n w a rd s (sometimes
to the poi nt at which the foot now
straight
ahead or may even have crossed the m i d l i n e - see Fig. 3 . 1 6B),
the binding outwards on the left side
w i l l create a counter-rotational force: •
There w i l l now be i ncreased pressure medial aspect of the left forefoot as the
a nd telemark skiers often end the tries to
turn inward s . This pressure may b e a llevia ted w i th
up
having to place most o r a l l o f their
weight on one ski for short d istances. How they fare when tha t
an orthotic to 'counter pronation'. An orthotic that l a terally wou ld, h o wever,
shi fts
position.
the
at w h ich
and the � " " � � H
further i ncrease the rigid ity of a foot that is often in a neutral to
to be the i nsecure leg
o n their level o f
be attributable to mala lignment, i n can
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corrected by
286
THE MALAL I G N MENT SYNDROME
Preference for attempt i n g a sudden stop
Box 5.8 Factors aHecting the ability to undertake a 'hockey stop'
A sud den stop, which Parker (1 988) appropriately
refers to as a 'hockey stop', entails 'a rapid two-footed 1 . The ability of the pelvis to rotate in the transverse
twisting a n d resu l tant two-footed skid' (p. 52), the skis
plane is limited into the direction of the posterior
end ing up parallel to the fa ll line but the skier still
innominate rotation or inflare (see Fig.
looking down the hill (Fig. 5.1 9). In other words, the
2.
3.4C)
I n some, the ability to dig i n the more 'secure' edges
pelvis rota tes with the skis, whereas the trunk contin
may be a more important factor. The more common
ues to face the fal l line to a varying degree. This rota
pattern of right pronation, left supination should make it easier to dig in the right inner and left outer
tion occurs in the transverse plane, with trunk rotation
edges; this pattern, especially when combined with
primarily through the thoracic segment and in a direc
a left anterior rotation, may make it easier to
t ion opposite to pelvic rota tion.
complete a left turn. I f , however, the pronating right
For most sk iers, the combina tion of impaired rotation
ankle feels weak and insecure, the skier may prefer to get onto a more secure right outer edge and turn
of the pelvic and thoracic segment to one or other side,
to the right instead; right innominate anterior rotation
difficulty getting an edge and perceived weakness on
or outflare will facilitate a turn in this direction
one side makes it consistently easier to accomplish such a quick stop by turning to either the right or left. The
main determining factors appear to be those listed in Box 5.8. The skier is a t increased risk of injury at times when the terra i n or fellow skiers prevent the quicker, and usually more stable, turn into the preferred direction for stopping. For those in competitive ski events, the combination of problems relating to turning prefer ence a n d the asymmetry of turning, getting an edge and lower extrem ity strength and balance, assumes more significance as a poten tia l cause of poorer per formances and injuries. The ability to crouch in order to reduce drag may be ham pered, especially by: •
an inability to tolerate a sustained increase in tension on tender posterior pelvic ligaments and m uscles
•
restrictions imposed by a n terior innominate rotation, especially a restriction of right hip flexion (see Figs 3.64A and 3.69B).
SKI I N G : N O R D I C OR C R OSS-COU NTRY, A N D T E LE M A R K Differences between the various styles relate primarily to the method of achieving propulsion and making turns.
Traditional N ord ic and track ski i ng Propulsion is usually achieved using an alternating stride pattern, the most common being the diagonal stride, in which pole action is coupled with a backward thrust of the opposite, tra i l ing ski. This thrust is pro duced by rapid hip extension with terminal plantar flexion of the foot, and resu lts in the forward gliding Figure 5 . 1 9 'Hockey-stop' on skis. (From Parker 1 988, with permission.)
action of the lead ski. Speed is determined, in part, by the following.
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from one a n d then the other
5.20B). I n
both methods, the rear o r thrust s k i i s
a t approx
The strength of the backward thrust
a nd right an terior rota tion, t h e could b e decreased on either side a s a
to t h e d i rection of
i ma te l y 30
the glide
(Watanabe The skier with a n upsl ip or one of the 'alternate' pre
•
a ny ankle weakness a n d instabili ty, assoc i a ted i n with a n increased tendency towards right
sentations, for example, is a ffected by the l i m i ta tion of left
a bd uction a n d external rotation, as well as the to left
pronation and external rota tion •
a limitation of left a nkle dors i flexion (see Fig. 3.77 A),
onto the
w h ich has been associated with a d ecrease in flexor •
a l l of which make it more
d i fficu l t to
30
a nd
As a res ult, the
p u sh-off
the left ski outwards i n n er
w i t h the righ t .
thrust may be decreased
torque (Mueller et a 1 1 995) of
functional weakness a n d increased
presenta tion, t h e
With t he l e f t a n terior a n d
of the left foot and
towards inward
the muscles acting on t h e a n kles, i n
a n d a n i ncreased
muscles, a n d the right extensor h a l l ucis
outwards, may make it easier to get onto the left inner
longus a nd tibialis an terior and
w h ile
these same manoeuvres more
d i fficu l t on the
Stride
Stride
w i l l be i n fl uenced by the
of
a nd a n kle ranges o f motion and t h e l i mitations i rn nr.,oarl
by the innom inates. Left hip extension is, for decreased with left posterior rotation (see
Telemarking A turn to t h e right can be i n i t iated from the ' h a l fposition, where t h e
by the
3.64 and 3.65). The problem is l i m i tation o f left a nkle dorsiflexion
( inside) s k i
and t h e l e f t i s
in those w it h
t h e 'al ternate' presentations a n d upsl i ps (see
rem a i n s o n t h e
is transferred to the left forefoot in for
further
o f the
tight c a l f muscles a n d plantar fascia
the
and
in
'windlass' mec h a n i s m
of the a n kle.
earlier, accelera ted In a n
t o compensate for t he .li m i ta tion o f left
h i p extension, the skier may try left
to
in order to increase the Active coun terclockwise rotation of the in the tra n sverse
will a l so increase left leg but this
to help to even out the stride a ction is l i m i ted i n those w i t h left
ski initiates a
on the
asymmetry means more work a n d a n increase i n energy
To make a telemark turn to the right, the left ski leads and assumes the
position, pressure
applied to the l e ft inner edge. The
is 'tucked
under', the
extended and the knee flexed, and the
foot moves
of pressure to the ski contin ues to
righ t outer advance so that the righ t
and the
flexes e v e n further t o a l low the skier to slightly back. The weigh t is primarily on the
are primarily related to d iffi
culties in getting a n inside or outside
a n d restric
a n d tru n k, similar to
those d iscussed above for down h i l l
of the turn, As the turn pro-
( l e ft) leg a t the gresses, the
tions of rotation o f the
direction
(p.
telemark stance: the left foot forwards and
rotation or in flare. Ei ther way of
Problems on
s k i , ' t h e pressure t h a t develops
rocks back,
on the trailing (right) com m u n i ca tion, 1 993). Turns t herefore
squat, d o rs i flexion
o f the foot and a n kle, a nd partial flexion of t h e hip a n d knee on t h e lead i n g
leg ( w h i c h w i l l end
u p being down h i l l a t the completion o f the turn), w h il e
Ski-skating: marathon and V-skate stride are presently the two m a i n types o f used in is
stride
The m a rathon skate stride with the thrust coming from
lower extremity w h ile the other
one
in a track (Fig.
5.20A), wh ereas with the V-skate t he thrust comes aIter-
tra i l ing the eve n t u a l u p h i l l l e g w i t h t he
extended,
the knee flexed and the a n k l e Turns w i l l b e a f fected
l i m i ta tions of ranges o f
motion: •
dorsi flexion and 3.77)
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(see Figs 3.68A a nd
288
THE MALAlIGNMENT SYNDROME
(B)
\
(A)
•
Track
/
h i p extension and pelvic rotation on the side of the posterior rotation (or an in flare); hip flexion on the side of the anterior rotation (see Figs 3.4, 3.64, 3.65 and 3.69)
A restriction of pelvic rotation will be even more of a problem than in down hill or nordic skiing, given that the telemark skier is squatting to a variable degree, and the turns are much tighter. The tendency will be to compensate by rotating more through the trunk on executing a turn into the restricted side.
SNOWBOA RDING Snowboarders have their feet placed on the board pointing towards one edge of the board or rotated to a varying degree towards the front relative to a line dissecting the board ( the so-called stance angle Fig. 5 . 22A). The left foot leads in a 'regular', the right
Figure 5.20 Ski-skating: (A) Marathon skate stride; (B) V-skate stride. (From Matheny 1 989, with permission.)
in a 'goofy-foot' boarder (Fig. 5.22B). Steering is accomplished largely with the rear foot when the board is on the ground, as well as with rotation of the h ips and pelvis; the trunk is angled at about 45 degrees to the fall line. In a 'regular' snowboa rder, whose feet face the right edge of the board and who uses his or her right (rear) foot for steering, the effects of mala lign ment with right anterior rotation are as follows. The more the feet face forwards the greater the stance angle and the more the bind ings are actually fixed in a way that runs counter to the abnormal ten dency towards right external, left internal rotation of the lower extremities.
The snowboarder may eventually feel more comfortable with adjustments, perhaps even with the bindings mounted so that the stance angle is zero degrees (Fig. S.22A).
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a number of torsional stresses initiated in the air con tinue once the rider has contacted the ground, so that trunk a nd pelvis are repeatedly subjected to rotation into extreme ranges of motion w hile the feet a re 'fixed'; a lternatively, the board may a l ready be rotating i n the opposite direction as this part of the rider twists to prepare for the next trick. The less the rider can get onto an edge because of malalignment-related lim ita tions of pronation or supination, the more he or she depends on rotating the trunk and arms or on leaning the body towards the ground in order to carve a turn.
SWI M M I N G Detrimental effects relate primarily to asymmetrical propulsion, increased resistance and the increased energy required to correct for any torquing of the pelvis, trunk or lower extremities.
Head a n d neck
Figure 5.21 Basic turns in telemarking. I l lustrated is a right 'half-wedge turn', initiated by 'wedging' what will become the leg on the outside of the turn, by rotating the left leg and ski inwards. Most of the weight remains on the straight-running right 'inside' ski; while the pressure on the inside edge of the wedged 'outside' ski is gradually increased as the turn progresses. For progression to a right 'telegarland' or telemark turn: as the 'outside ' left ski is 'wedged', the left leg is simultaneously internally rotated and slid forward, the skier sinking into the 'telemark' stance by flexing the right knee further and extending the hip on that side. (From Parker 1 988, with permission.)
The frequently noted lim itation of head and neck rotation to the right and of side flexion to the left (see Fig. 3.9) may in terfere with the ease with which breath ing ca n be carried out on the right side when a t tempt ing alternate breathing o n doing the crawl or freestyle swimming. The increase in tension noted in the right upper trapezius in particular, compounded by repeat ed ly stra ining to rotate the head and neck into the d irection of the limita tion, may precipitate or exacer bate neck and upper back pain. The swimmer may compensate for any limitation by increasing the clock wise rotation of the trunk, but this could prove costly in terms of efficiency of style and energy expenditure.
U p per extrem ities The feet will then be in better alignment relative to the tendency to right external and left internal rotation, and there may be more comfort and ease of control; this is similar to the adjustments made by a cyclist or skier (see above). The limitation of counterclockwise rotation of the pelvis in the transverse plane may interfere with the ability to rotate the pelvis to the left; this is likely to create more of a problem with 'zero stance angle' when trying to manoeuvre the board on the ground (see Fig .. 3.4C). Limitations of ra nges of motion become a problem particularly at the time of a fa l l or collision, not only when rid i ng the board, but also when performing ver tical 'tricks'. When 'riding the half-pipe', for example,
Decreased right internal and left external rotation (see Fig. 3.15A). Asymmetry of upper extremity internal and
external rotation will affect arm entry and pull-through where these are dependent on utilizing maximum range in the d irection of the restrictions. The end resul t is: •
•
increased strai n at the end of the restricted range of motion a n asymmetrical contribution of the arms to propulsion a n d l ift.
Decreased left arm extension (Fig. 3.1 5B). The butter fly swimmer who has less left than rig ht arm extension should conceivably be able to compensate by: •
pulling with more force on the left side than the right
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290
THE MALALIGNMENT SYNDROME
�
"STANCE ANGLE"
,
\
l\y
c �
r�
J
,
i. increased stance angle with feet facing toward tip
I , I
C m (A)
I , I
m J
i i . zero "stance angle"
Figure 5.22 Snowboard ing. (A) A 'regular' foot placement relative to a line dissecting the board: (i) increased stance angle, with the feet facing towards the tip; (ii) zero stance angle. (After Bennett & Downey 1 994, with permission.) (B) A 'regular' snowboarder (left foot leading) and a 'goofy-foot' (right foot leading) . (From Bennett & Downey 1 994, with permission.)
