The Effects of Pronation Distortion Syndrome and Solutions for Injury Prevention

January 23, 2014 by Leave a Comment

Issues starting at the foot and ankle can cause distress to other regions of the body. Read this article by Scott Lucett, MS, NASM-CPT, PES, CES who is a Senior Research Director for the National Academy of Sports Medicine for great insight on this topic! Then come see us at San Diego Sports Physical Therapy for great exercises. 619-756-7500

Dysfunction at the foot and ankle complex can lead to a variety of musculoskeletal issues in other regions of the kinetic chain that can eventually lead to injury. In this article, we’ll review the common postural distortion pattern, Pronation Distortion Syndrome, its effects on the kinetic chain, and corrective solutions to decrease injury risk.

Introduction

Pronation distortion syndrome is characterized by excessive foot pronation (flat feet) with concomitant knee internal rotation and adduction (“knock-kneed”). This lower extremity distortion pattern can lead to a chain reaction of muscle imbalances throughout the kinetic chain, leading to foot and ankle, knee, hip and low back pain.

It has been shown that excessive pronation of the foot during weight bearing causes altered alignment of the tibia, femur, and pelvic girdle (Figure 1) and can lead to internal rotation stresses at the lower extremity and pelvis, which may lead to increased strain on soft tissues (Achilles tendon, plantar fascia, patella tendon, IT-band) and compressive forces on the joints (subtalar joint, patellofemoral joint, tibiofemoral joint, iliofemoral joint, and sacroiliac joint), which can become symptomatic (1,2). The lumbo-pelvic-hip complex alignment has been shown by Khamis to be directly affected by bilateral hyperpronation of the feet. Hyperpronation of the feet induced anterior pelvic tilt of the lumbo-pelvic-hip complex (3). The addition of 2-3 degrees of foot pronation lead to a 20-30% increase in pelvic alignment while standing and 50-75% increase in anterior pelvic tilt during walking (3). Since anterior pelvic tilt has been correlated with increased lumbar curvature, the change in foot alignment might also influence lumbar spine position (4). Furthermore, an asymmetrical change in foot alignment (as might occur from a unilateral ankle sprain) may cause asymmetrical lower extremity, pelvic, and lumbar alignment, which might enhance symptoms or dysfunction. An understanding of this distortion pattern and its affects throughout the kinetic chain becomes particularly important for recreational runners and walkers as the accompanying stressors to the soft tissues and joints can lead to Achilles tendonitis, plantar fasciitis, IT-band syndrome, and low back pain.

Assessment

When assessing for pronation distortion syndrome, both static and dynamic assessments can be done. When performing either a static or dynamic assessment, have the individual take their shoes off and make sure you have the ability to see their knees as well. During a static assessment, from an anterior and posterior view, look to see if the arches of their feet are flattened and/or their feet are turned out. When performing a dynamic assessment, such as the overhead squat, look to see if the feet flatten and/or turn out and if the knees adduct and internally rotate (knee valgus). These compensations can also be assessed both from an anterior and posterior view. For many, it’s easier to see excessive foot pronation from a posterior view in comparison to an anterior assessment, so assessing in both positions can help in confirming your findings.

Corrective Exercise Strategies for Pronation Distortion Syndrome

Functionally tightened muscles that have been associated with pronation distortion syndrome include the peroneals, gastrocnemius, soleus, IT-band, hamstring, adductor complex, and tensor fascia latae (TFL). Functionally weakened or inhibited areas include the posterior tibialis, anterior tibialis, gluteus medius and gluteus maximus. Following NASM’s Corrective Exercise Continuum programming strategy can help address these muscle imbalances that may be contributing to the distortion pattern (5). First, inhibit the muscles that may be tight/overactive via self-myofascial release. Key regions that should be addressed would include the peroneals, gastrocnemius/soleus, IT-band/TFL, bicep femoris and adductor complex.

The next step is to lengthen the tight muscles via static stretching. Key muscles to stretch include the gastrocnemius/soleus, TFL, bicep femoris and adductor complex. Hold each stretch for a minimum of 30 seconds perform 1-2 sets of each stretch.

Once the overactive muscles have been addressed, activate the underactive muscles. Key areas to target with isolated strengthening are the anterior tibialis via resisted dorsiflexion, posterior tibialis via a single-leg calf raise, gluteus medius via wall slides and gluteus maximus via floor bridges. Perform 1-2 sets of 10-15 repetitions.

