Knee valgus – there are many misconceptions surrounding this motion.
Knee valgus is a normal physiologic motion and should take place in a walk/run/squat/lunge – it is a triplane motion consisting of knee flexion, abduction and internal rotation. Tradition describes staying away from a valgus moment during rehab and training; which isn’t wrong, however, the question for me is: can it be more right? Just take a look at any traditional ACL prevention or rehabilitation program – knee valgus typically isn’t avoided. However, notice what happens when a basketball player grabs a rebound, or swing sport athlete wind up for a serve. Valgus!
Knee valgus should occur with foot strike and similar to supination and pronation, it is a triplane motion. The knee feels flexion, abduction & internal rotation when the foot hits the ground and momentum, body weight as well as gravity drives us towards middle; and must be controlled by the body, because if it isn’t, injury will occur.
Injuries occur when forces are presented to the body that the body can’t handle (i.e. the Goldilocks Principle – too much motion, not enough motion, motion at the wrong time). If knee valgus isn’t trained logically, sequentially and at the neurological threshold of the individual, how can it be expected to REACT and CONTROL the motion when it is forced into that position?
What are your thoughts on knee valgus? How do you rehab, recondition and train it?
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**FOOT STRENGTHENING**In my experience, those with bottom of the foot pain often have weak intrinsic foot muscles. Below is a progression beneficial for some people with foot weakness. Top left, the name of the game is to move the big toe independently from toes 2-5, & vice versa. Those that have foot pain tend to have difficulty with this movement. If the toes can't be moved independently, IMO it's because a lack of representation in the somatosensory cortex, which can be improved via neuroplasticity. the objective is to build connections with the brain for this region. Top right, again, the objective is to move the toes independently, this time with resistance. Be sure to not extend from the distal interphalangeal joint when flexing the toes, rather keep them neutral and focus on motion from the proximal interphalangeal joints.Bottom left, integrated toe strengthening. With this movement, the be sure to drive the pelvis forward when plantarflexing. This is exaggerating what the foot, knee and hip would be doing, when they'd be doing it, relative to the 2nd phase of gait. A verbal cue is to hinge from the shoulders, rather than bending the elbows when driving forward in space. Bottom right, integrated foot strengthening progression, using suspension straps. This movement, like the preceding, is more on the integrated spectrum, and requires much more core stability to properly perform. Notice how wobbly my left leg is compared to my right. It's not a coincidence that I also have some bottom of the left foot pain. progressions include performing on a blue airex padAre you strengthening the intrinsic muscles of the foot in isolation and integration? if not, do it! like it or love it then show it!
Posted by Adam Wolf PT on Wednesday, November 16, 2016
In conjunction with my previous post about “hurty feet” and the importance of toe independence, here are four exercise progressions that I enjoy using in my day-to-day practice.
Top left (ISOLATION): Move the big toe independently from toes 2-5, and vice versa
In my opinion, if the toes have difficulty moving independently, it is due to a lack of representation in the somatosensory cortex.
This can be improved via neuroplasticity with the objective being building connections to the brain for this region.
Top right (ISOLATION): Move the toes independently, with resistance
It is important to avoid extending from the distal interphalangeal joint when flexing the toes.
Keep the distal interphalangeal joints neutral and focus on creating motion from the proximal interphalangeal joints.
Bottom left (INTEGRATION): Integrated toe strengthening
Drive the pelvis forward while plantarflexing.
A verbal cue I find helpful when teaching patients how to drive the pelvis forward in space would be to “hinge from the shoulders, rather than bending the elbows”.
This exercise exaggerates the motions that occur at the foot, knee and hip in the 2nd phase of gait.
Bottom right (INTEGRATION): Integrated foot strengthening with suspension straps
Due to the integrated nature of this movement, core stability is required to properly perform.
Notice the difference between my left and right legs as I go through this movement – my left leg is more wobbly. It is no coincidence that I have bottom of the foot pain in this leg!
