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The shoulder is a complex ball-and-socket joint that is made up of the humeral head and its contact with the glenoid fossa of the shoulder blade or scapula.  The shoulder is designed to move the arm and position the hand in space and completes this task with extreme accuracy through an intricate system of ligaments and muscles that restrain and provide motion.  Because the shoulder must accommodate such a wide range of motion, it gives up a degree of stability and is more susceptible to injuries.  This can be contrasted against the hip, which is also a ball-and-socket joint, but offers much more stability and less mobility through a deeper joint socket, stronger ligaments and more powerful muscles.

Joint stability at the shoulder is dependent on the strength of the rotator cuff muscles and the muscles that surround the scapula and the integrity of all surrounding ligaments.  Since we can not strengthen our ligaments, this article will focus on improving performance of the muscles and their corresponding tendons.

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Part 1 of our gait discussion ended with a description of basic foot types and how these different types may decrease an individual’s shock absorption capacity.  Part two of this topic will cover the ankle and issues related to the spine and pelvis, which are commonly seen in the orthopedic physical therapy realm.

Ankle:  Limited Range of Motion

The ankle is a hinge joint that is capable of moving through both plantarflexion (pointing the foot) and dorsiflexion (pulling the foot toward one’s head).

While both motions are vital for normal gait, plantarflexion is rarely seen as a major problem, except for maybe after ankle related surgery.  Dorsiflexion, on the other hand, is commonly restricted in the normal population and can adversely affect gait mechanics.

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Gait analysis or the study of the human walking cycle is an important component of the physical therapy examination and is useful for identifying potential causes of dysfunction and pain.  As a physical therapist, I use gait analysis with nearly every new patient and with current patients in order to assess baseline performance and changes that may occur with treatment. 

A healthy, balanced gait cycle is extremely important for preserving tissue integrity throughout the body and preventing painful conditions often associated with an abnormal gait pattern.  Such conditions often include spinal pain, scoliosis, hip and knee joint pain, foot pain, bursitis, tendonitis, plantar fasciitis, heel spurs and bunions to name a few!

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Besides low-back and neck pain, another common source of pain is the the thoracic spine or mid-back region.  The spine is divided into three sections, which include from top to bottom, the cervical spine (neck), thoracic spine and lumbar spine (low back).  The thoracic spine is made up of 12 vertebrae and 12 ribs and is the longest region of the spine.  The thoracic spine is also the stiffest region of the spine due to its attachments with the ribs.  Because less motion occurs at the thoracic spine, this region usually suffers from less dysfunction as compared to the neck and low back.  This being said, the thoracic spine is a common source of pain, especially when poor posture is involved. 

Pain in the thoracic spine is most often experienced between the shoulder blades and is associated with positions where the shoulders and mid-back are rounded.  When the spine is not aligned properly, research has shown that it is able to support somewhere around 10 times less than in a position of proper posture.  So, if an individual begins to slouch (like most of us do), the musculature surrounding the spinal column must become active to prevent the spine from collapsing.  Over time, our muscular tissue becomes fatigued from supporting the weight of the thorax, which is the point when we either shift to a healthier position or begin to experience pain.  Keep reading, there’s more

The neck or cervical spine is composed of an intricate system of bones, discs, ligaments and muscles that are responsible for stabilizing our head while still allowing for a wide range of flexibility.  The neck is made up of 7 vertebrae labeled C1-7 that are connected to each other via two facet joints, which slide across each other during normal movements.  Between each vertebrae exists an intervertebral disc, which acts as a shock absorber and maintains normal spacing among adjacent vertebrae, which is also important for normal range of motion.  Without normal spacing, more load is placed on the facet joints, thus, preventing normal cervical movement.  Besides joints and discs, 8 pairs of cervical nerve roots (C1-8) that are responsible for providing motor and sensory function to the neck and arms and numerous local and global muscles and ligaments are present.