•
torqu ing the body counterclockwise, to the point at which the left and right arms clea r the water to an equal extent.
These ma noeuvres may assure symmetry of stroke strength. Any torquing could, however, i ntroduce a 'wobble' that would increase energy expenditure by decreasing efficiency and increasing overall resista nce.
Lower extre mities Propulsion using extension and external/i nternal rota tion. The kick used for the breaststroke requires i ni tial
hip and knee flexion followed by forceful extension. Richa rdson (1 986) describes how 'maxima l valgus force is appl ied to the knee and the foot is maxi mally dorsi flexed and everted' during the flexion phase, so that 'abduction of the h i ps is minimized during the push ing phase' (p. 1 1 0). As a result, the lower extrem ities go from an initial position of i n ternal rotation and extension, to one o f external rota tion and flexion, finally again assuming a n a d d ucted a n d fully extended position by the end of the kick.
In other words, the propulsion phase consists of simultaneous hip and knee extension, internal leg rotation, ankle plantarflexion and foot inversion. The propulsive force is created in la rge part in reac tion to the water d isplaced by the inner aspect of the shin and the bottom of the foot. Any asymmetry of movement will result i n a n asymmetrical contribution to the propulsion force. With upslips and the 'alternate' presen tations of malalignment, for example, there is more external rotation possible on the right than the left side. The sole of the right foot is, unfortuna tely, set in increased va rus angulation compared with the left when non weight-bearing (see Fig. 3.22), decreasing the surface area that ca n generate a propulsion force on extension. This balance of factors may result in asymmetrical propulsive forces being generated by the right and left sides. Lower extremity orientation, joint range of motion and strength. The efficiency of propel ing the body is also a ffected by lower ex tremity side-to-side di ferences of
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orientation and asymmetries of joint ranges of motion and strength. Upslips a n d 'alternate' presentations, for example, limit right internal rotation and plantarflex ion, left external rotation and dorsiflexion. These asymmetries may help to explain the predicament of swimmers who are slow to move forwards, or worse, fail to move forwards or even move backwards when using the flutter kick hanging on to a board but procede forward without problem once in alignment.
Box 5.9 • •
• •
It helps to think of the lower extremities as acting like two propellers. Because of the malalignment, each of these propellers is set a t a different angle. In addition, there are side-to-side asymmetries in strength. Significa nt here is the common finding of a relative decrease in right hip flexor and extensor strength, whereas these same mu scles a re usually of full strength on the left side. These muscles are crucial for doing the flutter kick. In comparison, weakness on the left side il ffects primarily the hip abductors, ham strings and ankle evertors, none of wh.ich plays m uch of a part. The combined e ffect of these asymmetries appears to be that, in some swimmers, the 'propel lers' actually work against each other, so tha t the propul sion e ffect is reduced, ca ncelled or even reversed. Correction of the malalignment serves to realign the propellers and promote forward propulsion. Swimming is, with exceptions such as the sidestroke, a mainly symmetrical activity. However, asymmetrical stresses imposed by malalignment increase the likeli hood of a particular injury occurring on one side. Frequently seen knee inju ries, for example, include medial collateral ligament stress syndrome, patello femoral compartment syndrome, medial synovitis and med ial synovial plica syndrome. These are more likely to occur on the right side with upslips and 'alterna te' presentations, and on the left ·with the left a n terior a nd locked pattern. A n kle a n d foot extensor tendonitis commonly associated with the flutter a nd dolphin kick are more likely to occur on the side on which the exten sors are tight (lnd plantarflexion is decreased. In add ition, symmetrical strokes will result i n increased stress on structures t h a t are now asymmet rical; in the butterfly, for example, back extension further com presses facet joints that a re a l ready approximated on one side by vertebral rotation, espe cially in the thoracolumbar ju nction, where this problem is compounded by the curve reversal (see Fig . .3.1 2). Box 5.9 summa rizes the overall effects of these asymmetries. In a sport i n which races are sometimes won by one hundredth of a second, these effects can prove costly indeed .
Effects of asymmetry on swimming
Speed is reduced by any decrease or asymmetry in propulsion and the lift forces generated Energy is wasted by the need for corrective action in order to 'keep an even keel' and counterbalance any asymmetry in propulsive forces generated by the right versus the left side Asymmetry and corrective torquing further increase energy requirements by increasing drag Injuries, particularly involving the back, hips and knees, are more likely to occur
SYNCH RO NIZED SWIM M I N G Problems with malalignment relating particularly to an asymmetry of lower extremity ranges o f motion may be more easily evident in routines in which the body is submerged with the legs protru ding from the water. In an athlete who is not blessed with a general degree of i ncreased mobility, malalignment may well result in d i fficulties. Limitations of hip flexion and extension will affect those positions in which one leg flexes to 90 degrees and one leg remains vertical, either completely (e.g. the 'crane' - Fig. 5 . 23A) or partially (e.g. the 'knight' Fig. 5.23C3). Restrictions of flexion or extension may also cause a problem with a 'split' in the sagittal plane (Fig. 5.23C4), which the athlete m(lY be able to correct by 'opening' the pelvis, rotating the pelvis in the trans verse plane - forwards on the side of restricted flexion (lnd backwards on the side of restricted extension (see Fig. 2.9). In those with left posterior rotation, however, the limitation of pelvic rotation in the transverse plane to the left side may make this manoeu vre less effective to compensate for the restriction of right flexion and left extension (see Fig. 3.4C). Extension can also be increased by accentuating the lumbar lordosis, at thEl risk 01 precipitating back pain. For the split in the frontal plane, both legs should abduct 90 degrees to become horizontal with the water (Fig. 5.23B), but malaIigrunent may result in an obvious limitation to one side. Symmetry may be preserved by actively limiting abduction on the more mobile side to match that on the restricted side, but then both will fall short of horizontaL The asyrrunetry of plantar flexion may result in an obvious inability to point the foot on one side as much as on the other (see Fig. 3.77B). As in swimming, asym metries related to mal alignment ma y also play a role i n the causation and
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Figure 5.23 Synchronized swimming positions. (A) 'Crane'. (6) A 'split' in the frontal plane (abduction). (C) A 'walkover front' sequence: ( 1 ) initial position and (6) finale; (2) back pike; (3) 'knight' or 'castle'; (4) 'split' in the sagittal plane (extension/flexion).
loca lization of injuries seen with synchron ized swimming. Weinberg (1986) has noted the following common problems.
Back pain Back pain has been a ttributed to an increased lumbar lordosis and to the hyperextension required to carry out manoeuvres such as the split in the sagittal plane, the knight position and the walkover sequence (Fig. 5.23C); for exam ple, going from the back pike (2) i nto the knight position (3), with one leg extended and the other vertical, into a sagittal split (4), and finally bring ing the trunk into horizontal alignment with the legs. Needless to say, back pain is more likely to develop when an increased lordosis or repeated hyperextension is superimposed on the asymmetry of pelvis and spine, and the rotational stress, particularly on the thoraco lumbar and lu mbosacral junction, that results with rna lalignmen t.
Knee injuries Ci ted as one of the common overuse injuries is chon dromalacia patellae, possibly related to 'the constant emphasis on forceful extension of the knee' (p. 1 61 ),
and to a repeated use of the eggbeater kick, as well as exaggerated Q-angles, which increase the tendency to lateral tracking of the patella on knee extension (see Figs 3.33, 3 .74 and 4.5). These knee problems are more likely to occur on the right side in those with an upslip or 'a lterna te' presentations, for reasons previously noted to predispose to patellofemoral compartment syndrome (see Ch. 3).
Shoulder injuries Aside from rotator cuff impingement syndrome, shoulder pain can be produced by extensive support sculJing. The shoulder is 'slightly abducted and maxi mally rotated [externally J on the outward phase, and adducted and internally rotated on the inward phase. The major stress . . . is a stretch ing of the anterior capsule at the point of maximal external rotation' (p. 1 62), which predisposes to developing laxity, sub luxation or even d islocation. A malalignment-rela ted limitation of external rota tion on one side and internal rotation on the other, combined with asymmetrical strength, may reduce the overall effectiveness of the sculling manoeuvre. Stress on the anterior capsule will be increased on the side on which external rotation is relatively reduced (see Figs 3.l5A and 4.7).
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THROWING SPO RTS In most sports, the execution of a throw involves the whole body rather than consisting of an isolated arm action. Most throws basically require some rotation of the pelvis, thorax and extremities in order to generate maximum velocity. The following two throws serve to illustrate these points.
Javel i n At the end of the run up, the right-handed athlete trans fers weight from the right to the left foot in preparation for release. Just prior to this transfer, the athlete 'winds up' for the throw by rotating the trunk clockwise, simul taneously extendi.ng the spine, side-flexing to the right and rotating the right arm externally (Fig. 5.24). The transfer to the left foot is accompanied by a counter clockwise rotation of the pelvis to advance the right hip and thereby add to the length of the step. The trunk then flexes and unwinds counterclockwise as the right arm rotates internally. 'The final force, added to the forward movement of the body, is derived from pelvic and spinal rotation, [and] medial rotation . . . of the humerus' (Adrian & Cooper 1 986, p. 526), with simulta neous passive internal rotation of the weight-bearing left leg.
Pitch i n g The movement of t h e throwing a rm and t h e trunk i s much the same a s the sequence after t h e run-up described for throwing the javelin. Looking at a right handed pitcher throwing overhand, the initial 'wind up' phase ca lls for balancing on the right leg while accentuating the passive internal rotation o f that leg as the body winds up (Fig. 5.25A). Simultaneous pelvic rotation to the right d u ring this phase 'can be more than 90 degrees from the intended d irection of flight of
the projectile' (Adrian & Cooper 1 986, p . 498) The trunk rotates along with the pelvis until it a lso is a t a right a ngle to the intended d i rection of the throw. As the 'wind-up' proceeds, the left leg rises upwards in the air, partly to counterbalance s i m u l taneous right side flexion of the trunk and partly in preparation for stepping forwards on to the left foot. During the 'forward force' phase or actual 'cocking' phase, the ha nds separate (the right hand moving backwards), the throwing arm moves into extreme external rota tion, and weight is transferred onto the left foot (Fig. 5.258). 'Acceleration' sees an increased weight-shift forwards onto the left foot, and a simultaneous 'unwinding', con sisting of a counterclockwise rotation of the pelvis that subjects the now-supporting left leg to passive internal rotation (Fig. 5.250. Further rotation of the pelvis, unwinding, and forward flexion of the spine, combined with internal rotation and extension of the upper extremity, constitute the 'deceleration' phase and all aid the force of the release (Fig. 5.250). Con trol of the throw is perfected by going through the 'follow-up' phase, which also involves passive internal rotation of the left leg (Fig. 5.25E). Some of the restrictions i mposed by malalignment a re capable of affecting the 'four axes of motion' felt to be crucial for the execution of any of these throws. Limita tions o f joint ranges of motion, combined with asymmetries of strength and problems with balancing on one leg, distract from speed and accuracy and can result in a suboptimal th row. Take the example of the pitcher. In the 'wind-up' phase, any limitation of right a rm external rotation results in: •
a compensatory increase in elbow flexion, which will increase tension o n the u l n a r nerve and increase the chance of precipitating or aggravating nerve subluxation, irritation and inflammation
Figure 5.24 Javelin Ihrow: Ihe wind-up phase leading 10 weigh I transfer onto Ihe left leg, with passive internal rolation of Ihal leg just prior 10 release. (From Worth 1 990, wilh permission).
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Figure 5.25 Phases of ball throw: right-handed pilcher (see Fig. 3.47). (A) Wind-up (including 'cocking' of the left leg). (9) True 'cocking' ph ase . (C) Acceleration. (D) Deceleration. ( E) Follow-through.
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CLINICAL CORRELATIONS IN SPORTS
In the pitcher with an upslip or one of the 'alterna te' presentations, internal rotation of the right lower extremity is restricted compared with that of the left. Once the limit of internal rotation has been reached, any further movement into the right required for the wind-up either cannot occur at all or has to take place through increased right side flexion and/or increased clockwise rotation of the pelvis, trunk or both.
