Sports Injuries
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Sports Injuries
Sports injuries occur when participating in sports or physical activities associated with a specific sport, most often as a result of an accident. Sprains and strains, knee injuries, Achilles tendonitis and fractures are several examples of frequent types of sport injuries. According to Dr. Alex Jimenez, excessive training or improper gear, among other factors, are common causes for sport injury. Through a collection of articles, Dr. Jimenez summarizes the various causes and effects of sports injuries on the athlete. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444. http://bit.ly/chiropractorSportsInjuries Book Appointment Today: https://bit.ly/Book-Online-Appointment
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Inflamed Plantar Fascia, Heel/Foot Pain, and Chiropractic | Call: 915-850-0900 or 915-412-6677

Inflamed Plantar Fascia, Heel/Foot Pain, and Chiropractic | Call: 915-850-0900 or 915-412-6677 | Sports Injuries | Scoop.it

One of the most likely causes of foot/heel pain is inflamed plantar fascia, which causes plantar fasciitis. It can be a painful and common injury from overuse of the ligaments in the foot. When this pain presents, it can make an individual not want to walk or place any type of pressure on the feet, as the pain worsens with pressure or impact on the foot.

  

Chiropractic care doesn’t just treat the spine but can help with various other musculoskeletal issues throughout the body. With chiropractic adjustments, rest, icing, and exercises, the ligaments, and tissues of the feet are worked out, massaged, and stretched back to their normal range.

Plantar Fascia

There is a ligament called the plantar fascia. It runs along the bottom of the foot and connects the toes to the heel. The plantar fascia absorbs shock and helps support the feet when walking. However, ligament tension can begin to increase, specifically when standing for long periods. When the tension reaches its limit, small tears can begin to form along with inflammation causing pain.

 

The pain occurs when walking, standing, or immediately after waking up. The condition can happen to anyone but is more likely to become an issue for those who stand or walk as a regular part of their job, home activity, etc. Side effects from the foot pain often cause individuals to adjust their walking gait to avoid feeling discomfort, that stresses the rest of the body like the muscles, ligaments, joints that can lead to various types of injury/s.

 

Chiropractic Treatment

Individuals with an inflamed plantar fascia often experience a shooting/stabbing pain that worsens in the morning or after standing or sitting for an extended time. Repetitive impact on the feet and poor arch support from shoes cause small tears to happen over time from the continued stress. If it has just started the pain can be treated with ice and rest, but they are not for solving the root cause. Chiropractic can help bring pain relief that lasts along with recurrence prevention. Here are some a few ways a chiropractor can help:

 

Ankle Re-alignment

  • Ankle misalignment can contribute to plantar fasciitis at the plantar fascia has to work harder to move the foot without the ankle's support. Manipulation and realignment of the ankle will improve foot function.

 

Massage

  • A chiropractor along with a physical therapy team can be utilized for soft tissue massage and trigger point therapy to release tension.

 

Exercises and Stretches

 

  • Various stretching and exercising techniques can be implemented to help speed up the healing process. A chiropractor will work the individual through exercises and stretches designed to relieve inflammation and stretch out the tissue. Specific exercises will also be taught to help strengthen the lower leg muscles to stabilize the heel and help prevent pain.

 

Posture

  • A chiropractor will correct any improper posture/s that has contributed to the foot pain or has become a way of being able to function as a result of the pain. This will return the individual to a normal gait when walking and running. Pressure on the feet and plantar fascia will be alleviated.

 

Spinal/Hip Re-alignment

  • Individuals learn to avoid pain by walking/moving in a different way than how the body is supposed to. This results in pain in the hips and back, as the body is being pulled in various ways. Manipulation and mobilization will be used to realign the body to its proper form.

 

Footwear/Orthotics

 

  • A chiropractor will make adjustments to the feet, ankles, and spine to reduce pain and relieve the pressure on the plantar fascia. Supportive footwear and orthotics could be recommended for extended/preventative care. Once diagnosed with a foot problem wearing proper shoes that support the feet is essential.
  • Orthotics can also help prevent injury to the back, joints, and muscles that were stretched or over-worked from an abnormal gait. When the pressure is relieved, the ligament starts to heal. This can take a few weeks. The result is a healthier heel/foot with proper function. Chiropractic can accelerate the healing process combined with home care. If pain is presenting in the heel, do not delay and focus on healing the foot.

 

Walking Incorrectly

 

 

   

 

Dr. Alex Jimenez’s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

 

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*

References

Goff, James D, and Robert Crawford. “Diagnosis and treatment of plantar fasciitis.” American family physician vol. 84,6 (2011): 676-82.