Finally, perform an integrated exercise to improve muscle synergy to enhance neuromuscular efficiency and overall movement quality. An example integration exercise would include a multiplanar single-leg balance reach while maintaining neutral foot and knee alignment. Perform 1-2 sets of 10-15 repetitions.

Summary

Pronation distortion syndrome is a common lower extremity postural distortion pattern that can lead to other movement dysfunction patterns throughout the kinetic and ultimately injury. By incorporating static and dynamic assessments of the foot and ankle complex can help to identify this distortion pattern. Once identified, following a systematic corrective exercise strategy can help to improve functionality and movement quality, leading to decreased risk of injury.

References

Powers, C.M. (2003). The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. Journal of Orthopedic & Sports Physical Therapy, 33:639-46.
Powers, C.M., Chen, P.Y., Reischl, S.F., & Perry, J. (2002). Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot & Ankle International, 23:634-40.
Khamis, S., & Yizhar, Z. (2007). Effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture, 25:127-34.
Levine, D., & Whittle, M.W. (1996). The effects of pelvic movement on lumbar lordosis in the standing position. Journal of Orthopedic & Sports Physical Therapy, 24:130-5.
Clark, M. C., & Lucett, S. C. (2011). NASM Essentials of Corrective Exercise Training. Baltimore, MD: Lippincott, Williams and Wilkins.
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The Yoga Injury Debate

January 7, 2014 by Leave a Comment

If you do yoga, do you experience any injuries? Come see us at San Diego Sports Physical Therapy to get back on track,

To yoga or not to yoga seems to be a common question for individuals. The debate is heating up in both trade and consumer publications, each explaining various relevant perceptions. The controversial topic has had the yoga community and advocates in upheaval about the negative perceptions that some have about yoga.

Although yoga has many advanced “acrobatic-like” qualities, classes offered in most health-club settings do not promote or practice advanced postures. In addition, yoga, like any other form of exercise or athletic pursuit, can pose a risk of injury. Awareness, acceptance and proper training are the keys to preventing injury.

What Causes Yoga Injury?

Injuries occur for a wide variety of reasons; in some cases, the cause may be unknown. Injuries may occur on the point of action, while other ailments creep up over time, with no explainable cause as to why the pain or injury occurred.

Some individuals argue that specific yoga poses cause injury due to a joint’s vulnerability in the pose, while others believe advanced postures are the primary cause of injuries.

While there is no single cause of yoga injuries, here are some common reasons why they often occur:

-Pushing beyond one’s physical capabilities to more advanced postures
-Forcing the body to stretch beyond one’s flexibility level
-Not being mentally prepared, or stable, for advanced postures
-Striving for perfection in poses

The Flexibility Spectrum

The occasional yoga participant potentially faces the greatest risk of injury due to a restricted range of motion in the joints. When there is a lack of mobility, other joints may try to compensate, which may result in overstraining, overuse or injury.

On the other hand, many yoga instructors may have experienced injuries due to having a highly flexible body. Having muscles that are too lax or flexible may make the individual more likely to overstretch the ligaments and tendons.

Ideally, one should be located near the center of the flexibility.

Personal Flexibility Awareness

Every body is gifted with a natural ability. Just as athletes are “born” with genetic gifts that, along with considerable training, enable them to excel in their sports, some individuals are naturally more flexible than others. In addition, some individuals who have practiced yoga, gymnastics or dancing from a young age are flexible and strong enough to perform advanced postures in their adult years.

Individuals who start a yoga practice after the age of 30 may or may not progress to advanced postures. It can sometimes take years to get the mind and/or body in an advanced state. Progressing yoga poses is similar to progressing traditional exercises, requiring one to build a solid foundation before moving toward the advanced state.

Wanting to look and perform like others in class, however, can increase the risk of moving beyond one’s current flexibility.

Acceptance of One’s Ability

Mass marketing yoga advertisements show yogis effortlessly performing beautiful postures. This makes us strive to or become curious about how to perform these poses. Generally, this is the point where we force ourselves to move, bend or stretch beyond our capability.

In yoga, this is called the ego—the driving force that wants to shine and succeed, or the voice that tells us we are not good or strong enough. Yoga instructors and attendees need to step off their mat and analyze their abilities and embrace their strengths. Acceptance is what keeps us satisfied in our practice and trusting ourselves on when to progress a given posture.

