Those Multifidi

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.

“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.”

see also our post here.

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print]
The immediate effect of dry needling on multifidus muscles’ function in healthy individuals. Dar G1,2, Hicks GE3.

 Why does this gal have so much limited external rotation of her legs? 

 We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.

 Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.

Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion.   This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation.  She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.

 So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius,  gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient. 

confused? Did you miss our awesome post on femoral torsions: click here to learn more.

A visual example of the consequences of a leg length discrepancy.

This patient has an anatomical (femoral) discrepancy between three and 5 mm. She has occasional lower back discomfort and also describes being very “aware” of her second and third metatarsals on the left foot during running.

You can clearly see the difference in where patterns on her flip-flops. Note how much more in varus wear on the left side compared to the right. This is most likely in compensation for an increased supination moment on that side. She is constantly trying to lengthen her left side by anteriorly rotated pelvis on that side and supinating her foot  and trying to “short” the right side by rotating the pelvis posteriorly and pronating the foot.

With the pelvic rotation present described above (which is what we found in the exam) you can see how she has intermittent low back pain. Combine this with the fact that she runs a daycare and is extremely right-handed and you can see part of the problem.

Leg length discrepancies become clinically important when they resulting in a compensation pattern that no longer works for the patient. Be on the lookout for differences and wear patterns from side to side.

So here is somewhat of a controversial subject.

Perhaps, though not discussed in this article, activating more axial extensors (vestbulospinal pathways, things like your erector spinae) could be somewhat protective, in that it could, at least theoretically, help to normalize flexor/extensor ratios in the lower extremity. 

We see flexor dominance (increased corticospinal activity) in many cases of lower extremity problems causing an imbalance. Perhaps activating extensors the lower extremity (tibialis interior, extensor digitorum longest, etc.) could explain, in part, some of these (controversial) results.

We’re not recommending or condoning taking up smoking to preserve your knees. This is merely food for thought in the ever-changing landscape of clinical application.

Pain on the outside of the leg? Could it be your orthotic? What you wear on your feet amplifies the effect of the orthotic.

This woman presented with right-sided pain on the outside of her leg after hiking approximately an hour. She noticed a prominence of the arch in her right orthotic. She hikes in a rigid Asolo boot ( see below). Remember that footwear amplifies the effect of an orthotic!

In the pictures below you can see the prominent arch. The orthotic has her “over corrected” so that she toes off in varus on that side. The rigid footwear makes the problem worse. The peroneus group is working hard (Especially the peroneus longus)  to try and get the first Ray down to the ground.

The “fix” was to soften the arch of the orthotic and grind some material out. Look at the pictures where the pen is pointing to see how some of the midsole material was taken out. Notice how I ground it somewhat medial to further soften the arch.

She felt better much better after this change and is now a “happy hiker” 🙂

1st met pain in an orthotic?

This patient came in with pain at the base of the first metatarsal that she believed was related to her orthotic. The first picture shows the foots relationship to the orthotic. Notice how the sesamoid bones and distal aspect of the first metatarsal under lap the orthotic shell. In other words, the shell is longer than her foot. When she dorsiflexes her big toe, she’s hitting the distal of the orthotic.

The next view shows the orthotic with a typical first ray cutout. Notice how far forward the shell of the orthotic goes (next picture). I have placed a pen pointing to the area where the orthotic shell is too long.

In addition to reviewing her first ray descending exercises, a simple fix was to grind back the orthotic shell and be careful to bevel the edge so that it was not hitting the sesamoids and it did not impinge upon the descending first ray. I have placed a pen where the cut out now is (pre and post gluing in the pictures). The cork underlying the base of the first ray was also ground away (last picture)

A simple fix for a common problem. Make sure that your orthotic shell lengths fall just short of the 1st ray and not impinge on the sesamoids!

The Elusive Iliocapsularis

As with many things, one thing often leads to another. I had a patient with anterior hip pain and what i believed was iliopsoas dysfunction, but I wanted to know EXACTLY which muscles attached to the hip capsule, to make sure I wasn’t missing anything.

I turned up some great info, including a nice .pdf lecture, which I am including the link to along with a second paper that began my journey.

I had thought the iliopsoas attached to the hip capsule, but it turns out it doesn’t, but the iliocapsularis does along with a host of others, including one of my favs, the gluteus minimus, which was believed to be part of the psoas, but actually is a completely separate muscle.  Did I mention that these are  FREE, FULL TEXT articles?

Anyway, I began reading, with great interest, about the iliocapsularis and I found yet another great review paper on it, along with mechanical hip pain. This last paper has some real clinical pearls and I recommend reading it the next opportunity you have a bit of time.

I began thinking about when the iliopsoas fires in the gait cycle (terminal stance to mid swing). So, it is firing eccentrically at pre swing (perhaps limiting or attenuating hip extension?), then concentrically through early and mid swing, when it becomes electrically silent. During running gait, the activation pattern is similar. This muscle is also implicated in femoroacetabular impingement (FAI), or more correctly anterior inferior iliac spine subspine impingement (AIIS Impingement) or iliopsoas impingement (IPI). They all can cause anterior hip pain and they should all be considered in your differential.

The iliocapsularis muscle has its proximal attachment at the anterior-inferior iliac spine and the anterior hip capsule and does not attach to the labrum . Its distal insertion is just distal to the lesser trochanter. It can sometimes inset into the iliofemoral ligament and/or the trochanteric line of the femur. It is innervated by a branch of the femoral nerve (L2-4). It is believed to act to raise the capsule of the hip and be an accessory stabilizer of the hip. 

OK, there you have it. the iliocapsularis. Another muscle you didn’t know you could access. It pays to know your anatomy!