Exploring the Links Between Human Movement, Biomechanics & Gait
The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.
Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.
RESULTS and CONCLUSION: “Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.”
One point and 1 treatment can profoundly influence gait
When talking about the lower extremity and gait (as I have been know to do at more that one seminar), I often talk about the “reverse engineering” principle. This is looking at a muscle or muscle group from a “ground up” perspective, as it would be functioning during the gait cycle. This, along with knowing when a muscle should be firing in the gait cycle, can provide clues to what may be going on and how you may be able to help.
When discussing the quads, we often employ this principle. It can be a little difficult to think of the vastus medialis as a lateral rotator of the thigh and the rectus femoris as a flexor (anterior nutator) of the pelvis, but if you put your foot on the ground and think about it, you will see what I mean.
The VMO is often implicated in patello femoral syndromes but cannot be selectively activated. The ratio between vastus medialis and vastus lateralis does seem to be alterable and perhaps is a siginificant factor.
How about if we look at the vastus lateralis instead?
The vastus lateralis is the largest and most powerful portion of the quadriceps. One paper reports that the muscle volume of the the vastus lateralis was 674 cm3 followed by the vastus intermedius at 580 cm3, vastus medialis 461 cm3 and lowest in the rectus femoris 339 cm3. This makes the vastus lateralis is twice the volume of the rectus femoris!
Studies of muscle fiber orientation show that VL force component is directed approximately 12-15° laterally with respect to the longitudinal axis of the femoral shaft. This would mean it has a tremendous mechanical advantage and could (should?) pull the patella directly laterally compared to the VMO force, whose component is directed approximately 55 ° medially. The muscle “balance” between the VMO and the VL, along with the periarticular soft tissue structures acting on the patella, is considered major component in the control of normal patellar alignment and function. The VL is often considered to be the “overactive” one by many clinicians, particularly in cases of patellofemoral dysfunction. It turns out that from an EMG standpoint, they may be correct.
The vastus lateralis arises posteriorly from the femur along the linea aspera and circumnavigates the thigh in a counterclockwise fashion to attach laterally to the patellar tendon. Because of its size and fiber orientation, it would stand to reason that needling it would have more cortical representation than say the vastus medialis.
There is an interesting paper where they needled a single acupuncture point: Stomach 34. For those who haven’t studied acupuncture (or don’t remember) this point is located on the thigh, in a small depression about 2.5 inches (63 mm for the metric folks) lateral to and above lateral border of the patella. In other words, it is in the vastus lateralis (see above).
The results showed statistically significant improvement in velocity, cadence, stride length, cycle time, step time and single/double leg support after treatment. The effect was small, but positive.
Think about where the trigger points are for this muscle (see above) ; fairly close to this point, sometimes (depending on the trigger point), even directly over this point. Needling has many effects on muscle and its trigger points and we like to think that needling “normalizes” function of a muscle; perhaps it influences the apparent “dominance” of this muscle and allows the patella to track more medially?
So, in this popultion of patients of elderly individuals, 1 acupuncture (needling) treatment had a positive influence on their gait. Perhaps if the folks in the knee study were treated a few more times, we would have seen a change. Imagine what could have happened if aditional treatment modalities, like exercise, proprioceptive work and gait retraining were added!
What a great, cost effective alternative or addition to your rehabilitation this could be. Consider adding this modality (and point!) to your current clinical toolbox, not only for older patients but for any patients that may have a gait abnormality.
Kim, H. H., & Song, C. H. (2010). Effects of knee and foot position on EMGactivity and ratio of the vastus medialis oblique and vastus lateralis during squatexercise. Journal of Muscle and Joint Health, 17(2), 142-150.
Lam, P. L., & Ng, G. Y. (2001). Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain. American Journal of Physical Medicine & Rehabilitation, 80(11), 804-808.
Erskine, R. M., Jones, D. A., Maganaris, C. N., & Degens, H. (2009). In vivo specific tension of the human quadriceps muscle. European journal of applied physiology, 106(6), 827-838. [PubMed]
Grabiner MD: Current Issues in Biomechanics (9th ed). Champaign, Human Kinetics Publishers, 1993.
One way to correct an dysfunctional Extensor Hallucis Brevis
The Extensor Hallicus Brevis, or EHB (beautifully pictured above causing the extension (dorsiflexion) of the proximal big to is an important muscle for descending the distal aspect of the 1st ray complex (1st metatarsal and medial cunieform) as well as extending the 1st metatarsophalangeal joint.
