Faulty Biomechanics Of The Lower Extremities, How A Simple Biomechanics Dysfunction Accelerates The Aging Process, The 10th International Congress On Anti-Aging and Biomedical Technologies,

Faulty Biomechanics of the Lower Extremities: A presentation of how a simple biomechanical dysfunction accelerates the aging

process. The most effective diagnosis, treatment and prevention.

James Stoxen, D.C. President, Team Doctors Treatment Centers

Discussion of anti- aging issues with lack of care and how the body ages more rapidly with the cascading domino effect of this syndrome. We will discuss the risks and complications of the development of more life threatening diseases, which can manifest from the lack of treatment of inappropriate care to this simple biomechanical dysfunction. The dysfunction is easily treated with the care cycle outlined if caught early, given effective treatment and prevented, the biomarkers affect the aging process.

Faulty Biomechanics of the Lower Extremities Related to Simple Foot

Pronation and its Effects on the Aging Process

By Dr James Stoxen DCPresident

Team Doctors PCChicago

(773) 735-5200Teamdoctors.org

[email protected]@teamdoctors.org

How Common

10,000 -15,000 average steps per day 640 metric tons of stress on the joints

Even subtle faulty biomechanics can easily yield a chronic condition or predispose a patient to serious injury

How common are conditions related to faulty biomechanics of the lower extremities related

to simple foot pronation?

What are the long term effects to the aging process?

The abnormal strain effects the entire kinematic chain effecting all muscles, tendons, ligaments and joints.

Tonic/chronic protective spasm, pain and arthritis

Inactivity due to pain Chronic fatigue Depression “I’m just getting old”

Long term effects of faulty biomechanics of the lower extremities

Chronic Arthritis The most common cause of disability in the

elderly 43 million cases in 1997

Heart Disease Genetic Factors Diet Lack of proper exercise

Simple Foot Pronation

One of the most common examples of faulty biomechanics of the lower extremities is simple foot pronation

Simple Foot pronation causescollapse of the kinematic chain

Pronation of the foot causes a collapse of the kinematic chain causing pain, arthritic changes in multiple joints in the kinematic chain leading to inactivity, fatigue and possible depression. When the foot pronation becomes chronic this condition can lead to chronic fatigue and subsequent heart conditions due to inactivity.

The leading cause ofsimple foot pronation is...

Shoes with weak counters

Improper lacing of shoes

Not lacing shoes at all!

Foot & Ankle Symptoms

Foot and or ankle pain Plantar Fascitis History of a heel spur Shin splints

Knee and Calf

Pain (especially after sitting for long periods)

Crepitus (especially when walking upstairs) Peripatellar pain Calf cramps Poor circulation in calves Cold feet

Hip and Thigh

The legs ache Leg cramps Illiotibial band pain Crepitus in the hip History of hip arthritis pain Tired legs

Lower Back Pain

Insidious lower back pain Lower back pain from a lifting

injury

Chronic Fatigue

Patient is fatigued all the time Negative laboratory work-up All other tests for pathology are

negative

Objective Findings

Orthopedic Tests and Radiographic Findings

Orthopedic FindingsFoot & Calf

Tenderness on deep palpation of Plantar Media Aspect of the Foot

Tenderness on deep palpation of the (lateral aspect) of the Calf

Heel Spur

Knee

(+) Clarks - crepitus on extension of the knee

(+) Waldron’s Chondromalacia

patella radiographic findings

Hip and Thigh

Weak and painful biceps femoris (on deep palpation)

Weak and painful tensor fascia latae (on deep palpation)

(+) Modified Obers Test (TFL)

(+) Nobles Test (TFL)

Hip Muscle testing

Weak & painful gluteus maximus (upon deep palpation)

Hip muscle testing

Weak & painful gluteus minimus and medius

Weak & painful piriformis

Difficulty with internal rotation of the hips

HipOrthopedic Tests

(+) Trendellenburg Test (poor balance)

