Alicia Canzanese, DPM, ATC

The National-Washington DC-2018

Track 2-Biomechanics

Short answer: Yes, it is quite important

Functional anatomy

Kinetic chain

Injury specific applications

Treatment and prevention

Evaluation tools and techniques

Evidence Based Medicine

(Kibler, Press

and Sciascia

2006)

Hip Stability

Abd and Adductors

Glutes

Hip Flexors

“The ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities.” –Wilkerson, et al.

“Core Stability is the ability of the lumbopelvic-hip complex to prevent buckling and to return to equilibrium after perturbation”–Wilson et al.

Purpose: maintain integrity of the spinal column, alignment of the pelvis, and to provide a stable base for movement of the extremities

Primarily maintained by dynamic muscle function

Important in any sport/activity that involves walking/running

Internal Corkscrew

Rotational or translations abnormalities in any segment effect the entire chain

Bottom can effect the top

Top Can effect the bottom

“Impaired proximal function increased the likelihood of uncontrolled joint displacements or unsolicited accessory movements throughout the lower kinetic chain” – Ridder et al

EMG studies show us that the core and hip muscles activation is coordinated with lower extremity muscle activation

Multisegmental coordination

Bobbert et al evaluated jumping activities and showed that knee extension and ankle plantar flexion were strongly related to the rise time of the gluteus medius

The multifidus and transverse abdominus muscles have been shown to be activated before any lower extremity movements occur -Hodges et al

ITB “runners knee”

PFPS

ACL Injures

Medial Tibial Stress syndrome (MTSS)

Chronic Ankle Instability (CAI)

Acute ankle injuries

Tendinopathy Peroneal

Ipsilateral hip abductors weakness after inversion ankle Sprain

Friel et al. Journal of Athletic Training. 2006

Following Chronic Ankle Sprains

Ipsilateral Hip Ext and Hip ABD weakness

Initially after acute injuries altered hip muscle recruitment

McGuine et al. reported that high school basketball players who sustained acute ankle instability events, demonstrated considerably greater postural sway

Doherty et al in 2016 showed that those who developed CAI had impaired proximal hip function to those who recovered from their ankle injury

Hamstra-Wright et al. BJSM- 2015

Meta-analysis of risk factors for MTSS

Of the 100+ risk factors noted only 9 were included in the study

Those which showed strong correlation

BMI

Navicular Drop

Ankle PF ROM

Hip External Rotation ROM

Study investigating male military recruits

Decreased hip IR was a risk factor for MTSS

Excessive ER of hip had increased incidence of tibial stress fractures

Very clinically relevant for overuse knee injuries

Clin J Sport Med in 2004/2005

Runners with Lower extremity injures demonstrated significantly weaker hip ABD and ER

Novice runners

Stance Exam

Hip Level

Lumbar Lordosis

Trendelenburg sign

Hip Excursion/Pelvic Level

Arm Swing

Cross Over

N=3-6cm from midline

Causes

Poor Core stability

Weak Hip ABD

STJ Pron leading to pelvic tilt

LLD

Natural Excursion during gait

Look for excess or asymmetry

Increased movement with increased running speeds

“Injury-induced neural inhibition of muscle function can produce subtle and persistent performance deficiencies”-Wilkerson et al

Core and Hip Stability should be included in their rehab program

Especially in Ankle sprain

Knowing your Physical therapist/Athletic Trainer

“A growing body of scientific evidence suggests that clinical tests of core strength and stability can help predict risk of lower extremity injury in athletes”

Debate over what those factors are specifically

EBM: Wilkerson et al, Journal of Athletic Training 2015 3 year prospective study of Division I football players

Preseason screening and injury occurrence

Strong predictors of core and lower extremity

sprains and strains

High exposure to game conditions

Low back dysfunction (even if mild)

Poor endurance of core musculature

Trunk flexion hold

Wall sit

DeRidder et al. AJSM 2017 3 year prospective youth soccer players

Hip extension muscle strength as an

independent and modifiable risk factor for ankle

sprains

YES! Core Stability is Important

Core Stability involves more than just the 6-pack Muscle of the entire abdomen, back, pelvis, gluts, hips