In the presence of right posterior innominate rota tion or inflare, the limitation of clockwise rota tion of the pelvis will increase the stress on the trunk. The right-handed pi tcher with left posterior rotation or inflare will have a restriction of counterclockwise rotation of the pelvis in the transverse plane. This may limit the ability to rotate the pelvis to the left through the throw, especia lly when both feet are fixed to the ground. Any restriction of pelvic rotation to the right or left increases the torquing force through the thoracic segment - in particular through the thoracolumbar junction - in either the wind-up or accelera tion / decel eration phases. Restrictions of thoracic spine side flexion and rota tion, as a result of a compensatory curva ture of this segment and an asymmetry of paravertebral muscle tension, could limit its contribution to these phases and decrease its ability to cope with any increase in rotational stress tha t occurs because of restrictions of pelvic and lower extremity movement. Balance may also be a problem, whether because of a functional weakness, an alteration of proprioceptive input or both. This is more likely to occur during the single-support phase on the right leg in conjunction with one of the 'alternate' presentations.
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restricting effect imposed by any coexisting malalign ment. It wiil, for example, conceivably be easier to execute a turn to the left with a n upslip or any of the 'alternate' presentations that would make it easier to get on the right inside and left outside edge.
Sl alom Malalignment wil.! have a more pronounced effect on the ability to execute turns in this event. Most slalom skiers have the left foot moun ted forwards on the ski, the rea r right foot steering by selectively weighting the inner or outer edge. I n those with a n upslip or one of the 'alternate' presentations, the associated tendency to right pronation and left supin a tion: •
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•
increases the ease with which they can weight the left edge may make it easier to turn and to fall to the left allows a more acute lean of the body to the left before triggering a fear of falling may a llow them to raise a higher wall of water more easily when executing a left turn.
The insecurity experienced by some on a right turn may relate in large part to the difficulty they have with shifting onto the right edge and with a n increased need to lean towards the water in order to do so. The skier who has the right foot mounted forwards is known as a 'goofy foot' (Fig. 5.26). This may again be an expression of malalignment. Certainly the left a nterior and locked presentation increases the ease with which weight can be sh ifted to the inside of the left foot a nd the outside of the right, which wil l make it easier to steer with the left foot trailing and to get onto the right edge to execute a right turn.
WEIGH T-LIFTING WATERSKIING The waterskier 's success depends in large part on maintaining balance while trying to execute turns and other manoeuvres by getting onto an inner or outer edge of the ski(s).
Two skis The ability to turn to the right or left is determined largely by the ease with which the skier can simulta ne ously get onto the inside edge of one and the outside edge of the other ski. The skier can seemingly accom plish this simply by leaning the body to one or other side. The ease with which this shift can occur will, however, a lso be influenced by the facilitating or
Some power lift competitions, such as the squat exer cise or deep knee bend, are judged partly on style. A spotter on each side looks to see whether each bu ttock has dropped below the level of the ipsila teral bent knee when the a thlete is in the full-squat position. Points may also be ded ucted if the height of the buttock and knee on one side does not match tha t on the other side. With right an terior innominate rota tion, the right buttock (ischial tuberosity) and iliac crest are usually noticeably elevated relative to the left (see Figs 2.46B, D, 3.69A and 3.79A). The right thigh may be noticeably higher or lower than the left (Fig. 3.69B), with coun ter clockwise pelvic rota tion in the frontal plane causing elevation, whereas tight hamstrings, anteriorly rota ted
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Figure 5.26 'Goofy-fool' slalom water skier: the right foot leads, the left steers. ( From West 1 989, with permission . )
superior acetabular rim, o r painful iliopsoas a n d liga ments all counter hip flexion. The full squat may also be limited on one or both sides by pa in provoked from tender muscles or posterior pelvic ligaments put under increased tension by this manoeuvre. Pain from these structures may also create problems with the full squat required part way through: 1 . the s natch lift, when the weight-lifter is in the
'catch' or 'receiving' position (Fig. 5.27 A3)
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2. the clean-and-jerk lift, when the weight-lifter is in the catch or receiving position for the clean (Fig. 5.27B3). The clean-and-jerk lift proceeds to the catch or receiving position for the 'split' jerk, which is a n asymmetrica l position with one leg fully extended behind the body a n d the other flexed to a pproximately 90 degrees at the hip and knee. At the same time, the fu lly extended arms balance the weight directly above the head (Fig. 52785).
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THE MALALIGNM E NT SYNDROME
[f the athlete reports pain, the MET may have to be modified as follows: For right an terior rotation
The athlete lies supine. If the i n i t i a l attempt to flex the right h i p to 90 degrees proves painful, or if the initial effort to extend the right h i p in the sagittal plane causes pain, try the same manoeuvre with the th igh add ucted or abducted 5-1 0 degrees. If this ma kes no difference, try starting with the right h i p flexion a ngle decreased to 60 degrees or even less, resistance being provided by a helper (Fig. 7. 14A) or by lengthening the reach using a towel or wide belt (Fig. 7.1 48). The manoeuvre ca n even be performed with the right leg lying almost straight a n d hip ex tension attem pted against the forearm of the helper, whose hand is secured on the athlete's opposite (left) thigh (Fig. 7 . 1 4C). The mechanical advantage of gluteus ma x i mus decreases as the right hip flexion a ngle is decreased, b ut most ath letes will still derive benefit with repeated contractions. [n these situations in particular (e.g. postpartum), the emphasis is on repetitions rather than on the strength of the contractions. If pain does not occur u n t i l some point after the right hip has a lready been flexed to more than 90 degrees with progressive stretching and relaxation of the gluteus maximus, simply bring the thigh back to the previous position that did not provoke pain. After repeating the manoeuvre a few times in that position, try it once more at an i ncreased h i p flexion a n gle to see whether that still provokes pain. If it does, go back to the previous pain-free position and stay there from then on. It may be that progressive right h i p flexion is provoking pa in by: •
•
Putting tender posterior pelvic l iga ments a nd buttock muscles under increas ing tension Compressing a tense and tender right i l iopsoas muscle, which is particularly vulnerable within its narrow space when hip flexion i s combined with adduction.
Left posterior rotation
The athlete l ies supi ne, the left h i p flexed to 90 degrees and repeated ly resisting either left hip flexion or left knee extension, for a set of 6-10 times each (see Figs 7. 1 0-7.1 3). If either manoeuvre proves painful, the athlete may have to try changing the a ngle of the thigh, decrease the strength of the contractions or abandon one or both manoeuvres for the time being. Concentrating on the correction of the right anterior rotation (see Figs 7.8 and 7.9) will often actually res ult
i n simulta neous correction of what amounted to a compensatory contralateral (left) posterior rotati on. . Always remind the athlete to relax all the muscles other than those needed for a pa rt icular MET manoeuvre. The most common mistake is to tense up the muscles in the neck a n d upper back region while hanging on to the towel or belt to provide the required resistance. Worse still is actually to raise the head and /or shoul ders off the plinth. Tensing these muscles inevitably results in a domino-like i nvolvement of the abdominal, erector spinae and other tru nk muscles, all the way down to their attachments to the superior pubic rami, iliac crests and the thoracodorsal fascia. A contraction of these muscles can easily i nterfere with achieving rotation of the innominates in the desired direction.
Contract-relax The contract-relax method is one way of achieving both progressive rela xation and realignment. The relaxation of a muscle following an isometric contraction is usually more profound than can be achieved voluntarily. Sometimes just relaxing any tense attaching muscles al lows the bones to rotate back into proper a lignment. This is the sa me principle as the hold-relax method used to treat localized muscle spasm . The decrease in tension following each contraction al lows for the further passive movement of a body part into the direction of the restriction. The contract-relax ma noeuvre can be useful for the correction of innominate rotation, in particular the rota tion and d isplacement tha t occurs anteriorly at the symphysis pubis. Realignment of the pubic bones, for example, may be achieved by alternate bilateral hip abduction and adduction against resistance while sitting or lying supine (Fig. 7.1 5). The symmetrical activ ation of these muscles exerts an equal pull on pelvic structures tha t are in an asymmetrical position to begin with, thereby aUowing them to come back to the mid line or to a 'neutral' position. The tech nique is covered in some deta i l below under 'Self-help techniques to correct maJaJignment' (pp. 346-348). W hen m a l a l i gnment is present, there is often increased tone in the l eft hip abductors and right piri formis, which exert opposite rotational forces on the lower extremities. Asymmetrical tension in the piri formis also creates a sacral torsion strain by way of its
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Figure 7.14 Modifications of the muscle energy technique using resisted hip extensor contraction for the correction of anterior innominate rotation. (A) Decreasing the hip flexion angle to avoid pain. (8) Using a towel or wide belt: (i) to serve as an extension for short arms; (ii) to allow for a decrease in the hip flexion angle and/or a relaxation of the neck/upper back muscles during the manoeuvre. (C) When the hip flexion angle needs to be markedly reduced because of obstruction (e.g. during maternity) or pain (e.g. postpartum or after surgery). The assistant's forearm: (i) can provide resistance; (ii) can be steadied by securing the hand on top of the opposite thigh. (D) Simultaneous resisted right hip extension (versus right anterior rotation) and left hip flexion (versus posterior rotation).
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Figure 7.15 Contract-relax method for the correction of innominate rotation: alternating simultaneous right and left resisted hip abduction and adduction. (A) One-person technique lying supine: a belt acts to resist abduction, with a cushion between the knees to prevent bruising on adduction. (B) One-person technique sitting: (i) the hands (or chair arms) resist abduction; (ii) the forearm resists adduction. (C) Two-person technique lying supine: (i) resisted abduction (ii) resisted adduction.
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(Ci) Figure 7 . 1 5
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(Cii) Continued.
origins from the anterosuperior aspect of the sacr u m (see Fig. 2.31 A). T h e h i p abductors a n d t he ex ternal rotators of the thigh can be activated by resisting bi lat eral h i p abduction while lying supine or sitting, main taining the hips in a tlexed position, the knees some 20-40 cm apart and the feet together (Fig. 7.15). The repeated simultaneous isometric contraction of these muscles may correct a sacral torsion or rotation of the lower extremities, and cause relaxation to the poi nt of re-establishing symmetry of muscle tension. Simu ltaneous hip ad d uction aga inst resistance with the knees held 20-30 cm apart reverses the add uctor origin a nd insertion, res ulting in a symmetrical trac tion force on the i n ferior pubic ra m i (Fig. 7.1 5). These forces ca n sometimes re-establish symmetry at the symphysis p ubis. It may do so by temporarily separat ing the symphysis and then al lowing the adjoini ng pubic bones to fall back into the normal, al igned posi tion as the add uctors relax. It is th is separation that is felt to be responsible for the frequently reported sen sation of something having 'moved' i n the region of the . symphysis, often accompanied by an a u d i ble popping sound, much l i ke 'popping' a knuckle. Reassessment may show the partial or complete red uction of a previously noted step deformity at the symphysis a n d even the correction of rotational
malalignment, suggesting that the manoeu vre ca n also exert a rotational force on the innominates through the prev iously asymmetrical pubic bones, to bring them all back to the neutral poin t. Pain experienced w ith this technique is primarily attributable to contracting the m uscles too forcefully, too often or both . Athletes easily get caught up in thinking that 'more is better' and can end up with an 'overuse' type pain. The h i p a d d uctors and a b ductors seem particularly vu l nerable, perhaps because they are not likely to be very strong m uscles in comparison with the ham stri ngs a nd quadriceps, except in goalies a nd others who repeatedly ad d uct a nd a bd uct the legs as part of their sport. Discomfort from overuse may not be felt for some hours after an overzealous attempt at this manoeuvre. Therefore, the fol lowing guid elines seem a ppropriate: •
•
Limit the strength of the contraction to 50% of max i m u m to start with Do only five repeats to a slow count of 3 initially; add one more contraction each week unti l you are up to a total of 1 0
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THE MALALIGNMENT SYN DROME
Once 1 0 repeats at 50% strength are easy, progressively increase either the length or the strength of the contractions.