The neck moves through all 3 planes of motion, which include the sagittal plane (up and down or ”yes” motion), frontal plane (side to side or ear to shoulder motion) and the transverse plane (rotation or “no” motion).  A loss of normal cervical spine range of motion is common especially as people age and is often due to intervertebral disc degeneration and arthritis at the facet joints.  However, the neck is no different than any other region of the body and the old “use it or lose it” principle still applies.  The following images and descriptions will describe normal neck range of motion and can also be used as simple exercises to help improve movement in directions that may be tight.  Keep reading, there’s more

The achilles tendon attaches the gastrocnemius and soleus or calf muscles to the calcaneus bone at the back of the foot. The calf muscles are capable of generating large amounts of force and are responsible for plantarflexing or pointing the foot during everyday activities including walking, running and jumping.  The calf muscles must be extremely strong considering the fact that the largest torque demand placed on the body during normal walking occurs at the calf in order to keep us from falling during forward progression.

Achilles tendon ruptures usually occur 2-6 cm above the point of insertion on the calcaneus and are more common on the left leg as most people are right handed and push off of their left leg when jumping.  Ruptures are also more common in males between the ages of 30-50 years old who are intermittently active in sports that require explosive movements.  These individuals are often referred to as “weekend warriors” due to the fact that they are fairly sedentary throughout the week and then become more active on the weekend.  Guys are especially at risk because they often believe that they can perform at the same level they did during college even though they now spend most of their time behind a desk and are slightly overweight.  All of these factors lead to decreased tissue strength through the gastrocnemius, soleus and achilles tendon related to decreased activity and increased stress secondary to possible weight gain and involvement in activities that exceed the strength of the musculotendinous unit.

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The hamstrings are made up of three different muscles and are located at the back of the thigh.  These three muscle include the biceps femoris, semitendinosus and semimembranosus and reach from the pelvis to just below the knee.  Because of their attachment sites the hamstrings are capable of causing movement at both the hip and knee joints.  Muscles of this type are referred to as biarticular, meaning they cross two joints.  In the case of the hamstrings, they work by causing knee flexion (bending the knee) and hip extension (moving the leg backwards with the knee straight).

When using the traditional hamstring machine at the gym (either sitting or laying on the stomach), the hamstrings contract in order to bend the knee.  The problem with such an exercise is that the hip portion of the hamstring is neglected and, thus, the hamstrings are not maximally challenged.

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One muscle group that people are constantly looking to improve are the gluteal muscles.  These muscle include, from most superficial to deepest, the gluteus maximus, gluteus medius and gluteus minimus and are the muscles that give shape to the buttock region.  As for function, they work together to propel the body forward and are involved in almost every task that involves the use of the legs including squatting, lunging, walking and running just to name a few. 

A recent study from the Journal of Sports and Orthopaedic Physical Therapy (JOSPT) used electromyography (EMG) to identify which exercises placed the greatest demand on the gluteal muscles.  The study compared a number of commonly prescribed therapeutic exercises and identified the top 3 for activating the gluteus maximus and gluteus medius.

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As a physical therapist, a great deal of my time is spent educating people on the importance of proper body alignment, symmetry and posture.  I would be willing to bet that most of us have been told since an early age that correct posture is important, but how many people can actually explain why this is true.

As I have mentioned in previous posts, most humans fall into a few typical movement or postural patterns and it is these patterns that are responsible for the majority of musculoskeletal complaints.  Now take a minute and think about what I am saying…imagine that on average you are awake 16 hours per day and that a large percentage of those hours are spent in a gravity dependent position such as standing or sitting, whether at school or at work.  Both school and work, in most cases, involve prolonged periods in which we are not moving a whole lot and even sitting for extended amounts of time.  I realize this does not count for everyone, but trust me this scenario is true for most.  While you are sitting or standing in place, your postural muscles are active in an effort to fight the effects of gravity and keep you upright.  This is where the problem occurs.  Most of us give in to the effects of gravity and begin to slouch either out of habit, muscle weakness or fatigue.

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I just wanted to send out a quick note to let everyone know that I will be in Aspen, Colorado and Billings, Montana over the next month visiting friends and family so my posts may be a little sporadic depending on whether or not I have internet access.  I apologize in advance, but will try to post anytime I get a chance.