Dr. Alex Jimenez's insight:

One of the most likely causes of foot/heel pain is inflamed plantar fascia, which causes plantar fasciitis. Chiropractic can bring relief. For answers to any questions you may have please call Dr. Jimenez at 915-850-0900 or 915-412-6677

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Tensor Fascia Latae: Behind The Mystery | El Paso Back Clinic® • 915-850-0900

Tensor Fascia Latae: Behind The Mystery | El Paso Back Clinic® • 915-850-0900 | Sports Injuries | Scoop.it

Chiropractor, Dr. Alexander Jimenez examines the relevant anatomy and biomechanics of the tensor fascia latae. He explains, what role it plays in pain and dysfunction, and what can be done in the presence of a tight and overactive TFL muscle.

 

The tensor fascia latae (TFL) is a hip muscle that is well known to rehabilitation therapists and allied health practitioners. It is a muscle that may play a role in pain and dysfunction in the lower limb, pelvis and spine. It is however poorly understood, as the research studies that exist on this muscle are few and far between. Furthermore, much of the research and opinions have simplified the exact anatomy of, not only the TFL, but also its anatomical relationship to the iliotibial band (ITB).

 

TFL is a muscle that has a complex anatomical arrangement with the ITB, and it performs various functional roles – not only in producing hip movement, but also imparting fascial tension through the fascia latae of the thigh and the specialised ITB. Therefore TFL also plays a key role in not only postural support during one legged stance, but also in limiting the tensile stress on the femur caused by the combination of bodyweight, ground reaction force and how these create unique bending forces on the femur.

Regional Anatomy

Discussing the anatomy of the TFL cannot be done in isolation without also discussing the anatomy of the iliotibial band/tract (ITB or ITT). Pare et al (1981) have presented arguably the most comprehensive anatomical and electomyographical study (EMG) study on the TFL to date(1). This followed a much earlier study in 1958 when Kaplan presented an exhaustive study on the TFL and iliotibial tract(2).

 

Interestingly, Kaplan extended his study further by comparing the TFL and ITB in humans to other primate and mammals and discovered that human beings are the only mammals to have a defined ITB. Gottschalk et al (1997) also added a substantial amount of knowledge regarding the anatomy and function of both the TFL and ITB(3). In this millennium, Fairclough et al (2006)(4) and Feto et al (2002)(5) have provided even further knowledge of the TFL and its relationship to the ITB via cadaveric and biomechanical modelling studies.

TFL & MLL

The general consensus is that the TFL originates on the iliac crest starting at the ASIS (just lateral to the origin of the sartorious), and extends posteriorly along the iliac crest about 2 to 5 cm to incorporate both bony investments into the iliac crest and investments onto the gluteal fascia(1-3). Pare et al (1981) highlights that the muscle actually has two functionally and anatomically distinct heads – the anteromedial (AM) and posterolateral (PM) head(1). These will be discussed in detail later.


The contentious issue however, is where the muscle ultimately inserts. It appears from available research, that the muscle has both a bony insertion onto the femur and a fascial insertion onto the ITB – or more specifically onto the specialised portion of the middle longitudinal layer (MLL) of the fascia lata of the thigh which we know as the ITB (see figure 1).


The ITB, also called the ‘band of Maissiat’, was originally studied in 1843 and was perceived to be a ligament that connected the ilium with the knee and was responsible for maintaining the balance of the body in stance and in motion(5). Later work by Kaplan (1954)(2) showed that human beings are the only mammals to own a distinct facial lateral band down the thigh highlighting further that the ITB may play a role in bipedal stance and balance(2). This view was further supported in biomechanical models suggested by Feto et al (2002)(5).

 

However, much later cadaveric studies showed that the exact anatomy of the ITB and its relationship to the TFL and gluteals was in fact far more complex. The fascia lata of the thigh has a rather multifaceted array of layers that all interconnect. Of particular importance to the TFL, is the middle longitudinal layer (MLL) of the fascia lata. The MLL is a thick, longitudinal connective tissue, commencing on the iliac crest and extending downwards to have several insertions. A large portion of the MLL blends with the inner transverse layer of the fascia lata to insert directly onto the femur. The MLL also has superficial fibres that extend all the way down to insert about the knee.

 

Anteriorly at the hip, the MLL envelopes the TFL so that this muscle is effectively joined and sandwiched between the superficial and deep MLL. It also has fibres that directly blend with the superficial fibres of the gluteus maximus The MLL therefore is joined in part to the gluteus maximus, and in part to the TFL.