Leverage to effect counter-rotation The femur can act like a lever to effect rota tion of the ipsilateral i nnominate. Progressive h i p flexion, for exa m ple, eventually puts the posterior soft tissues un der maximum tension and causes the femur to i m pinge on the a nterosuperior rim of the acetabulum (see Fig. 2.32A). At that point, further passive hip flexion creates a mechanical force capable of rotating the innominate posteriorly. Progressive hip extension will eventually have the opposite effect: anterior rota tion of the innominate (see Fig. 2.32B). This leverage effect can sometimes be used to correct a rotational malalignment. Passive right hip flexion carried out w i th the athlete lying supine may, for exa m ple, correct for an a n terior rotation on that side (Fig. 7.1 6A). Passive left hip extension with the athl ete lying prone may correct for a posterior rotation (Fig. 7. 1 6B ) . Leverage forces for the correction o f a right an terior, left posterior rotation can a lso be achieved by: 1 . pushing the right thigh onto the athlete's chest while applying a gentle downward pressure on the left thigh (or letting it hang freely over the edge of the bed - see Fig. 7.16C), to force the left h i p i n to extension • Combined tru nk and hip flexion (Fig. 7. 1 7): - the a thlete's right foot is securely placed on a
•
fairly high support - the athlete then lets the trunk bend forwards as far as comfortably possible, the head and arms hanging down in a relaxed position, to help to exaggerate right hip flexion a n d create a right posterior rota tional force A modified lunge (Fig. 7 . 1 8) : - the a th lete puts the right foot up o n a cha ir or other high support, w i th the knee flexed - the left foot is on the floor behind, the knee being in full extension - leaning forwards w ith the trunk, and allowing the pelvis to gradually sink downwards, the athlete turns the right and left femurs into levers capable of exerting a posterior and anterior rotational force on their respective innominates.
Leverage manoeuvres may cause pain from stressing a degenerating h i p joint or an i n flamed or malaligned SI joint. More often, pain arises from putting tense and tender s tructures under even more tensi o n . For exa mple, passive hip flexion on the side of the anterior rotation, especially with the knee straight, typically
precipitates pain from the involved piriformis and hamstring muscles, and posterior pelvic ligaments, passive hip extension on the side of the posterior rota tion, pain from a tender iliacus, rectus femoriS, tensor fascia lata (TFL) or anterior SI joint l igament. The vigour with which coun ter-rotation manoeuvres can be carried out should be guided by the attempt to avoid, i f at all possible, precipitating any pain and trig gering reflex muscle spasm.
TECHNIQUES FOR CORRECTION OF A SACROILIAC JOINT UPSLlP Gradual rela xation of the hip girdle muscles achieved with traction may a llow the SI joint on that side to 'come down' and resume its i ntended position. This manoeuvre lends itself to a one- or two-person approach. Repeatedly having someone apply a steady downward traction force 10-12 times to the leg on the side of the upslip may be adequate to resolve the problem with time (Fig. 7.19A). When alone, the athlete can try sta n d ing with a weight attached to the foot and the leg freely suspended on the side of the upsIip (Fig. 7.1 9B). Th is approach is described i n more detail under 'Self-help techniques to correct mala l ignment', below (pp. 34�348). M a n i pu la tion is particularly helpful for correcting some types of malalignment. An SI joint upslip, for example, can usua lly be corrected with quick down ward traction on the leg. The exact position of the i n nominate needs, however, to be determined in order to establish how the manoeuvre should be carried out. The reader is referred to Lee ( 1 999), Lee & Wal sh ( 1 996) and Vleeming et al ( 1 997) for further rea d i ng on this topic, and should have su pervised hands-on train i ng before applying these techniques to athl etes. Basically, the athlete is asked to lie in either the supine or the prone position. The therapist gets a firm hold of the an kle on the side of the upsli p, moves the leg into position - with the hip flexed, extended or in neutral depending on the examination findings - and then gently moves it about in order to ensure complete relax ation of the hip girdle muscles. The athlete is d istracted by keeping up a conversa tion, and a traction force is exerted by pulling downwards on the extremity. Another technique is to have the athlete concentrate on breathing in and out. Sudden traction is applied during the exhalation phase on the second or third cycle.
Successful reduction is usually indicated by the sensation of a joint having moved, similar to the feeling associated with 'popping' a knuckle.
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(C) Figure 7.16 Using a leverage eHect to correct rotational malalignment. (A) Passive hip flexion to counteract right anterior rotation (i) one-person technique; (ii) two-person technique. (S) Passive hip extension to counteract left posterior rotation: (i) one-person technique; (ii) two-person lechnique. (C) Simultaneous correction of right anterior and left posterior rotation by passive right hip flexion and left hip extension respectively.
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Figure 7. 1 7 To correct right innominate anterior rotation, a right posterior leverage effect can be created by resting the right foot on a high support and then letting the trunk h an g down in forward flexion as far as feels comfortable.
This sensation can be felt by the therapist as it is trans mitted through the femur a nd tibia down to his or her hands around the ankle. There i s sometimes also an audible sound. The athlete may spontaneously report the feeling of one bone having slotted i n to proper align ment with another. I t just 'feels right again', and the d is comfort is often immediately decreased or abolished. If the athlete's anatomical leg length is equal, successfu l reduction is confirmed by fin d i ng that leg length once again matches on the long-si tting to supine-lying test, and the pelvis is level in both sitting and standing (see Figs 2.50 and 2.51A). The bony la ndmarks and hip ranges of motion w i l l be symmetrical. Several attempts may be required to achieve correc tion. Even when the manoeuvre appears to have failed to achieve complete correction, one will usually after wards note a change for the better. Leg length d i ffer ence (LLD), for example, may have been red uced, a n d t h e h i p ranges o f motion become less asym metrica l . The stretch i m parted b y repeated downward traction has probably rela xed whichever hip girdle muscle or m uscles (e.g. i liopsoas a nd quadratus l umboru m) that
have been exerting an upward pull on the in nominate and displacing it relative to the sacrum (see Fig. 2.40). It is for this reason that it Illay sti l l be worth while carrying out the traction and /or manipula tion on a repeated basis in the hope that this will relax the muscle(s) enough even tua lly to allow these bones to slot back into norma l a lignment.
TECHNIQUE FOR CORRECTION OF OU TFLARE AND INFLARE Outfiare and i n fiare occur normally with pelvic move ment (see Figs 2.10 and 2.14). Excessive outfiare or i n fiare can occur in isolation, but the most common presentation is with outfiare on one side and infiare on the other (see Figs. 2. 10 and 4.25). When associa ted with rota tional malalignment, inflare is often seen with an anterior and outfiare with a posterior rotation, but the reverse fi ndings are not uncommon. Correction of the ou tfiare u s i ng MET: •
often resolves a contralateral infiare
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Figure 7.18 When there is a right anterior, left posterior rotation, this modified lunge position (right foot forwards and up on a support, left leg in extension with the foot on the floor) simultaneously creates a right posterior and left anterior rotational force.
•
may be necessi HY before a coexisting rota tional
•
may sim ultaneously correct a coexisting rotational
malalignme nt will respond to attempts at correction malalignme nt or upslip, re gardless of whether these are on the same side as the ou tflare. If an outtlare co-e xists with an upslip and/or rota tional malalignme nt, it seems appropriate initially to attempt correctio n of the outflare, given that it will usually correct the other conditio ns simulta neously. A right o u tfla re may correct with an MET that uses the resisted contraction of what are p rimarily the follow ing muscles (Fig. 7.20) : 1. posteriorly: primarily the external rotators and abductors of the hip, whose posteromedii d origins from the innomi nate allows them to pull this part of
Figure 7.19 Correction of a right upslip with traction on the leg. (A) Two-person approach : repetitively pulling down on the leg. (8) One-person approach: using a weight suspended Irom the loot.
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Piriformis (cut)
Sacrotuberous ligament I n ferior gemellus
Pi riformis insertion
Sacrospinous ligament
Obturator externus
Obturator internus
Figure 7.20
Quadratus femoris (cut)
Muscles that can be activated
using the muscle energy tech n ique in an attempt to correct a right i nnominate outflare.
the innominate laterally on reversal of their origin and insertion
Box 7.3 Technique to correct right outflare
- obturator internus and externus (from the ischiopubic ramus) - superorior gemellus (from the outer surface of the ischial spine)
•
Flex the left hip and knee, leaving the left foot on the plinth
•
Flex the right hip and externally rotate the thigh in order to place the lateral aspect of the right ankle against the anterior aspect of the left thigh (the so-called 'figure-4' position) Ca rry out a set of four or five contractions against a resistance supplied by either the athlete (Fig. 7.2 1 A) or a helper (Fig. 7.21 0) against the outer aspect of the right knee; with these contractions, the athlete is attempting simultaneousty to externally rotate, abduct and extend the right thigh
- inferior gemellus (from the ischial tuberosity) - quadratus femoris (from the ischial tuberosity) - to some extent, the inferomedial part of the
•
origins of gluteus maxim us and minimus (from the posterior il ium) - piriformis (through its origins from the greater sciatic notch area) 2. anteriorly: primarily iliacus which, through its
s uperolateral origins from the innominate, can pull it
•
Carry out three further sets of four resisted contractions
•
After each set of four contractions, progressively increase passive teft h i p flexion, which results i n : - the left foot rising gradually f u rther o H t h e plinth (Fig. 7 . 2 1 B) - a progressive increase i n passive right hip flexion (and external rotation), which wilt increase the tension i n most of the muscles activated - particularly piriformis - by taking up any slack after each contraction, i n order to make the next contraction more eHective The correction of right outflare is then followed by a correction of left inflare, if this has not already
media lly. A simu ltaneous left inflare can be corrected using pri ffiil rily adductor longus and magnus which originate from the inferior pubic ramus and outer inferior ischial tuberosity and are, therefore, capable of rotating the innominate outward on reversal of origin and insertion. For a right outflare, the supine-lying athlete would •
und ergo the sequence shown i n Box 7.3. I n other words: •
occurred: - the left leg is held i n external rotation , the left
with a right o�ltflare, the right leg is in external rotation so that the right knee d rops outwards, and resistance is applied to the outer aspect of the right knee as the athlete attempted to push it ou twards
•
with a left inflare, the left leg is also positioned in external rotation, but resistance is applied to the inner aspect of the knee as the ath lete attempts to
•
•
foot being anchored by the flexed right thigh - pressure is applied to the medial aspect of the left knee, to resist attempted internal rotation of that leg (Fig. 7.2 1 C) Reassessment and a repeat of the manoeuvres if the outflare i s still present Once the outflare is no longer evident, the correction of any residual rotational malalignment (or upslip)
push it inwards.
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(A)
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(8)
(Cii)
(Oi)
(Oii)
Figure 7.21 Muscle energy technique: to correct a right oulflare. Note the starting position for resisting right external rotation, with the right foot anchored on the left thigh and the left foot resting on the plinth (A). (A) A towel against the right anterolateral knee provides resistance (dotted arrow) against active right external rotation. (8) A towel against the right and left shin helps passively (dotted arrows) to increase bilateral hip flexion after every set of four resisted contractions (as in Fig. 7.21 A). (C) The reverse manoeuvre to counteract left inflare: resisting left internal rotation: (i) one-person technique; (ii) two person technique. (0) Two-person technique for resisted external rotation: (i) starting position; (ii) progressing by passively increasing left hip flexion with pressure against the left shin after every set of four resisted contractions.
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THE MALALIGNM ENT SYNDROME
SELF HELP TECHNIQUES TO CORRECT MALALIGNMENT It cannot be stressed enough that a lasting correction of the malalignment will be achieved more quickly if the athlete can supplement this formal treatment with a regular home exercise programme.
Visits to a therapist usually occur once, twice or even th ree times a week initiaJJy and a re subsequently ta pered to increasing i n tervals as the athlete starts to respond. However, i t serves little purpose to have the therapist correct the malalignment only to have the ath lete lose that correction within hours or days and then wait, out of a lignment, until the next formal treat ment session. Any recu rrence of malalignment between trea tments is a step backwards because it keeps sub jecting the pelvis, spine, l i mbs and a ttaching soft tissues to ongoing stresses and strains. Recu rrences also in terfere with the grad ual adaptation that myofas cial tissue has to undergo in order eventua lIy to rea d just to the a ligned position. I f recurrence during these in terva ls between formal treatment sessions can be mini mized or prevented al together, the whole trea tment process can be ex pected to take less time to complete and to be much more effec tive in returning the athlete to full activity. Correction of rotational ma lalignm ent
If recurrent rotational ma lalignment is one of the prob lems, a home programme with the fol lowing compo nents is recommended. Muscle energy technique to correct rotation
The technique, as described above, can achieve several things. First, it may result in the correction of any recur rence(s) of malalignrnent between the formal treatment sessions. Second, even though it may fail to achieve 100% correction, it can usually decrease the extent of the rotation and will, in doing so, often decrease discomfort. It can also play an i mporta nt part in helping to maintain correction because it results in a strengthen ing specifically of those muscles which help to coun teract a n terior rotation on one side (e.g. gluteus maximus) a nd posterior rotation on other (e.g. rectus femoris and i liacus). Finally, a home muscle energy technique p rogramme allows the athlete to carry out a self-reduction manoeuvre whenever and wherever malalignment recurs. This is particularly important when formal help is not immediately available.