To take this movement up a notch, perform it on an airex pad.
Strengthening the Flexor Digitorum Brevis
Since a conversation with Tom Michaud about the feet a couple weeks ago on #2movementguysandaguest I've come to appreciate the importance of the flexor digitorum brevis. for those with "hurty feet". Some takeaways include:1. press the toe tips into the ground during exercise & also while walking (during acute issues). This will take the pressure off the metatarsal heads & distribute the weight better throughout the transverse arch. it will also more specifically towards the flexor digitorum brevis (FDB)–this cue has been helpful for me, especially for people that curl their toes when trying to strengthen, which is a reason I don't love towel & marble toe grabs.The FDB is one of those intrinsic 'force producing muscles' that often is important to strengthen with a hurty foot. 2. Tom described the importance of strengthening the FHB at the back phase of gait, particularly as the heel rises. At heel rise, the calcaneus inverts & the forefoot (FF) relatively planter flexes (PF) & everts, assisting in the windlass to provide stability to the midfoot for propulsion. This exercise does just that, as the rearfoot is inverted & PF and the (FF) is relatively everted. a towel is placed under toes 2-5 to extend them, which would occur at this time & also under the heel to invert it, which occurs as the heel lifts. I start w/ isometric holds for 10s and progress to 60s. Do you strengthen the intrinsics? if so how? if you like this please share, comment and like :)#realmovement #integratedmotion #motorcontrol #flexordigitorumbrevis #hurtyfeet #hurtyfoot #plantarfascitis #footpain #physicaltherapy #massagetherapy #chiropractic #footexercises
Posted by Adam Wolf PT on Wednesday, November 8, 2017
Since a conversation with Tom Michaud about the feet a couple weeks ago on 2 Movement Guys and a Guest (Tom’s episode coming soon!). I’ve come to appreciate the importance of the flexor digitorum brevis (FDB) in foot pain. Some takeaways from our conversation include:
“Press the toe tips into the ground during exercise and regular walking.”
This takes pressure off the metatarsal heads and distributes weight better throughout the transverse arch (specifically towards the FDB).
The FDB is one of the intrinsic “force producing” muscles that are important to strengthen in a patient presenting hurty feet.
I find this cue helpful, especially for patients that curl their toes during toe strengthening exercises (which is a reason why I don’t love towel & marble toe grabs).
“Strengthening the FDB in the back phase of gait, particularly as the heel rises.”
At heel rise, the calcaneus inverts and the forefoot relatively plantarflexes & everts, providing stability to the midfoot for propulsion.
The exercise in the video above accomplishes that by inverting and plantarflexing the rearfoot and everting the forefoot.
The towel placed under toes 2-5 mimics extension in the toes and the towel placed under the heel inverts the heel, both of which happens as the heel lifts.
Start with isometric holds for 10 seconds and progress to 60 seconds.
Taping For Plantar Fasciitis
Objective:
Tape the bottom of the foot (create a heel cup) to support loading when the foot hits the ground and during the toe off phase.
Are you strengthening the intrinsic muscles of the foot in isolation and integration? If not, do it!
Plantar fascitis, or what I like to refer to as “hurty feet” is something many of us deal with, and something I see a lot of in my clinical practice.
While there can be many reasons why one gets hurty feet, most often the issue lies with the inability of the midfoot (defined as the intersection between the forefoot and rearfoot) to lock up for the second phase of gait. As my friend and mentor Gary Gray says, the foot needs to be a mobile adapter when it enters into the ground and a rigid lever when the foot is behind in preparation for push off.
Anatomically the foot is made up of 26 bones, 33 joints and 34 muscles, which means a beautiful synchrony must take place in order for optimal function.