Difficulty getting up from seated position

(+) Patrick Fabres test

Treatment training tip for weak gluteus medius

Hip Abductor training Restrict Spinal motion Short arch No Hip External

Rotation

10 x 3 (reps x sets)

Lower Back

(+) Hibs (+) Elys Chronic idiopathic

paraspinal muscle spasms

Bilateral or unilateral (SI) flexion fixation subluxation

Herniated disc or discs

Lower Back (Continued)

Anterior Tilted Pelvis Unilateral or Bilateral

Lower Extremity Anatomy Review

Foot – 28 bones– 55 articulations

Joints Ankle Joint

– Bones Tibia Fibula Talus

Mid Tarsal Joint– Bones

Talus Navicular Calcaneus Cuboid

Subtalar Joint– Bones

Talus Calcaneus

– Subtalar Joint Primary Motions

Eversion/Inversion Abduction/Adduction

Lower Extremity Anatomy Review

Mid Tarsal Joint Axis

The mid tarsal joint has 2 axis which function as a unit to allow for triplanar motion around these 2 axis

Mid Tarsal Joint Axis

Oblique Mid Tarsal Joint Axis– Primary Motions– Dorsiflexion Plantarflexion– Abduction Adduction

Longitudinal Midtarsal Joint Axis– Primary Motions– Pure inversion and eversion

Foot pronation occurs at the mid tarsal joint axis

Midtarsal pronation is limited when the cuboid comes in contact with the calcaneus

As long as the calcaneus is not in a valgus position

If the calcaneus is in a valgus position then the entire complex will collapse

The Leading Cause of Simple Foot Pronation

Shoes with weak counters (sides)

Shoes which are tied weak

not tied at all

The Leading Cause of Simple Foot Pronation

The Leading Cause of Simple Foot Pronation

The Leading Cause of Simple Foot Pronation

The Leading Cause of Simple Foot Pronation

The Leading Cause of Simple Foot Pronation

The Leading Cause of Simple Foot Pronation

Key to our Treatment Program

Maintaining the calcaneous in the neutral position is one of the key points to our treatment program. This demands excellent footwear selection with motion control. Use shoes with strong counters both for treatment and prevention purposes

Ligaments that Restrict Foot Pronation

Mid tarsal pronation is restricted by various restraining ligaments of the foot– Ligaments (See Figure)

Long and short Plantar Ligaments

Calcaneonavicular Ligament Bifurcate Ligament

Key to our treatment program

If these ligaments are damaged or chronically stressed they will not assist in limiting pronation. We manipulate the bones of the foot and work on the intrinsic muscles of the foot to increase the natural strength of the arch.– Midtarsal pronation is further limited in excessive

pronation in various stages of the gait cycle by the pronation/supinator cuff muscles

Key to our treatment program

Similar to the premise of treatment of rotator cuff musculature, we find that treatment of tonic protective spastic activity in Phase I and active strengthening of these muscles in Phase II, III and IV is a key component of our treatment program

Calf Muscles

Primary Movers Tibialis anterior– Soleus– Gastrocnemius

Pronator/Supinator Cuff

These muscles can act to prevent excessive pronation and supination of the foot (analogous to the rotator cuff muscles of the shoulder)