A typical exa mple is that of the skier who has taken a fall and a fterwards notes d ifficulty executing turns to the left because the recurrence of a left po sterior i n nominate rotation is restricting left pelvic rotation in the tra nsverse plane (see Fig. 3.4C). Successful self correction of the rota tional malalignment righ t there on the slope, using the MET outlined above, wil l allow for im mediate retu rn to unhindered skiing. It will also prevent, or at least hel p to minimize, any recurrence of sym ptoms that a re the result of the increased stress on skeletal and soft tissue structures associated with malal ignment, a phenomenon that is defi n i tely ti me-con tingent: the longer any one recur rence of the malalignment is a l lowed to persist, the more l ikely it is that these same structures ,·vill again become symptomatic. The athlete is instructed to: 1. start by resisting hip extension 6-10 times on the side of the a nterior rotation (see Figs 7.8 and 7.9), tak.ing up any slack in the gluteus maximliS folIo wing each contraction (by letting the knee drop towards the chest) 2. follow this with resi sting hip flexion (see Figs 7.10 and 7. 1 1 ) and knee extension (see Figs 7."1 2 and 7. 13) 6-10 times each on the side of the posterior rotation 3. repeat the manoeuvre of resisted hip extension on the side of the anterior rota tion 6-10 times more, ofter which it is time to 4. recheck to see whether real ignment has been ach ieved; if not, the above sequence can be repeated a nd another check made. If th ere is any pain on attempting correction of the anterior rotation, the athlete can often avoid this by trying resisted hip extension with the thigh moved further away in order to decrease the hip flexion angle. The thigh may, however, end up so far away that it is out of reach. In this case, the athlete can usualJy compensate by using a towel or wide belt, either around the back of the thigh or over the upper part of the shin (see Figs 7.13 and 7.14B). Contract-relax of hip abductors and adductors
The athlete can do this manoeuvre alone in a nu mber of ways. Lying supine, the hips and knees flexed to 90 deg rees
(see Fig. 7.1 5A) • Abduction phase: resistance to abduction is best achieved using a broad belt. The loop is sli pped directly a round the upper part of the thighs or over the flexed knees and should enci rcle the thighs just below the popliteal space or 5-10 cm below the patellae respectively (see Fig. 7.15A). The knees should be able to separate by abou t 20-30 cm on ottem pted abduction
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• Adductior! phase: a cushion or ball placed between the knees pro tects the i nside of the knees from bru ising on adduction.
Sitting • Abduction phase (Fig. 7.1 5Bi): the athlete GI ll push with the hands against the outside of the knees to resist repeated ilttempts ilt abd ucting both thighs s i m u l taneously. Alternatively, the ilfm rests of il chair or il nil rrow doonvil)' or other ilrrangement Ciln serve to stop ilbd uction • AddLictioll phase (Fig. 7.1 SBii): ildd uction Ciln eilsily be resisted by wedging a forearm between the knees, the elbow flexed to 90 degree. The inside of the knee on one side ends up pushing against the arm just ilbove the ole cranon, the other against the heel of the hil nd, with the wrist in extension.
Le verage manoeu vres
The leverage principle can also be incorporilted i n to some effective self-help ma noeuvres that a ttempt to correct both an anterior ilnd posterior rotation simulta neously: 1 . The athlete sits over the edge of the bed or plinth, then lies back supi ne ilnd stilrts grad ua lly to pull the thigh on the side of the anterior rotiltion onto the chest. At the sa me time, the thigh on the side of the posterior rotil tion passively extends ilS it hil ngs over the edge (see Fig. 7.1 6C). 2. The foot on the side of the anterior rotiltion is put on il fil i rly h igh support (see Fig. 7. 1 7A). The tru n k is then a l l o wed to hang forwilrds and d o wn so that the right thigh ends up al ongside the chest (see Fig. 7 . 1 7B). This ma noeu vre, which res ults in acute flexion of the thigh, is often descri bed by the athletes ilS being probably more effective tha n techni ques ( 1 ) and (3). 3. The ath lete Ciln put the foot on the side of the anterior rotation up on a chair or other type of raised su pport (see Fig. 7.1 8) . The other foot remains on the ground, the hip and knee on that side fu lly extended. The body is then a llowed to lean forwards into the 'sprint start' or 'lunge' pOSition in order slowly to hyperflex the hip on the side of the anterior rotation while at the same time hyperextending the hip on the side of the posterior rotation. The athlete should be warned to avoid bouncing but in stead to sink down grad ually and hold tha t position for 30-60 seconds, like a stretch. The manoeuvre should be repeated four or five times in succession. These sim ple ma noeuvres have iln ildvantage in that the athlete does not have to lie down, so they can
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easily be ca rried out ilnywhere: in the home or office, by the playi ng field or while travel l i ng. They Cil n ilfford milny athletes at the very least some temporary relief.
Sacroiliac j o int upslip lf the problem is one of an upslip that fai l s to correct or that keeps recu rring, the ath lete should be instructed i n a daily home traction programme. For the ath lete with a recurrent right upslip the following can be tried . One approach has the athlete lying either su pine or prone while someone exerts a steildy downward pull on the right leg for 30-60 seconds, followed by complete relaxiltion (Fig. 7.19A). A check should be done after 1 0-1 2 traction-relilxation cycles to decide whether fu rther trea tment is needed. The athlete can also sta nd with the left leg up on a stool, cha i r or stilircase a n d i nitially hang the ilffected right leg down over the side with il weight a ttilched (see Fig. 7. 1 9B). The progressive il ddition of wrap-on ankle weights may suffice. Alternatively, the athlete ca n start with a hi king or ski boot, which serves as a bilsic weight of ap prox i miltely 2-3 kg as well a s helping t o protect the skin il n d illiow for the gradual addition of further weight i n l kg increments every 3 or 4 days as tolerated. This progressive increase i n weight ca n b e achieved simply b y hanging a small bucket conta i n i ng an i ncreasing il mount of water or sa nd from the boot, or a bag grild ually fi lled with ha nd-weights, Cilns of food il nd so on. Most athletes ca n even tually hold 7-9 kg. Tra ction is appl ied for 1 5-30 minutes once or twice a day. While the weight is attached, the a thlete is encour ilged to move the right leg gently through a limited range of motion at the h i p joint (e.g. circumduction through no more than 1 5-20 degrees). This movement, combined with the traction, gradually helps to relax the m uscles and stretch out any tight structures in the hip girdle and pelvic region in order to allow for a red uction of the upsli p. Recu rrences of the upslip may be decreased i n fre quency, or altogether prevented, by ca rrying out trac tion manoeuvres on a regu lar basis, both before and i mmed iately after any activity li kely to precipitate a recurrence.
Correction of outflare and inflare The MET manoeu vres described above for the correc tion of these presentations can be carried out with the ath lete providing the required resistance (Fig. 7.2 1 A above). In the case of a right ou tfla re, this i s done by having a towel or sheet cross the right anterolateral
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knee region and the left upper shin. This support can be used to provide the force required to prevent the right knee moving. It can also be used to bring the left thigh gradually closer to the trunk after each set of four con tractions, simply by pulling on both ends to i ncrease the overall tension in the set-up (Fig. 7.21 B above).
INSTRUCTION IN SELF-ASSESSMENT A ND MO B I LIZATION Ath letes presenting with the mala l ignment syndrome who w i l l benefit from carrying out mobil i zation exer cises at home are given a handout describing how to carry out the self-assessment to determine whether or not they are out of a l ignment in the first place and, i f so, whether there is an u pslip, a rotational ma lalign ment, outfla re a n d / or inflare or a combination of these. The handout instructs them how to carry out the a ppropriate M ET, traction or other ma noeuvre, either on their own or with someone's help. Athletes receive the handout a fter ha ving been ta ught how to do the exercises by their therapist as part of the trea tment ses sions and by the a u thor at the time of initial assess ment or reassessment. They are also asked to attend a 3-hour workshop that the au thor holds once a month in order to: •
• •
•
•
give the athletes a better understanding of the changes a n d problems seen in association with the malalignment syndrome in order to make it easier to recognize whether or not they are in or out of a l ignment review the contents of the handout do a 'hands-on' demonstra tion of the sel f assessment and self-trea tment techniques for the various presentations stress the avoida nce of inap propriate activities, especia l ly those which a re asymmetrical or have a torsional component d iscuss the a lternate trea tment options (e.g. orthotics, or 51 belt or ligament injections). Athletes are reminded that self-help techniques are no substitute for a formal treatment programme but are intended to supplement it.
The athlete's efforts should be rega rded as helping to maintain day-by-day correction, whereas the thera pist does the 'fine-tu n i ng'. I n add ition, i t is emphasized that the self-help ma noeuvres should not provoke pain, for fear that pain may trigger reflex spasm, result in a loss of any correction that has been achieved or d iscourage the
athlete from continuing with this approach. It is always wise to have the athlete demonstrate on a sub sequent visit how he or she carries out the self-assess ment and self-treatment manoeuvres in order to ensure that these are being done correctly.
POST-REDUCTION SYNDROME Following a successful correction of vertebral malrota tion or pelvic malalignment, some athletes experience discomfort from areas that were previously asympto matic. A typical example is that of the athlete with one of the 'a l ternate' presentations who has been com plaining of d iscomtort from a tense and tender left TFL / i liotibial band ( lTB) complex. Following realign ment, he or she is suddenly bothered with symptoms from the same complex on the right side. This pheno menon can be easily explained on the basis of: 1 . the shortening of soft tissues put in a relaxed posi t i on d u ri n g the time that m a l a Lignment wa s present. In the example, the tendency to right med ial weight-bearing decreased tension in the right TFL/ITB complex and eventually caused it to shorten. In con trast, the tendency to left lateral weight-bearing, faci li tation and other factors increased tension in the left TFL/ITB a nd caused it to lengthen (see Figs 3.33, 3.37, 3.39, 3.40, 4 . 1 a n d 4.4) . 2. the red istribution of stresses that occurs with rea lignment. In the example, tension in the shortened right TFL/ITB complex w i l l i ncrease as weight bea ring on the right side shi fts from being med ial to becoming more neutral or even I.ateral on rea lignment (see Fig 3 .29). Symptoms may occur i n the form of localized dis comfort and /or referred pain or paraesthesias originat ing from the affected structure(s). These symptoms usua lly d isappear within 2--4 weeks with natural tissue adaptation supplemented by appropriate stretching.
EXERCISE During the in itial stage of trea tment, emphasis should be on symmetrical routines and on strengthening the thoracic and pelvic core muscles in order to increase sta bility and decrease the chance of recurrence of mala l ign ment. Graduated increases are advised to allow for progressive i mprovement and to minimize the cha nce of precipitating pain and reflex muscle spasm.
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CONTRA-INDICATED ACTIVITIES Malalignment presents primarily as a muscu loskeletal problem, but the definitive treatment is realignment. Standard treatment a pproaches to muscu loskeletal problems emphasize specific stretching, strengthening and flexibility routines. In the face of maialignment, some of these standard a pproaches and certa in sports activities are con tra indicated because they are more likely to cause recurrence of malal ignment and /or put the a th lete at i ncreased risk of i njury.
Contraindicated stretches As indicated in Chapter 3, malalignment results in a n increase i n tension i n certa i n muscles. This increase may be the result of a mecha n ica l separation of origin and i nsertion, a response to pain or instability, or a facil itation, with a change in the setting of the muscle spindle effected at a spinal segmental or possibly even cortical level. A chronic i ncrease i n tension eventually results in tenderness to palpation of these m uscles, their tendons and points of attachment. Discomfort from these sites perpetua tes the increase in tension and initiates a vicious cycle. It is important to note that some of the standard treatment approaches to muscles tha t are tight and tender are u n likely to be helpful and may in fact cause further harm .
Stretching a tight muscle may fail if the increase in tension is occu rring on the basis of malalignment and/or in reaction to a chronic source of pai n . Stretching attempted under these conditions in fact increases the chance of perpetuating the problem by temporarily causing a further restriction of the inflow and exit of blood, increasing tension on the points of attachment and preCipitating more pain.