Clinically, I often find that people with hurty feet have weak intrinsic muscles that start and end in the feet. In a situation like this, the multi-joint muscles end up having to do the job of the single joint muscles, resulting in dysfunction and pain. I’ve found that working to strengthen the muscles at the bottom of the foot is a great place to start in situations like these. Of course, the question then becomes which exercise to utilize in treatment. In the video below, I discuss:
The importance of toe independence
Building somatosensory cortex space through short foot progressions and taping
Exercises: Big toe flexion; 2nd-5th toe flexion using a theraband
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In Dealing with Hip Pain: Part 1, we talked about banded distractions and mobilization strategies using a True Stretch. Today, we’ll be going over Controlled Articular Rotations (CARs) in various positions – so that you can regress/progress the exercise to suit your patient’s ability and comfort level. At the end of this post, I’ll show you how I utilize CARs with my patients.
Standing hip CARs
Key points:
Preparation: Isometrically engage the whole body – think “bracing the gut for a punch”
Start: Pull moving leg into hip flexion, followed by hip abduction, hip internal rotation and hip extension. Lower leg back to start position.
Finish: Reverse the motion by performing hip extension and external rotation, followed by hip adduction into flexion. Lower leg back to start position.
Quadruped hip CARs
Key points:
Quadruped position: Knees under hips, hands under shoulders
Start: Pull moving leg into hip flexion, followed by hip abduction, hip internal rotation and hip extension. Lower leg back to start position.
Finish: Reverse the motion by performing hip extension and external rotation, followed by hip adduction into flexion. Lower leg back to start position.
Compensations:
a) Spinal movement
b) Torso rotation
c) Elbow bending
Prone hip CARs and Compensations
Key points:
Prone position: Lay face down on the floor
Start: Slide leg out to the side into hip flexion and abduction. Internally rotate the hip and then extend the hip. Lower leg back to start position.
Compensations:
a) Spinal movement
b) Torso rotation
c) Pelvis & elbow lifting off the floor
Case Study: A Crossfit Athlete with Hip Pain due to Capsular Restriction
The movement above was performed at the end of my client’s session, after working to gain more capsular mobility over the past few weeks.
For this exercise, we focused on keeping his body in a neutral position; avoiding any closing angle pinch. He performed an isometric contraction of the entire body, and also the lateral glut complex when taken into the end range.
Notice the compensation (0:03 in the video) during horizontal abduction of the hip, where he tries to compensate by internally rotating the hip. This is evidenced by his foot moving out faster than his knee. I chose to find the threshold of the movement, and then worked to engage the lateral glut muscles with a band in order to find the space in his brain to retrain the neurological component while strengthening said tissue region. I chose to use a dowel over a fixed object because it is less stable. Pushing hard into it to isometrically engage the entire system to try and independently move one part
This version of a Controlled Articular Rotation (CAR) is part of the system known as Functional Range Conditioning (FRC) and is a brilliant way to engage the nervous system to get long muscles working long and more importantly, short muscles working short. Mobility work is INTENSE!
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Patient must respond well to joint distraction vs. joint compression
Wrap superband around stable anchor (if at home – knot it and place it under a closed door), double wrap band around foot, distract back by moving in a straight line away from the anchor. Lay down and breathe until the distracted foot falls asleep.
Variation: Lay at an angle to create hip ABD (stretches out the ADD as well)
People with hip/shoulder impingement move from their spine rather than just from the joint – this exercise teaches people to move from their joints
Wrap superband around stable anchor (if at home – knot it and place it under a closed door), bring band up to the hip and get into a quadruped position. Move away from the anchor to increase tension on the superband. Pull hands to knees, knees to hands to engage the “core”. Move hips towards heels (this allows the band to pull the head of the femur down into the joint)
Variation: Straight lateral distraction
Key points:
Mobilized left hip (tight) into the 2nd transformational zone while getting the t-spine into type 2 (side bending and rotation in the same direction) motion to the left
Place emphasis on keeping the t-spine aligned over the pelvis and finding the threshold where it starts to be lost.
If you don’t have a True Stretch, place a chair in a doorframe instead!
How do you deal with hip pain? Let’s get the discussion going – share your thoughts in the comment section below!
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