Since this muscle is frequently dysfunctional, and is one of THE muscles than can lower the head of the 1st metatarsal, along with the peroneus longus and most likely the tibialis posterior (through its attachment to the 1st or medial cunieform), needling can often assist in normalizing function and works especially well, when coupled with an appropriate rehab program. Here is one way to needle it effectively.
Treat the paraspinals in addition to the peripheral muscle
As people who treat a wide variety of gait related disorders we often emphasize needling the paraspinal muscles associated with the segemental innervation of the peripheral muscle you are treating. For example, you may facilitate or needle the L2-L4 paraspinals (ie: femoral nerve distribution) along with the quads, or perhaps the C5-C6 PPD’s along with the shoulder muscles for the deltiods or rotator cuff for arm swiing. We do this to get more temporal and spacial summation at a spinal cord level, to hopefully get better clinical results.
White and Panjabi described clinical instability as the loss of the ability of the spine, under physiologic loads, to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots, and, in addition there is no development of incapacitating deformity or pain due to structural changes.
Increased movement between vertebrae (antero or retrolisthesis) of > 3.5 mm (or 25% of the saggital body diameter) during flexion and/or extension suggests clinical instability. This often leads to intersegmental dysfunction and subsequent neurological sequelae which could be explained through the following mechanisms:
Recall that the spinal nerve, formed from the union of the ventral (motor) and dorsal (sensory) rami, when exiting the IVF splits into an anterior and posterior division, supplying the structures anterior and posterior to the IVF respectively. The posterior division has 3 branches: a lateral branch that supplies the axial muscles such as the iliocostalis and quadratus; an intermediate branch, which innervates the medial muscles, such as the longissimus, spinalis and semispinalis; and a medial branch, which innervates the segmental muscles, (multifidus and rotatores) as well as the joint capsule. Inappropriate intersegmental motion has 2 probable neurological sequelae: I) alteration of afferentation from that level having segmental (reflexogenic muscle spasm or vasoconstrictive/vasodilatory changes from excitation of primary afferents and gamma motoneurons) and suprasegmental (less cerebellar afferentation, less cortical stimulation) effects and II) compression or traction of the medial branch of the PPD, causing, over time, demyelination and resultant denervation, of the intrinsic muscles, resulting in impaired motor control both segmentally and suprasegmentally. The segmental effects are directly measurable with needle EMG. This is a form of paraspinal mapping, which has also been explored by Haig et al. So, in short, instability can lead to denervation and denervation can lead to instability.
We often see clinically that treating a trigger point (needling, dry needling, acupuncture, manual pressure) can alter the function of the associated muscle . Improvements in muscle strength and changes in proprioception are not uncommon. Needling also seems to increase fibroblastic activty through the local inflammation it causes. Wouldn’t better muscle function and some scar tissue be a beneficial thing to someone with instability?
The next time you have a patient with instability, make sure to include the paraspinals in your quest for better outcomes.
Do you treat runners? Do you treat folks with knee pain? Patellar tracking issues? Do you treat the quadriceps? Do you realize that the vastus lateralis, in closed chain, is actually an INTERNAL rotator of the thigh (not a typo), and many folks have a loss of internal rotation of the hip? Do you give them “IT band stretches” to perform?
In this short video, Dr Ivo demonstrates some needling techniques for the quads and offers some (entertaining) clinical commentary on the IT band. A definite view for those of you who have needling in their clinical tool box.
Dry Needling and Proprioception. What a great combination.
Since dry needling and proprioception both have such profound effects on muscle tone, why not combine them to treat chronic ankle instability? We do all the time and here is a FREE FULL TEXT article that ties the two together nicely!
And what better to muscle to use than the peroneii? These babies help control valgus/varus motions of the foot and influence plantar and dorsiflexion AND the longus descends the 1st ray. We call that a triple win!
“This study provides evidence that the inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the end of the therapy in individuals with ankle instability. Our results may anticipate that the benefits of adding TrP-DN in the lateral peroneus muscle for the management of ankle instability are clinically relevant as large between-groups effect sizes were observed in all the outcomes.”
Any of your patients of clients taking anti inflammatories? Especially after a rehab session or dry needling/acupuncture? They may be thwarting the healing process. Excerpted from a recent lecture, Dr Ivo talks about how they can down regulate the healing process.