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The athlete, unless otherwise instmcted, is asked to carry out only symmetrica l stretches. U n i l a teral stretches that exert a rotationa l force on the innominate bone are frequen tly the cause of a recurrence of malalignmen t, hence the emphasis on symmetrical stretchi ng, avoid ing any twisting of the tmnk, pelvis or extremi ties. I f symmetrical stretching is not possi ble, the athlete should be cautioned to a void stretching i n a way that crea tes a torquing effect on the pel vis or tha t turns the thigh into a lever arm on the innominate. Consid er, for example, the following stretches carried out by an athlete who su ffers from recurrent right anterior, left posterior innominate rota tion: 1. A left hamstring stretch while standing with the left leg up on a fence rai l or other support (Fig. 7.22A): as the tru nk lea ns progressively forward, the i ncreasing tens ion in gluteus maximus and the hamstrings, in addi tion to the lever effect of the femur, come to exert an un wa nted posterior rotational force on the left innominate. 2. A right quad riceps m u scle stretch in prone-lying or stand ing (Fig. 7.22B; see Fig. 3.38). As the h i p is pro gressively extended, the increasing tension in rectus femoris and i liacus, a n d the lever effect of the femur, all come to exert an unwanted anterior rotational force on the right innominate. Unilateral stretches carried out on the appropriate side can be used effectively to correct a rota tion, but ini tia lly that should only be attempted under the express guidance of a therapist. Intensive stretch ing on one side, in an effort to achieve the same range of motion in a given direction as is possible on the other side, may lead to grief. In the presence of malalignment, a muscle may not be a b le to respond to such a stretch for completely d ifferent reasons. Inability to stretch the hamstrings, for example, may result for the followi ng reasons. Standing hamstring stretch
This is not to preclude the gentle stretching that is often carried out: • •
to relax muscles just prior to a ttempts at mobilization to decrease any residual increase in tension noted after real ignment a nd thereby decrease the chance of the subsequent recurrence of malalignment.
All muscles tha t show an increase i n tone and ten derness should be i ncluded in the routine. Graduated stretching should be carried out three or four, if poss ible even five or six times a day. Stretching a m uscle tendon unit once or twice a day only lets it creep back to its shortened state i n the interval and slows the rate of recovery.
The athlete with a right anterior, left posterior innomi nate rotation may find that, in standing w ith the right leg propped u p on a support, there is a l i m itation when attempting a right ha mstring stretch by bending the trunk forward towards the righ t leg compared with carry ing out the same stretch on the left side (Fig. 7.22C). The right l i m i ta tion comes from the fact that: •
•
tension has been i ncreased by a sepa ration of right hamstring origin a nd insertion (see Fig. 3.38) and probably also by a n automatic i ncrease i n tension (facilitation) anterior rota tion of the right innomina te bone creates a mechanical block to right h i p flexion (see Figs 3.64 and 3.65).
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Figure 7.22
Asymmetrical stretches that result i n a unilateral pelvic rotational force. (A) Left hamstring: posterior rotational. (8) Right quadriceps: anterior rotational. (C) Right hamstring: posterior rotational.
(C)
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Selective st rengthening is unli kely to have an effect on
Sitting hamstring stretch
When the same athlete attempts a hamstring stretch by sitting on the floor, the legs in front and abducted, the limitation of t runk flexion because of 'hamstring tight ness' will be noted on attempts to bend the trunk for wClrds towClrd the left leg (see Figs 3.67 Clnd 3.68). The limitation is actually caused mainly by the posterior rotCltion of the left innominate. Unlike in the stClnding position, when the innominates a re still free to rotate in the sClgittCll plane, the pelvis is now relCltively 'fixed' to the floor in sitting. ForwClfd flexion of the trunk and reaching to the left is literally blocked by the posteriorly rotated left innominate. This limitation is often wrong fully attri buted to Cl t ightness of the left hamstrings , but there is usually 'tightness' from the malalignment related facilitation of the left cCllf muscles, often with a noticeable restriction o f dorsiflexion as well. In contrast, the fact that the right innnominClte is al ready in an ante riorly rotated position allows for increased t runk flexion
this fu nctional weakness, other than pOSSibly to help p revent or slow down the development of any compo nent of disuse wasting w hile malalignment is p resent. Once realignment has been achieved, st rengthening effo rts should also speed up the reversal of any d isuse wasting.
Contraindicated fl exibility exercises There comes a point at which a further limitation o f rClnge of motion is not a matter of lack of flex ibility but one of a mechanical limitation i mposed by the malalignment,
it
limitation that is unli kely to respond
to flexi bility exercises other than to achieve basic 'maintenance' . Reference is made to the asym metrical limitation of both axial and appendicu lar joint ranges of motion associated with mCl lalignment (see Figs 3.3, 3.9, 3 . 1 5, 3.69-3.73). Of interest is the fact thClt, follow ing realignment, there is often an immediate 5-1 0
on that side.
degree increase in the range of motion evident on what
On attempts at stretching in these vClrious positions,
the total range on the former 'bad' side (see Fig. 3.450.
this athlete may feel increased 'tightness' of the ham strings and calf m uscles on one side as compared with the other. He or she may increase efforts to 'stretch out' the tight groups at all costs , unaware of the true reason for the tightness and of the fact that stretching may not only be futile, but also dangeroLis as the muscle-tendon units involved are put at risk of suffering a sprain or even strain.
was previously the 'good' side, which is matched by
Specific contraindicated activities The following activities are contraindicated on the basis that they carry a pa rticula rly high risk of causing malalignment to recUT. These are in general actions that have a rotational component or that create asym metrical stresses on isolated body segments. First are those causing torquing of the trunk, such as
Contraindicated strengthening exercises The bulk of a weak muscle can u sually be improved by increasing the size of the ind ividual muscle f ibres through a selective strengthening of that muscle. The
golf and court sports (e.g. tennis; see Fig . 5.3). Next a re those which cause rotation of the trunk relative to a fixed pelvis: •
(see Fig. 5.28)
malalignment is, however, the result of reorientation and inhibition and may not respond fully, or as quickly as expected, to this a pproach. The wasting of vast us medialis on the side of the externally rotated lower extremity is, for example , more li kely to respond to first re-establishing the symmetry of lower limb bio mechanics by a correction of the mal alignment, followed by appropriate strengthening routines (see Figs 3.53B and 3.54) .
twisting the trunk f rom one side to the other while standing and supporting a weight on the shoulders
atrophy in some muscles seen in association with •
t runk rotation to reach alternat ively towards the right and left leg while seated on the floor with the legs apart (see Fig. 3.67); gymnastic routines with an asymmetrical and/or torqu ing component (see Fig. 5.9); canoeing in the sitting or half-kneeling position (see Fig. 5.2); and wrestling moves forcing rotation of the t runk when the pelvis is p inned to the floor (see Fig. 5.29). Also to be avoided are activities leading to rotation
. The asymmetrical pattern of functional weakness seen so consistently in the lower extremities is determined primarily by factors other than lack of muscle bulk and usually disappears immediately on correction of the malalignmenl (see Figs 3.49-3.5 1 ) .
of the pelvis rel a tive to a fixed trunk, for exa mple, wrestling moves that force rotation of the pelvis when the trunk is pinned to the floor (see Fig. 5.30). Lying supine, hips and knees flexed to 90 degrees and alter nately allowing both knees to d rop o utwards and
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down to the right a n d left side, may be a good way to
Repeated medial and lateral translation with sudden
strengthen the external and interna l obliques but not
stopping and pushing off occurs i n court sports and
without caution and through a limited range u ntil the
sports requiring a cutting or crossing action (e. . foot
pelvis a nd spine are starting to stabilize (Fig. 7.23).
ba ll, soccer and hockey) so these are not recommended.
g
Activities that ca n turn a lower extremity into a lever
LOW-impact aerobics may be a problem, especially if
arm capable of causing a n terior or posterior rotation of
it includes a lot of asymmetrical stretches; sometimes
an innominate are also contraindicated:
even aerobic classes carried out in water may be too
1 . pulling a thigh on to the chest on the side of a recurrent posterior rotation (see Figs 2.32A, 2.76 and 7.1 6); simila rly, l u nges that ca n act like levers when carried out on the wrong side (see Figs 5 . 8 and 7 . 1 8) 2. hip extension (intended for stretching) ca rried out on the side of the anterior, and hip flexion on the side of the posterior, rota tion; both may, however, be flexed or extended together in order to stretch the soft tissues symmetrica lly a n d decrease risk of malalignment
much, particularly i f the athlete gets carried away by the gyrations of a fit (and often younger) instructor and the natural, albeit needless, instinct to keep lip with the rest of the group, a l l of which results in temporarily for getting the risk of recurrence of malalignment. Repetitive actions with or without twisting, such as occur on the golf course a nd driving range, d uring a curling sweep or when bowling, are contraindicated. All these activities should be avoided until alignment is being maintained. Persistence with asymmetrical
J u m p in g alternately from one leg to the other
exercises and activities of the type listed above fre
i ncreases the forces being transmitted through one and
quently results in a recurrence of malalignment follow
then the other 51 joint, as in runn ing, h igh-impact aero
ing correction a nd accounts for a large number of
bics and some gymnastic and 'aquacise' routines.
so-called 'failures of treatment'.
(A)
(8)
Figure 7.23
Pelvis torqu ing on the trunk: supine , alternately letting the flexed hips and knees drop down to the right (A) and
left (8).
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RECOMMENDED EXERCISES AND SPORTS Unless otherwise indicated, the emphasis is again on symmetry d u ring the early period of real ignment, especia l ly for those in whom malalignment keeps recurring. Training should include the types of exer cise outlined below.
Cardiovasc ular (endu ra nce) training The fol lowing a re appropriate in that they a re fa irly symmetrical types of aerobic activity. Swimming
Swimming is one of the best exercises for improving and maintaining cardiovascular fitness because weight bea ring is avoided and the buoyancy and warmth of the water has a relaxing effect on the muscles while the water itself offers some resistance to effort. Rowing
Rowing machines and rowing sports requiring a sym metrical action (e.g. scu l l ing singles and doubles) are suitable as long as the athlete takes care not to twist the trunk and pelvis when getting in and out of the boat and is excused from helping to l i ft the boat in and out of the water, or off and on a transport vehicle (see Figs 5 . 1 3 a nd 5 . 1 4). River and ocean kayaking may also be tolerated, with the same preca u tions.
ential of no more tha n 1 0-1 5 cm to m i nimize the a mount of pelvic torqu ing a nd a ny tilting to alternate sides. For the same reason, the athlete should be warned to go up a flight of stairs only one step at a time and to limit the height of the increasingly popular step-up stations used in circuit training. It should a lso be stressed that the stairmaster is i ntended for a workout of the legs; the arms should be used mainly for ba la nce. Some athletes hang on to the frame so fiercely that they not only do a la rge part of the work w ith the arms, but also introduce a major component of twisting of the tru n k and pelvis with every step, thereby increasing the risk of recurrence of mala l ignment.
Strength training Unless otherwise specified, strengthening exercises (Box 7.4) should be carried out symmetrica lly. Any weight trailling is preferably done lifting bal a nced weights simu ltaneously with both arms and legs. If for some reason strengthen ing is to be l i m i ted to a muscle or muscles o n just one lower l i m b, avoid moving that limb to the point at which it turns into a
Box 7.4 Strengthening exercises •
•
Cycling
Lea ning forwards to hold on to the handle bars may provoke pai n by increasing tension in tight and tender muscles a n d posterior pelvic ligaments. A mountain bike is therefore preferable to one with dropped handle bars. Better still is to start on a reclining bicycle or, if that is not available, a stationary bicycle, sitting upright initially with the arms relaxed at the side and the legs doing all the work. Direct pressure on a tender structure (e.g. the sacro tuberous li ga ment i n sertion, h a m string origin or coccyx) may necessitate additiona I padding (e.g. a pillow or visco-elastic gel seat cover). Also now avail able are seats that have elevations to increase the weight-bearing on the ischial tuberosities, while the groove in between decreases the pressure exerted on the coccyx (see Fig. 5.5B).
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•
•
Stairmaster and stairs
The emphasis on the stairmaster should be on frequent repetitions initially at low resistance, using a step differ-
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Back extensor and abdominal muscles, to improve back mechanics and strength (see Figs 7.4 and 7.6) Pelvic 'core' muscles (Figs 7.24-7.28), exercises for strengthening in particular the elements of the 'inner' (see Figs 2.22 and 2.23) and 'outer' units the posterior and anterior oblique, deep longitudinal and lateral systems (see Figs 2.24-2.27) The quadriceps, hamstrings and other muscles that attach to the pelvic bones, particularly those which can affect the SI joint, the emphasis nowadays being on: - strengthening the muscles i n such a way as simultaneously to re-establish normal sequences of contraction (e.g. posterior oblique system: latissimus dorsi, through the thoracodorsal fascia to the gluteus maximus and finally the hamstrings - see Fig. 2.25A) - strengthening the core muscles initially to re establish stability of the trunk and pelvis (e.g. in strengthening of the pelvic core muscles: the outer ones, such as iliopsoas, piriformis and gluteus maxim us, the inner ones, such as obturators, gemelli and pectineus, and those of the pelvic floor; see Fig. 2. 36) Alternating isometric contractions of the hip adductors and abductors to effect realignment of the pubic bones and, at the same, a symmetrical
strengthening of these muscles (see Figs 7 . 1 5 , 7.28 and 'Self-help techniques', above)
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THE MALALIGNMENT SYNDROME
Figure 7.24 Exercises: one leg extension with co· contraction of the i nner pelvic muscle unit. (From Lee 1999, with permission.)