Proper Core and Hip Function is important to the entire kinetic chain

Proximal instability/weakness/poor neuromuscular control is in important factor in the prevention, treatment, and rehabilitation of lower extremity injuries More research is needed in terms of Cause and Effect

Core/Hip intervention should be included in your treatment protocol for ankle sprains, Chronic ankle instability, and MTSS Make sure you PTs and ATCs are addressing

There is a growing body of evidence in the sports medicine literature to support the importance of core stability in lower extremity function and really all gross motor activity

Slide 3: http://advantagestrength.com/what-is-core-stability/

Slide 4: https://www.sixpackfactory.com/six-pack-abs-shortcuts/ https://www.physio-

pedia.com/The_effectiveness_of_core_stability_exercise_with_regards_to_general_exercise_in_the_management_of_chronic_non_specific_low_back_pain

https://cor-kinetic.com/core-stability-does-it-work-for-lbp-a-look-at-the-evidence/

https://en.wikipedia.org/wiki/Muscles_of_the_hip

https://www.lyzabethlopez.com/glute-activation-exercises/

Slide 6: http://athleticlab.com/importance-lumbopelvic-hip-complex-1/kinetic-chain/

Slide 7: https://www.rchsd.org/documents/2014/02/rehabilitation-for-hip-pathologies.pdf

Slide 8: http://www.suseagulls.com/sports/mlax/2007-08/news/seasonpreview

Slide 9: https://www.youcoach.it/en-au/articolo/ankle-sprains

Slide 10: https://www.myfootdr.com.au/2017/06/dont-let-shin-splints-cut-your-netball-season-short/

Slide 11: https://www.youtube.com/watch?v=-6Ksus4QfE4 https://www.bebeautiful.in/lifestyle/health-and-fitness/5-exercises-to-help-tone-your-butt

Slide 12: http://epomedicine.com/clinical-medicine/trendelenburg-test-or-sign/ http://www.joannasoh.com/fitness/knowledge/workout-to-improve-bad-posture

Slide 13, 14: Ray Feehery, DPM

Slide 15: http://www.graychiropractic.ca/testing-you-core-part-3/ http://thorsenchiropractic.com/health-rx/exercise-rx/low-back-exercises/strength---stability-for-low-back.html

http://docsportsmed.com/exercises/low-back/lumbar-extensor-strengthening/

https://www.outsideonline.com/2176286/15-minute-bodyweight-workout-every-outdoor-athlete-needs-their-training-routine

Slide 17: https://www.youtube.com/watch?v=dKYXfbBQfLE

Wilkerson, et al. A refined prediction model for care and lower extremity sprains and strains among collegiate football players. Journal of Athletic Training. 2015;50(6):643-650.

Snyder et at. Core stability and lower extremity injury risk. http://lermagazine.com/article/core-stability-and-lower-extremity-injury-risk. Sept 2013.

Hamstra-Wright et al. “Risk factors for medial tibial stress syndrome in Physically active individuals such as runners and military personnel: a systematic review and meta-analysis.” British Journal of Sports Medicine. 2015;49:362-369.

DeRidder et al. “Hip strength as an intrinsic risk factor for lateral ankle sprains in youth sports.” American Journal of Sports Medicine. 2017;45(2):410-416.

Schmitz et al. “Do novice runers have weak hips and bad running form?” Gait Posture. 2014;40(1):82-86.

Blaiser et al. “Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review.” Physical Therapy in Sport. 2018;30:48-56

Leetum et al. “Core stability measures as risk factors for lower extremity injury in athletes” Med Sci Sports Exerc. 2004 Jun;36(6):926-34..

Mucha et al. Hip abductor strength and lower extremity running related injury in distance runners: A systematic review. J Sci Med Sport. 2017 Apr;20(4):349-355. Epub 2016 Sep 20.

Garnock et al. Predicting individual risk for medial tibial stress syndrome in navy recruits. J Sci Med Sport. 2018 Jun;21(6):586-590. doi: 10.1016/j.jsams.2017.10.020. Epub 2017 Oct 23.

Steinberg et al. The relationship of hip muscle performance to leg, ankle and foot injuries: a systematic review. Phys Sportsmed. 2017 Feb;45(1):49-63.

Email: gordonpodiatry@gmail.com