For example, a person may have a lack in spinal extension, which can make back-bending postures challenging, especially advanced spinal extension movements. However, this person may have exceptional wrist and forearm strength to perform beautiful inversions. This does not mean she has to avoid backbends; rather, she must understand and accept her limits and capabilities without forcing the spine into a foreign position.

What Comes First—the Fear or the Posture?

When progressing to advanced postures, many yoga instructors promote overcoming physical fear through advanced postures. For example, if someone has had wrist issues and a fear of re-injuring that joint or a fear of falling, one can perform a handstand (with or without wall support) to overcome the fear. Although this notion is successful for some, it poses another question of whether or not an advanced posture should be the driving force to overcome fear.

In yoga, as in many other sports, one must truly train the mind and be confident in one’s ability before progressing to advanced states. A baseball pitcher or tennis player must be mentally sound and visualize that perfect pitch or serve. If an athlete doubts his or her abilities, the majority of the time that pitch or serve will be unsuccessful or erratic. The same concept applies in yoga.

When performing a handstand, if one thinks, “I can’t do this. I don’t want to fall. I’m scared,” he or she is not mentally prepared yet. When the mind flutters, the physical body may weaken or fall, which can result in strain or injury.

Final Thoughts

Though some individuals have been seriously injured in yoga, it is best for practitioners to instruct various levels of yoga poses when working with the general population. Many yoga poses are not appropriate for everyone and instructors should understand which higher-risk asanas should be modified.

Neither the student nor the instructor should fear yoga. Education and awareness are essential for those who want to perform to perfection or advanced postures. Many students have that driving force to push forward, but it is through clear communication that we can educate them about the potential risks.

With various body types and mixed-level classes, the requirements are higher for instructors to know the anatomy and potential risks of each pose. When in doubt, teach the basic and common poses, such as Warriors, downward facing dog and balance poses.

References

American Academy of Orthopaedic Surgeons (AAOS) (2012). Yoga Injury Prevention.

Kerr, Z. et al. (2010). Epidemiology of weight training-related injuries presenting to United States emergency departments, 1990 to 2007.The American Journal of Sports Medicine, 38, 765- 771.

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Why Your Muscles Shake During a Hard Workout

December 31, 2013 by Leave a Comment

If you think you may be straining yourself during a workout, take a look at this article by Jay Cardiello. Then come see us at San Diego Sports Physical Therapy to get your work outs under control.

Pushing yourself during a workout is never a bad thing, and going so hard that your muscles start to shake is certainly a sign that you’re at your max—but your body may also be trying to tell you something. While many people pass this off as a simple sign that they’re out of shape and a majority of my fitness colleagues would agree that this trembling is not a great cause for concern, it could also lead to injury if you’re not careful to use proper form.

Let’s explore why your muscles may quiver during a barre class, Pilates, strength workout, or other type of exercise—and what to do about it.

1. Inadequate sleep. If you are heading into a cardio or strength training session feeling lethargic or lacking a good night’s rest, you will probably experience tremors at some point in your routine. [Tweet this fact!] The body continues to grow and heal when you get the proper amount of sleep. Disrupting this can cause your muscles to stay in a catabolic-like state. If you’ve been skimping on sleep, I recommend you skip the gym and stay in bed (if you work out in the morning) or head to bed (if you’re a p.m. exerciser).

2. Going to extremes. With fitness crazes like CrossFit and endurance events like Tough Mudder becoming the staple in mainstream fitness, people are really pushing themselves to the extremes these days. However, take caution and implement mandatory rest days into your fitness routine. Check out my last blog for the proper way to rest so you can keep up a sustainable workout routine and stop the shakes.

3. Too new, too much, too soon. If you try a new fitness class or jump into a new routine, at some point during your workouts you may feel your body start to wobble because working different muscles than you’re used to may be too much, too soon. While it may not be a cause for great alarm, it’s probably best to lighten up. You could place stress on other parts of your body in order to compensate for weaker muscles, which may cause injury. For example, if it’s your first time performing burpees, by the fourth or fifth one your legs may start to shake. Instead of resting, you decide to continue but with bad form, which can strain your lower back. Bad idea.

4. Dehydration. Your workout can be one of the best indicators of whether or not you are hydrated. When your body is low on water, your muscles and connective tissues have difficulty performing what they are meant to do, as improper hydration can cause an imbalance of your electrolytes, which are involved in muscle contraction. [Tweet this fact!] I recommend drinking half of your body weight in ounces daily. Remember, if you’re thirsty, you’re dehydrated.

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