Figure 7.26 Exercises: prone over a ball; one leg, one arm extension with co-contraction of the inner pelvic muscle unit (for the posterior obliques). (From Lee 1 999, with permission.)
Figure 7.27
Strengthening of one leg extensor in four point kneeling with a balance challenge on a shuttle MVP. (From Lee 1 999, with permission.)
2. actions requ iring reaching or incorporating simulta neous l i fting and twisting. Figure 7.25 Rise and sit with co-contraction of the inner pelvic muscle unit. (From Lee 1999, with permission.)
lever arm capable of causing the rotation of an innom i nate or vertebra. A typical example is hip abductor strengthening carried out in side-lying. The tendency is to bring the uppermost leg towards the ceiling as far as possible, a t the risk o f torquing that side o f the pelvis through the hip and SI joint (Fig. 7.29A). This risk can be avoided by l i m iting a b duction to the horizontal (Fig. 7.29 8) . Attention must also b e p a i d t o avoid ing: 'I . excessive forward bending of the trunk, by bending
a t the hips and knees a t the same time
Pilates exercise Joseph H. Pilates developed a d y na mic form of exer cise that has been very e ffective for those trying to regain 'form and function' and mainta ining rea lign ment. Suffering from asthma, rickets a nd rheumatic fever d uring most of his childhood i n Germany, PiJa tes was greatly i n fluenced by holistic medicine a nd learned to use it to heal himself. W h i le interned in England during World War I a nd tra ining to become a n u rse, he developed Pi lates mat work and a lso a form of resista nce train ing that used springs a ttached to the hospital bed, in order to fa cilitate the rehabi litation of the immobilized patients. After moving to New York
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(A)
Figure 7.28 Strengthening of the lateral system with co-contraction of the inner unit on a FITTER. (From Lee 1 999, with permission.)
(8)
in 1 926, he refined his method by developing over 500 exercises on 10 d i fferent pieces of appa ra tus over the next 60 years. The Pila tes tech nique relies on working out with spri ngs, which can elongate and contract, to resemble muscles. This method is in contrast to weigh t tra ining, which relies on a resistance to gravity. Pila tes is based on the 'six principles': you move your limbs w h ile stabilizing your torso and coord inating you r breathing, to bring an awareness to a l l parts of the body Control - you are in control of your body and of the equipment: you move the equipment, it does not move you Centring the exercise helps you to focus on your 'power centre' in the lower abdominal region Flowing movement you move with grace, ease, coord ination, control, efficiency and enjoyment Precision you perform a few repetitions i n an exacting manner to develop awa reness, efficient form and posture Breathing your brea t h i ng flows with the movements, your consciousness expands, and you feel revitalized.
1 . Concen tration
2.
3. 4. 5.
6.
-
(C) Figure 7.29 Hip abductor strengthening. (A) Excessive abduction, creating a torsional stress on the left innominate through the left sacroiliac joint and symphysis pubis. (8) Abduction limited to the horizontal to decrease torsional strain. (C) I nitial progression with the addition of 0.5-1 kg ankle weight.
-
-
-
-
The method probably has proved so successful i n helping athletes recover from mala lignment because it: • •
•
Uses muscles synergistica lly rather than i n isolation Stretches muscles and i ncreases j o i n t ra nge of motion, as well as strengtheni n g the muscles I m p roves postural al ignment a nd increases coordination, getting the muscles to work efficiently in an effortless and graceful movement
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•
•
THE MALALIGNMENT SYNDROME
Ta kes care to work on the deeper, smaller muscle groups intrinsic to joint stability, thereby strengthen ing the core of the body Looks at the function and strength of the whole body a nd tries to i mprove on this in a graduated manner.
RET U RN TO REGULAR S PORTS Un less otherwise instmcted by their therapist, ath letes should restrict themselves to symmetrical types of exercise u n t i l they have maintained a lignment for at least 2 or 3 months. If malalignment recurs on rein tro duction to regular sports, the programme needs to be re-evaluated to see whether any one component is responsible for the recurrence. A l l that may be needed is to modify or eli minate the particular exercise(s) for a w h i le. I f the athlete absolutely insists on ru nning early on, w h i le malalignment is still recu rring, he or she might try running in water: initially suspended with a life jacket or belt to avoid complete weight-bearing, pro gressi ng to the toes just touch ing the pool floor, a n d eventually running i n more sha l lo w water in prepar a tion for a retu rn to d ry land.
SHOES Weight-bearing problems related to mala l ignment can be compounded by wearing shoes built to accommo date a specific weight-bearing pattern: pronation or supination. Shoes built for a pronator are usua lly con structed with medial reinforcement of the midsole a nd u pper. In addition, some have a wedge of h igher density material tapering from medial to lateral (see Fig. 3.31). These so-called 'double-density' shoes typi cally a lso have a straight last to decrease the tendency towards longitud inal arch collapse. A pair of 'pronator' shoes, when worn by an athlete who presents with one of the 'a lterna te' patterns of malalignment, and the not u ncommon picture of right pronation and left supination, will: • •
•
decrease the tendency towards right pronation increase the tendency towards left supination, because of the straight last and medial reinforcement of the midsole res ult in even less abil ity to d i ssipate shock at the level of the left foot because of the h igh-density wedge a nd the fact tha t the foot is now even more rigid by having been forced into further supination (see Fig. 3.26B).
This type of shoe has been iden tified as one cause of new or ongoing problems in athletes presenting with malal ignment, for example complaints of latera l hip, thigh and knee pain related to excessive tension on the TFL/ ITB complex on the side of the lateral shift of weight-bearing and increased tendency to supinate. It is in teresting to speculate whether this type of shoe might not a lso increase the chance of su ffering ankle i nversion spra ins and stress fractures on tha t side. As mentioned above, there has been a preoccupation with pronation over the past two decades. As a result, those dealing with ath letes are generally more adept at recogn izing pronation than supination. An ath lete presenting with malalignment is there fore much more l i kely to be labelled a 'pronator' even though pronation is occurring only on one side, usually the right, whereas the tendency is towards a neutral position or even supination on the other side, usually the left. This athlete stands a good chance of being prescribed shoes i ntended for a pronator, and risking the consequences noted above. In a few cases, the supination on one side may be so blatantly obvious that athletes are labelled 'supinators' and are prescribed single-density shoes with a curved last to allow for collapse of the longitu d i nal arch. This has the effect of accentuating a ny tendency towards pronation on the opposite side.
FOOT ORTHOTICS A tri a l of longitud i nal arch supports should be consid ered when maJalign ment keeps recurri ng, in the hope that the orthotics will i ncrease the chances of main taining a l ignment. The ath lete may actually report a feeling of increased pelvic stability when wearing orthotics. In a d d ition, a previously weak and 'sloppy' foot and ankle may feel stronger and more stable on weight-bearing, at pu sh-off and when execu ting turns.
ORTHOTICS : WHEN, WHAT AND WHAT NOT Off-the-shelf arch supports These may be adequate but tend to be wider than custom-made orthotics. There may thus be di fficulty trying to fi t them into day shoes, which are usually narrower than ru nning shoes. These supports may, however, be helpful in terms of:
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• •
•
being rea d ily available 'off the shelf' al lowing for a quick assessment of whether or not orthotics would really make a difference in the first place, at a price most athletes can a fford (approximately a tenth of the price of custom-made ones) al lowing for a trial of modi fications to see whether any of these modifications would be worthw h i le i ncorpora ting into a subsequent custom-made orthotic; for example: - il lateral raise of the heel! forefoot section to cou n teract excessive lateral traction forces - right lateral and left medial forefoot raise to create a counterclockwise torquing force in an externally and internally rotated right and left leg, i n order to counter malalignment (see ' Risks associated with orthotics' below).
Custom-made orthotics If the decision is to use custom orthotics, casting should be carried out at a time when the athlete is in il lignment. The m a l a l i g n ment-related asymmetry affects the static and dynamic attitude of the feet, the passive ranges of motion possible at the foot a n d ankle, a n d hence the eventual shape and f i t o f the orthotics (see Figs 3.21 , 3.23 a n d 3.77).
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the side of the externally rotated lower extremity. Aggressive medial posting (e.g. of 4 degrees or more, which equa tes to about 4 m m) actually results i n further torquing of the lower extremity b y a u gment ing, a t foot level, the forces illready tending towards external rotation of that extremity. Torquing forces are more l i kely to occur i f the medial posting is l i m i ted to the forefoot section. By i.ncreasing the a mount of external rota tion, the medi a l posting may fai l t o counteract the excessive prona tion or may actually worsen it. Simila rly, aggressive latera l posting increases the forces promoting in ter n a l rotation a n d m a y a ugment the tendency to supina tion, especially if posting is l i mited to the fore foot section. The problem amou nts to more than just augmenting or perpetuating an abnormal weight-bearing pattern. Increilsing the forces responsible for the pathological internal and external rotation of the lower extremities augments the rotational forces acting on the h i p and SI joint region. In other words, injudicious posting will help to perpetuate the malaJignment. The corol lary is that malaJignment ca n sometimes be corrected with judicious posting that sets up a torquing force to cou n teract the tendency towards i nternal or external rota tion (Fig. 7.30). Ma lal ignment can be corrected from the ground up, so to speak. A combination of a ppropriate
Asymmetrical orthotics worn by an athlete who is now in alignment can result in asymmetrical proprioceptive signals from the sole and exert an asymmetrical torquing effect through the lower extremities all the way up to the pelvis. In other words, these orthotics can cause a recurrence of the malalignment. To prevent this complication, the athlete's a lignment should be checked just prior to the fitting, a nd a cor rection carried ou t if necessa ry. In the same light, all old custom orthotics should be suspect, especially i f there is d i fficulty ma i ntaining rea lignment when they are being worn. They were proba bly cast at a time when the athlete was out of alignment and could now be setting up unwanted asymmetrical forces at foot level.
RISKS ASSOCIATED WITH ORTHOTICS The athlete presenting with malalignment is at risk of fur.ther insu lt with the provision of orthotics tha t are posted or incorporate a medial or la teril l raise. The ten dency is, for example, to provide an increaSing a mo u nt of medial posting in an attempt to counteract the pronation that is sometimes so blatantly obvious on
Figure 7.30 An example of a simple approach using a forefoot posting of orthotics for the correction of malalignment: right lateral posting to counteract external rotation; left medial posting to counteract internal rotation.
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postings, for example, may result in the correction of a rotational malalign ment: 1 . A lateral posting of the forefoot on the side of the externally rotated lower extremity would set u p torquing force towards internal rota tion. 2. A med ial posting of the forefoot on the side of the i n tern a l ly rotated extremity would have the . opposite effect. ]f the a thlete presenting with an upslip or rota tional malalignment has been mistakenly labelled a 'pronator' because pronation or the inward collapse of a heel cup is so blatantly obvious on one side, the subsequent pro vision of orthotics having a medial raise bilaterally i n the forefoot section w i l l serve only to increase the forces promoting supination that in fact exist on the other side (see Fig. 5.33). On the pronating side, they may improve medial support to counteract pronation, but they could also result in a further, unwanted, external rotation of tha t lower extremity. The athlete may present with an aggravation of previous symptoms, for example: •
on the supina til'lg side: increased pain from the la teral
•
structu res (e.g. TFL/ ITS complex), which are now put under even greater stress on the pronating side: problems reJating to increased external rotation, knee valgus and stress on the med ial aspect of the knee. It must also be remembered that the weight-bearing pattern may change once the malalignment has been corrected.
