Got Hip, Knee or Ankle problems? Look up!
In last month’s newsletter, we examined the motions of the pelvis, the seat of our center of gravity, and coordinator of the tricky task of supporting our upright frame and driving locomotion. A close examination of pelvic movement during gait and other common body movements, as well as specific muscle strength testing, will determine which muscles need conditioning during a course of physical therapy. We have also hinted at the idea that upper body pain and trunk dysfunction are often accompanied by significant motion abnormalities in the pelvis, hips and knee.
This month, we expand our view above and beyond the pelvis to include the trunk. There are four muscle systems
that connect the pelvis with the trunk and are thought to sustain and power all of our functional (or meaningful) positions and movements, like standing, sitting, walking, running, climbing stairs, playing basketball or an instrument, for example. Just as we discussed last month, each muscle system
serves to control pelvic movement along the sagittal, transverse or frontal plane. The body depends on the smooth, coordinated effort of these muscle systems
operating simultaneously for our activities of daily living, recreation and work.
The four muscle systems are the anterior oblique system, the posterior oblique system, the deep longitudinal system and the lateral system.
Each system is composed of a myriad of large and small muscles, close to the skeleton or more superficial, but are characterized by the contribution of a few key, critical muscles which will be described.
The anterior oblique system
is two abdominal wall muscles, on the same side, the internal and external obliques
and the opposite inner thigh muscles, or adductors
. Since the obliques initiate and control rotation in the trunk, this system is largely called into play when we are taking a step and swinging our leg. As our speed increases, as for running or sprinting, we want the anterior oblique system
to step into high gear as well!
The posterior oblique system
is the latissimus dorsi,
an expansive muscle which extends from the upper arm to the pelvic crest and the opposite gluteus maximus
, or butt muscle. This system is active for any productive position: sitting at our desk, walking our dog, standing in line, walking up the stairs, etc. The pull from the latissimus, which is a superficial muscle across our midback, and the opposite gluteus max, which attaches our thigh to our pelvic crest, puts a supportive tension on a thick piece of fascia (connective tissue) located on our low back.
The deep longitudinal system
is the erector spinae
(strap-like muscles that line the spine), the biceps femoris
(a hamstring muscle), and two foot/ankle muscles, the peroneus longus
and the anterior tibialis.
Together, these muscles put the spring in your step-quite literally! The connections from the erector spinae and biceps femoris put a tension on deep fascia of the pelvis and low back to propel us forward, making all movements more efficient.
The lateral system
operates when the pelvis is resisting or driving a sideways movement, such as climbing stairs, using the climbing wall at the gym, or just climbing out of the bathtub. The muscles at work are the gluteus medius,
the gluteus minimus
, the adductors
on the same side and the quadratus lumborum
on the opposite side.
By way of these muscle systems, the trunk and pelvis coordinate to both power and limit motion. They are all at work to varying degrees depending on the movement task. The anterior oblique system
limits and propels the pelvis in the transverse plane, the lateral system
limits and propels in the frontal plane. The posterior oblique system
and deep longitudinal system
are particularly supportive muscle systems for sustained positions or transitional movements, like sitting at the computer and getting up from a chair.
Other than ease of movement, the reason we care about the integrity of our muscle systems is because a breakdown will cause excessive wear and tear on ligaments and joints, such as the lumbar discs, the lumbar facet joints, the hips, and the knees. With knowledge of the muscle systems, let’s consider how the breakdown in one woman’s posterior oblique system
contributed to her hip pain.
Mary is a 60 year old retired elementary school teacher. She would like to spend more time looking after her grandchild, who is 8 months old, but the pain in her right hip has become more and more bothersome in the last two years and actually accelerated her retirement. Standing and walking have become increasingly painful, and even getting out of a chair is moderately painful, depending on how long she has been sitting. Mary’s X-ray of her hip showed only mild degenerative joint space narrowing. Her doctor recommended she try a course of therapy before considering a hip replacement.
Mary’s physical therapist found that Mary’s hip was stiff when moved toward her trunk (flexion) and turning the thigh inward (internal rotation). The largest hip muscles were weak, including gluteus medius and maximus. Also, her hamstrings were weak. When walking, she took a slightly longer stride with her painful side, which means she was more comfortable when bearing weight on the other hip. Mary’s trunk angled forward as she walked and stood, which she did unconsciously to decrease loading through her painful hip, and also because her gluteals were weak. She appeared to slightly “waddle” when she walked. Mary’s care commenced with manual therapy to alleviate the stiffness in her hip. Her therapeutic exercise program included exercises on the treatment table to activate muscles of the posterior oblique system
and lateral system.
She was instructed in bridges and supine hip abduction with her arms pressing lightly into the table. Once she was able to walk with less pain, Mary began exercises that involved the use of the same muscle groups, now integrated with more muscles that commonly work together, but with a more functional aim, like marching and a modified squatting exercise.
Connecting the dots between the pelvis, trunk and lower body should be one of the aims of a well-designed physical therapy treatment plan. At Advance Physical Therapy, our therapists will perform a thorough examination of your problem area. Furthermore, we will reveal the role of possible dysfunctional muscle systems that perpetuate the problem and could cause future problems as well.
Next month, we will finish connecting the dots as we consider how the upper body plays a role in low back, hip and knee problems.
