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)

Abd and
Adductors

Hip Hip
Flexors Stability
Glutes
 “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