Flexor Hallucis Longus (See Figure) Strong plantar flexor

of the ankle joint Weak Sub Talar Joint

supinator

Pronator/Supinator Cuff

Peroneus Longus – Strong Plantar

Flexor of the First ray

– Pronator of the forefoot arouond the Longitudinal Midtarsal Joint Axis

Pronator/Supinator Cuff

Flexor Digitorum Longus (See Figure)– Strong ankle joint

plantar Flexor– Moderate subtalar

joint supinator– Very strong

supinator of the forefoot around the midtarsal joint

Pronator/Supinator Cuff

Extensor Digitorum Longus (See Figure)– Strong plantar flexor

Of the ankle joint– Moderate pronator of

the forefoot

Pronator/Supinator Cuff

Tibialis Anterior (See Figures)– Does not effect the

midtarsal joint axis– Strong supinator

of the forefoot– Slightly weaker

supinator of the subtalar joint

Pronator/Supinator Cuff

Tibialis Posterior

Anatomy of the Leg and Knee

Knee Anatomy– Bones

Tibia Fibula Femur

Knee Joint Motions– Flexion– Extension– Rotation

Muscles which control the knee– Quads

Rectus Femoris Vastus Medialis Vastus Lateralis Intermedius

– Hamstrings Biceps Femoris Semimimbranosis Semitendinosis

– Tensor Fascia Larae - Illiotbial Band (Figures on next slide)

Gluteus Maximus, Medius and Minimus

Muscular Anatomy of the Hip and Lower Back

External Rotators (See Figure)

Adductors

Lower Back Muscles Illiopsoas Extensors Abdominal Muscles

MuscularAnatomy of the 1Hip and Lower Back

Correct the Foot Pronation with Deep Tissue Work to the Intinsic Muscles of

the Foot and Lateral Calf

Pronation Treatment and Prevention takes place when supination is aided by reduced weakness of and increased strength of the intrinsic muscles of the foot (See Figures)

Training Rehab Tip correct through training not through orthodics

Correct the Foot Pronation

Foot Pronation Correction

Treatment Tip Motion Control stabilizing foot wearPick you shoes like you pick your fruit

Foot Pronation Correction

Treatment Tip Alternative shoe

lacing for added counter stability (start under)

Pronator/Supinator Cuff Treatment

Phase I - Passive Treatment: Reduce weakness via deep

tissue work or EMS– Abductor Hallucis– Flexor Hallucis Brevis– Flexor Digitorum

Phase II, III, and IV - Active

Strength Training

– Abductor Hallucis– Flexor Hallucis– Flexor Digitorum Brevis

Pronation, treatment and prevention takes place when supination is aided by reduced weakness and increased strength of the extrinsic supinators of the foot (AKA supinator Cuff Muscles)

Pronator Supinator Chronic Weakness

With chronic pronator supinator cuff weakness the body shifts the weight to other muscles and serious injuries can occur

Calf Training

Training/Rehab demands joint motion in flexion extension be along the metatarsal joint axis

Phase I - Passive Treatment

Phase II, III and IV - Active

Strength Training Reduce weakness via deep

tissue work or EMS– Flexor Hallucis Longus– Flexor Digitorum Longus– Tibialis Posterior

Treatment of the Faulty Biomechanics of the Lower Extremity Related to Simple

Foot Pronation

Pronation Treatment/Training/Rehab Tip

Stretch these muscles– Extensor Hallucis Longus

– Extensor Longus & Brevis

– Tibialis Anterior

During the push off phase of gait, pronation is reduced when the peroneus longus is strengthened to insure that toe off will occur with a stable first, second and third digit. Joint motion is lost and must be regained through manipulation of the joints of the foot.

Improve toe off and Stride Length “Windlass Effect”

Excessive pronation is reduced with the “Windlass Effect”. When the toes dorsiflex, the heel lift draws the plantar fascia around the metatarsal heads which acts to pull the pillars of the longitudinal arch together thus decreasing the fore foot rear foot distance or strengthening the arch. This only happens when the patient steps off with reasonable toe off force.

Pronation CorrectionPhase I - Passive Treatment - Reduce weakness via deep tissue

work or EMS (See Figures)

Peroneus longus

Phase II, III and IV - Active Strength Training (See Figures)

Peroneus Training Tip

Reduce Tibial Torsion

Increase stride length to reduce tibial torsion

The sub talar joint acts as a directional torque transmitter converter frontal plane motion of the calcaneus into axial rotation torque or torsion of the tibia/fibula (shank). This can cause considerable internal rotational stresses on the tibia, femur and thus hip and lower back. When in the swing phase the opposite side, when swinging a reasonable distance or a longer stride which causes the effected side to reduce in torsion.