Lower Cost for Back Pain Treatment
Referral to Physical Therapy Lowers Care Utilization for Low Back Pain vs Referral for Imaging
A recently published study of patients with new low back pain (LBP) who received referral from a primary care provider concludes that not only is physical therapy a less expensive next step than advanced imaging, it's an approach that results in lower utilization costs over time.
Researchers Julie M. Fritz, PT, PhD, FAPTA, Gerard P. Brennan, PT, PhD, and Stephen J. Hunter, PT, PhD, OCS, analyzed utilization records and other health information for 841 individuals who consulted with a primary provider about uncomplicated LBP and were referred for management outside primary care within 6 weeks. Of those individuals, 385 received advanced imagining and 377 received physical therapy (the remaining 79 patients received a physician specialist visit or "other care," including chiropractic). The study focused on records obtained from 21 different providers around Salt Lake City, Utah, between 2004 and 2010.
What they found was that across the board, physical therapy was the less costly approach. Initial referral for physical therapy cost $504 on average (for an average 3.8 visits), compared with an average of $1,306 for magnetic resonance imaging (the technology used in "almost all" of the imaging, according to authors).
Even more dramatically, average subsequent costs over the next year were over 66% lower for the patients who began with a physical therapy referral--$1,871, compared with $6,664 charged to the imaging group over the same time period. Those differences remained largely in place even when researchers matched individuals for covariates including prior surgery, use of medication, osteoporosis, and mental health issues. Results of the study appear in the journal Health Services Research.
Authors found that patients who receive imaging as a first referral often follow a different path than those who receive physical therapy. Writing that referral to have imaging completed "increased the odds of surgery, injections, specialists, and emergency department visits within a year."
Researchers attribute some of the variation to perceptions around imaging. "Advanced imaging often 'labels' a patient's LBP that might otherwise be viewed as nonspecific and uncomplicated, causing heightened concern in some patients and providers and motivating additional care-seeking."
On the other hand, they write, "physical therapy may avoid the negative consequences of a labeling effect from imaging" by "providing patients with an active approach to LBP, enhancing patients' perceived ability to self-manage their condition."
"This is important research, because it provides even more evidence that physical therapy is a less costly alternative to medication, surgery, and other invasive medical procedures," said Nancy White, PT, DPT, APTA executive vice president of professional affairs. "Not only do patients benefit from the improved outcomes resulting from an active approach to care, society benefits from the reduced financial burden on our health care system. The cost savings Fritz and her colleagues describe here are significant enough to be recognized by health policy makers, payers, and other health professionals."
Authors acknowledge that their study was limited to newly reported and uncomplicated LBP, and that patient-centered function or satisfaction outcomes were not recorded. Still, for individuals with this type of LBP who have expectations for additional care beyond a primary provider, "physical therapy may be the preferred initial step instead of advanced imaging."
At Advance Physical Therapy, we will provide you with a comprehensive evaluation for low back pain and can help you determine whether further diagnostic procedures is indicated or not. We have the resources necessary to provide you with the most optimal, non-invasive method for treating back pain and for minimizing its recurrence.
Research-related stories featured in PT in Motion News
Nutrition for Low Back Pain Recovery
Our bodies require the right nutrients for healing and restoration. What we eat helps determine how much or little inflammation we produce that can ultimately affect how are tissues heal from injury.
Our bones provides the structural framework for our muscles, tendons and ligaments to work. Without the proper nutritional support, our bones can be susceptible to developing osteoporosis. Osteoporosis, or thinning bones, is a serious condition that can result in tremendous pain with fractures. Prevention and treatment of osteoporosis include taking calcium, vitamin C & D, magnesium, zinc, copper and getting regular aerobic and resistance exercise.
Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving joint degradation, including articular cartilage and subchondral bone. To minimize exposure to degenerative joint changes, some of the key nutritional support include maintaining an allergen free diet, avoiding alcohol, caffeine and high levels of dairy products, and including omega-3 Fatty Acids (cold water fish, flax seed, walnuts, soybeans), omega-6 Fatty Acids (sunflower seeds, pumpkin seeds, safflower, sesame, corn), Vitamin C & E, glucosamine sulfate, calcium, and magnesium.
Nutritional support for strong muscles and tendons include magnesium (nuts, unmilled grains, dark-green leafy vegetables, legumes such as peas and bean), protein (beef, chicken), Vitamin C to promote collagen healing and collagen strength, bioflavanoids (plant compounds, antioxidants which improves cardiovascular health, capillary strength and structure of connective tissues and the immune system), glucosamine sulfate to promote cartilage and bone health and repair and omega-3 fatty acids to promote to reduce systemic and joint inflammation.
Maintaining good nutritional support means taking in the "good stuff" but also avoiding the foods and external factors that may contribute to the inflammatory process. These include minimizing the use of NSAIDS (non-steroidal anti-inflammatory agents) which decrease DNA synthesis, CORTICOSTEROIDS which decrease synthesis of collagen, and intestinal calcium absorption and STRESS which depletes intake of magnesium, iron, selenium, zinc, phosphorus, and calcium that are vital to a healthy metabolism and provide significant stress protection.
Foods to minimize include red meat, shellfish and dairy products which may increase arachidonic acid and increase the inflammatory response; caffeine (coffee, tea, soda) which slows reaction time, decreases work productivity, depletes sodium, calcium, and magnesium in the body; alcohol which decreases magnesium; and gluten products (wheat, barley, rye, starch, grains).