This change is most dramatica lly evident in children, who are usua l ly referred for assessment because they have been noted to pronate excessively and / or d isplay marked in-toeing or out-toeing. Again, the pronation, in-toeing or out-toeing is often actually unilateral, or worse on one side than the other, in keeping with the presence of a m a l a l ign men t. On realignment, the tendency towards pronation w i l l usually be markedly decreased or may no longer be d iscernible: the pattern has become one of neutral weight-bearing or may have completely reversed to become one of symmetrical supination. In fact, a surprising 5-1 0 % of athletes who were seemingly pronating on one or both sides when out of alignment end u p w ith a neutral to slight supi n ation pattern fol lowing correction (see Fig. 3.29). Reorientation of the lower extremities may a lso reduce any in-toeing or o u t-toeing. [t is therefore very i mporta nt to reassess the gait, al ong with a new pair of shoes worn regularly for 2-3 months a fter the correction, a n d to recommend a ppro-
priate changes to the orthotics and footwear if the weight-bearing pattern has changed. Should the athlete now have a neutral to supination pattern, for example: •
•
•
remove any medial posting if there are ongoing signs or symptoms consistent with lateral traction forces consider the addi tion of a lateral raise if lateral traction signs or symptoms have fai led to settle replace rigid or semi-rigid orthotics with a soft-shell type and recommend shoes with a curved last and 1 5-20 mm single-density mid sole cushion to improve shock absorption at foot level.
WHEN MALALIGNMENT CA NNOT BE CORRECTED Orthotics may still play a role when the correction of malalignment just cannot be ach ieved or maintained. They may provide a n u nexplai ned sensation of increased pelvic stability, felt sometimes even when the a t hlete is still out of alignment. More easily explai ned is the ability of the orthotics to decrease some of the bio mechanical stresses attributable to the malalignment.
Min i m i zing stresses caused by apparent leg length difference When malalignment cannot be corrected, it wou ld seem appropriate to provide a lift on the side of the apparent or functional 'short' leg when standing. This will decrease stress, particularly on the lumbosacral region and the spi ne, by decreasing the pelvic obliquity and the compensa tory curva tures of the spine. [t should, however, be remembered that sacra l rotation can com pensate for up to 5 mm of LLD. It is therefore more i mportant that a l i ft correct any resi d ual obliquity of the sacral base rather than obliquity of the pelvis per se. The lie of the sacrum is preferably assessed on a sta nding an teroposterior X-ray view of the pelvis. If the sacral base is level, no l i ft is ind icated, even though there may be persistent obl iquity of the pelvis (see Fig. 3.83). lf no X-ray is avai lable, a tria l with a l i ft may be worth w h il e . The functional LLD should be measured while sta nding, from the iliac crest, anterior superior i liac spine (AS[S) or other pel vic land mark down to the floor. A safe rule is initially to limit cor rection to 5 mm, using a simple heel lift ( Fig. 7.31 A). There are two possible ou tcomes to consider. The 5 mm lift is well tolerated. [n this case, consider i ncreasing the l i ft by another 5 mm every 2-3 months until the pelvis is level, or as tolerated. It usually takes that long for soft tissue ad aptations to occur. If the total d ifference is 1 cm, a hee l lift or a simple partial or
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(A)
359
(8)
Figure 7.31
Progressive heel lifts. (A) A simple 5 mm heel lift, used for the initial correction of a d iffere nce of 5 mm or more. (8) A 10 mm heel lift, tapering to 5 mm in the forefoot.
full-length insole, 10 mm high at the heel a nd ta pering down to 5 m m a t the forefoot, may su ffice (Fig. 7.31 B). Any ad d itional correction required usually has to be added to the heel and sole of the shoe. The lift is not tolerated. The soft tissues may have changed so much over the years as a result of the func tional LLD that they can no longer adapt to the bio mechanical cha nges imposed by the lift. Alterna tely, levelling of the sacra l base may already be compensat ing, and the a dd ition of the lift now creates unwa nted stresses by un levelling the base, something that could be confirmed radiologically.
Medial or lateral posting of an orthotic or shoe Posting shou l d be guided by ongoing signs or symp toms that can be related to the altered pattern of move ment and weigh t-bearing. The intent is to decrease the tension on stmctures that a re tender as a resu lt of being put und er i ncreased stress from persistent malalignment. This may call for med ial posting on one side to cou n teract stress from prona tion, lateral posting on the other to counteract traction a ttributable to a neutral or supination pattern. It is best to start with a posting of no more tha n 2 degrees - approxi mately 2-3 mm - and eva luate its effectiveness in 3-4 weeks. Further increases shou ld be guided by the response to temporary posting with moleskin or adhe sive felt, added one layer at a time at 2-3 day interva ls.
Always be aware that the posting may cause increased torquing of a lower extremity. As a n alternative, or in add ition to posting, consider reinforcing the heel cup of the shoe med ially or la ter ally to counteract excessive pronation or supination forces respectively (Scha mberger 1 983).
WHY DO ORTHO T ICS HEL P TO MAINTAIN ALIGNMENT ? Some of the possible mechanisms to consider i nclude the following. First, an orthotic increases the stability a t foot level by provid ing contact for weight-bearing across a la rger part of the sole. Pressure is therefore distributed more evenly across the entire area provided by the orthotics (Fig. 7.32A). Contrast this with the kidney-shaped i m print of a bare foot in sa nd: weight-bearing is primarily at the heel, l a teral sole and ba ll of the foot (Fig. 7.32B). Second , orthotics can be used to decrease any per sistent tendency of the feet to roll inwards into prona tion, or outwards into supination, once the athlete is in align ment. They may thereby decrease any torquing forces on the legs that coul d cause a recurrence of rota tional malalignment, especially if these forces are in any way asym metrical . Third, b y provi d i ng support over the ma j or part of the sole of the foot, the orthotics i ncrease both the amount a n d the sym metry of the sensory in put from the surface of the sole. Sti mula tion of the cutaneous proprioceptive receptors has been postulated to resu l t i n pain control. There a r e three neurophysiological mecha nisms currently in vogue (Box 7.5). There are several end results of these mechanisms, as affected by the increased cutaneous input from the larger weight-bearing a rea a n d more uniform pressure d istribution on the orthotic, including the following: 1 . A decreased perception of pain results i n a reflex relaxation of the muscles. This could d ecrease the recurrence of mala lignment by decrea sing or actual l y eliminating any asymmetry i n muscle tension. 2. The barrage of proprioceptive signa ls could also decrease excitatory input to the muscle spind le, a ga i n resu lting in a reflex relaxation o f the muscles in the i mmediate area.
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Box 7.5 Theories of pain modulation •
•
•
(A)
(B)
The gate theory of Melzack & Wall (1 965) Pain signals travel along the small-diameter, unmyelinated and slow-conducting C-fibres. Proprioceptive signals, in contrast, travel along large-diameter, myelinated and fast-conducting A-fibres. Signals from both pass through the substantia gelati nosa in the dorsal horn of the spinal cord before ascending to the brain. A barrage of proprioceptive signals arriving by way of the A-fibres may cause the substantia gelati nosa to block the signals arriving through the C-fibres. This effectively 'closes the gate', preventing pain signals from ascending further in the spinal cord and reaching the brain. The central biasing mechanism (Mayer & Liebeskind 1 974, Melzak 1 981 ) Pain signals ascending in the spinal cord can be prevented from reaching the brain if their transmission is subjected to the powerful inhibitory influence of the raphe nucleus in the brain stem. Cutaneous stimulation is one mechanism known to trigger activity in this nucleus, which in turn 'closes the gate' to fu rther ascent of pain signals. Release of endorphins (Pomeranz 1 975) The stimulation of cutaneous touch and pressure receptors results in the release of endorphins from the anterior pituitary gland.
3. The proprioceptive sign key fea tures 233-234 figu re-4 position 65, 66 figu re-4 test 69-70, 70 figure skating iliopso�s m u scle injury 1 44 l i m i til tions in h i p adduction a ffecting 1 4 1 set' also skil ting FITTER 355 fixator devices 378 'f1ilmingo' position 65, 66 flexibility exercises, contraindicated 351 flexion forward see forward flexion side see Side-bending Side-bend ing �nd rotation (FSR) 6 1 , 95, 242 flexion �nd extension tests 74-79, 76 leg length d i fference 75, 77 l umbosacral , normal 77 pel vic, norma l 76 rotationill m�I�l ignment 77-79 sacroili�c, norn1�1 77 sacroil iac joint u ps l i p 75, 77 foot a l ignment sec feet footba llcr's il n k le 1 80 foot extensor tendonitis, swi.mmers 29 1 foot orthotics sec orthotics footweil r see shoes; shoe we�r foramen magnum, craniosacral release method 1 52 force closure, s�croiliac joint 22-27, 23 anterior oblique system 82, 84 eval uation 27 d uring gait cycle 27 inner u n i t / core muscles 23, 23-24, 82 load transfer ability evaluation 82, 84 outer unit muscles 24, 24-27 see also 'outer unit/ core' muscles form closu re, sacroi liac joint 22, 23 eval uation 27 d uring ga it cycle 27 joint compression 82 load trilnsfer a bi lity ev�luiltion 82 forward flexion �bnorm�1 sacral function test 75 biomechilnics (st�nd i ng) 1 8, 18, 1 9 curva t u re o f spine exa mination 58 l i ne of gravity change 30, 31 pain, scu l l i ng 272 rota tional m a la lignment 77, 78 slump test 1 69, 1 69-170 trunk 1 8, ] 8, 1 9 side-to-side d i fference 1 69, 1 69-170
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forw�rd stretch, seated 1 67, 1 6 8 Fosbury f l o p 265, 266, 266-267 Fryette, laws of 95, 99 FSR movement pattern 61 , 95, 242 functional tech niques 390-39-1 , 392 b� l a nce il nd hold method :>'11 counterstril i n method 340, 347, 391 d y namic method 391 see a/so contract-relax method function ,, 1 tests, for millalignment 73-84, 74 flexion/extension sec flexion and extension tests i psil�teral k i netic rota tional sec G i l let test load transfer a bi l i ty eva luation 82-84, 83, 84 str�ight leg raising sec straight leg r� ising test G G�ensJen's test 70-71 , 71 ga i t assessment in horses 307, 308 asymmetry of lower extremity orientation 1 1 0 cha nges i n m a l � l ign ment xii, xi ii, 1 89-1 9 1 cycle (norma)) 27, 28 examination 1 89 instilbility of isolilted joints 1 89-1 9 1 normal 20, 20, 27, 28 pel vic rotation 7 3 , 1 4 , 1 5 s,lCroiliac joi n t movement 27, 2 8 varus angul a tion o f foot and 1 1 7, 1 20 vertebril l rotMion 'J6 gastrocnemius effects of tigh tness 1 70 mala l ign ment-related increased tension -1 65 gastroenterology, m�lill ignment impl ications 234-240 gastrointestinal symptoms, malal ignment c� using 234, 234-235, 237 g�te theory of pain 360, 362 genitourinmy system, symptoms linked to millalignment 234, 234-235 genu va lgum 1 39, 1 63 cycling 250, 251 m�lalignment-related i n crease in muscle tension 140 sec also knee, valgus tendency gen u varum 1 22 mala l i gn ment-related increase i n muscle tension 140 sk�ting and 278 G i l let test (ipsil�tera l kinetic rota tional test) 74, 79, 79-S2 a n terior rota tional test 79 normal 8 1 balance problems 1 8 7
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I N DEX
Gillet test (ipsilateral kinetic rotational test) (Contin ued ) causes of positive tests 79, 82 clinical correlations 82 completely abnormal (51 joint locking) 79, 8 1 pilrtia l l y abnormal 81-82 posterior rota tional test 79 abnormal 79 normal 79, 80 'giving way: of joi n t 2 1 , 2 6 ankle (tibiotalar joint) 1 90 h i p and knee 1 89 glucose, hypertonic 369 gluteus maximus 240 muscle energy technique ad va n tages 336 for a n terior rotation 328, 329, 330-331 tightness, false-positive sitti ng-lying test 54 gluteus med ius 1 37 mil la l ign ment-related i ncreased tension 1 65 reflex i n hibition 2 6 gluteus minimus 1 37 malalignment-related increased tension 1 65 reflex i n hibi tion 26 gol f 260-261 back pain 261 contraind icated activi ties 352 excessive rotation into pelvic/ thoracic restriction 246, 246-247 malal ignment-related problems 260-261 real ignment benefits 261 rota tional malali gnment effect on thoracic spine 1 01 swing, movement 260 typical case history 261 vertebral m a l rotation effect 244-245 gol fers' elbow (med ial epicond y l itis) 1 02, 2 1 6, 372 'goofy foot' slalom 295, 296 'goofy foot' snowboa rd ing 288, 290 gracilis m uscle, inhibition 90 gravi ty, line, forward bending 30, 31 greater sciatic foramen 2 1 3, 2 1 7 groin injuries, compression shorts for 363-364, 364 groin pa i n 1 28, 234, 237, 239 groin stra in, court, racquet and stick sports 248-249 'Grostic' technique 395-396 Cunn model 398-399 gymnastics 262-265 apparatus use 263, 264, 265 d ismount