Treatment of the Knee Disorders Related to Simple Pronation of the foot

Conditions– Knee Instability– Peri-patellar Pain Syndrome - Patellofemoral arthralgia– Infrapatellar Cartilage Damage - Chondromalicia Patella

Phase I - Passive TreatmentReduce weakness via deep tissue work or EMS

Tensor Fascia Latae Biceps Femoris

(See Figure) (See Figure)

Strength training tip to reduce tibial torsion

Tibial Torsion Treatment and Prevention takes place when Reduced Torsion is aided by reduced weakness and increased strength of the Tensor Fascia Latae and the Biceps Femoris of the thigh. (See Figure)

•Knee extensions - the quad group pull the patella in the correct alignment

•Knee Flexion Bicep femoris pulls the shank back into proper alignment

•Hamstring Curls

Strength training tip to reduce tibial torsion

Train your patient in hip abduction through the gluteus medius and indirectly TFL

Treatment of Hip and Thigh Disorders or Syndromes Related to Simple Pronation

of the foot

Conditions Tensor Facia Latae and/or

Illiotibial Band Syndrome (See Bottom Figure)

Piriformis Syndrome (Side Figure) Hip Arthritis

Phase I Reduced Weakness - Deep Tissue or EMS (See Figure)

– Tensor Fascia Latae– Gluteus Maximus– Gluteus Medius– Gluteus Minimus

Strength Training– Tensor Fascia Latae– Gluteus Maximus– Gluteus Medius– Gluteus Minimus

Treatment of Hip and Thigh Disorders or Syndromes Related to Simple Pronation

of the foot

Treatment of Lower Back Disorders or Syndromes

Non Traumatic Lower Back Pain Disorders or Syndromes Hyperlordosis Facet Syndrome

Traumatic Lower Back

Disorders and Syndromes Herniated Discs etc

We feel that a majority of these injuries are due to a prior predispositionfrom abnormal lower extremity biomechanics causing an anterior tilted pelvis and weight shift from the gluts and lateral thigh to the hamstrings and lower back causing overload and injury

Passive Phase I - Reduced Weakness of these muscles via deep tissue work or EMS

Hip External Rotators (See Figure)

Gluteus Medius Lumbar Extensors

Active Phase II - Active Strength Training in Phase II, III and IV

Midsection Training - This training must occur in flexion, extension, lateral flexion and rotation with the pelvis in a neutral position with reduced extensionof the lumbar spine.

The Spine must be trained in a neutral position.(See Figure)

Phase I - Goals - Reduced Inflamation and Tonic Protective Spasms, Pain Relief, Joint

Mobility Joint Swelling Reduced (Therapy) Joint Fixation Reduced via Manipulation of

Articular Structures Pronation Supported - Orthodics vs NMRE and

motion control shoe and active training Chronic Tonic Protective Reflex Reduction

(NMRE) Treatment Frequency and Duration Daily care

for 2 weeks or 3 days a week for 3 weeks

Phase II - Goals Flexibility, Joint Alignment, Joint Strengthening and Coordination

Joint fixation reduced via Manipulation of Articular Structures

Flexibility training technique (PNF) Light Strength Training Concentration on joint Alignment, Form and

Technique treatment frequency & duration 3 days a

week for 3 weeks

Phase III - Goals - Flexibility, Joint Alignment, Joint Strengthening and

Coordination

Manipulation of Articular Structures Flexibility training (PNF) Heavier and Faster Strength Training Concentration on Joint Alignment, Form

and Technique, Speed and Strength Treatment frequency and duration 3 days a

week for 3 - 4 weeks

Phase IV Goals - Heavier and Faster Strength Training

Concentration on Joint Alignment, Form and Technique, Speed and Strength

Sports Performance Training