 

To make things even more complex, as well as being enveloped by the MLL, some of the distal fibres of both heads of the TFL then insert into the MLL. The anteromedial fibres of the TFL blend with the MLL and course down the thigh to insert onto the lateral patella retinaculum. Therefore, this may influence somewhat the patella position in relation to the femoral trochlear groove.

 

However, none of these anteromedial fibres cross the knee joint to insert onto Gerdy’s tubercle, therefore they have no effect on motion at the tibia; the primary role appears to be at the hip. Some of the fibres (not all) of the posterolateral TFL, along with those superficial fibres of the gluteus maximus, invest onto the MLL and insert all the way down onto the lateral tubercle of the tibia. They therefore do cross the knee joint and thus may have a role in a stabilising the pelvis and the lower limb.

Inner TFL

What needs to be pointed out about the MLL, is that as it courses down the thigh it blends quite heavily with the inner transverse layer of the fascia lata(4). The inner transverse layer is quite developed and dense in the upper third of the thigh. These transverse fibres run obliquely to anchor strongly to the femur(4). These transverse layers represent part of the fibres that constitute the deep, thick intermuscular septum of the femur. This septum effectively forms an osteo-fascial wall between the anterior quadriceps muscle group and the posterior hamstring muscle group.

 

Fibres from the inner transverse layer also accept the superior fibres of the gluteus maximus to form an ascending tendon. The portion of the posterolateral TFL that did not blend with the MLL also blended with this ascending tendon to insert directly onto the intermuscular septum – and thus the femur. In other words, the majority of the TFL indirectly inserts onto the femur via the ascending gluteal tendon, and indirectly via the blending of the MLL to the thick transverse layer.

 

Further down the thigh, the ITB remains a thickened portion of the fascia lata, creating the fascial barrier between the anterior quadriceps and the posterior hamstrings. It completely surrounds the thigh, is anchored to the distal lateral femoral shaft by strong obliquely directed fibrous strands that can represent a tendon enthuses, and is continuous with the patellar retinaculum(4). The presence of these fibrous anchoring strands divides the ITB into a proximal ‘tendinous’ portion and a distal ‘ligamentous’ portion(4). Therefore Fairclough et al (2006) argue that the TFL has very little involvement in tibia movement and knee function and its role is primarily directed at the hip(4).

 

Based on the current anatomical understanding of the TFL, the following points can be summarised;

 

  • The anterolateral fibres of the TFL blend with a component of the MLL that inserts onto the lateral patella retinaculum.
  • The posterolateral fibres insert into essentially 2 parts:

 

1. MLL component that inserts onto the tibia

 

2. Femur via the ascending gluteal tendon

 

  • The superficial MLL appears to course downwards to insert either onto the patella or the tibia.
  • The deep MLL inserts onto the femur, via its thick blending with the deep transverse layer of the fascia latae.

 

This complex arrangement of insertions effectively influences the way the muscle works around the hip and knee.

Function Of The TFL

Anteromedial fibres (AM)

The main role of this functional head is to flex the hip in open kinetic chain movements such as hip flexion during the swing phase of gait. This has been confirmed via EMG and electrical stimulation experiments(1). The muscle becomes silent upon heel strike, suggesting that the muscle needs to be inactive to allow hip extension to occur during stance phase. The muscle is most active during the acceleration phase of running, again suggesting its main role is as a powerful hip flexor(1).

 

In pure open kinetic-chain movement, the AM fibres are most active in hip flexion movements and also in abduction movements. It is silent however if the hip is externally rotated whilst abducting – an important consideration when prescribing hip rehabilitation exercises for the gluteals and other hip external rotators(6).

Posterolateral fibres (PL)

These fibres are most active during stance phase of gait. This suggests the muscle acts as a major hip stabiliser in single leg stance by activating its hip abduction role. Interestingly the superior portion of the gluteus maximus is also active during this walking phase. Considering that the PL head has fibres that join the tendon coming from the superior gluteus maximus, this suggests that the PL fibres and superior gluteus maximus work synergistically to control pelvic stability in stance phase(1).

 

Both the TFL and gluteus maximus exert their influence as a hip muscle through the investments they have with the MLL, the deep transverse layer of the fascia lata and the intermuscular septum. They effectively insert onto the femur via this complex web of fascia and are thus considered muscles originating at the pelvis and inserting onto the femur. In pure open kinetic chain movements, the PL fibres are active in all hip internal rotation movements and in abduction movements. Similar to the AM fibres, the PL fibres stay silent if the hip is abducting whilst in external rotation(6).

Role At The knee

Most of the comprehensive studies investigating the role of TFL in influencing knee movements and patella stability find it difficult to identify a direct role for the TFL in knee function. It almost certainly does not contribute to knee extension, flexion or rotation(4). Therefore, all previous descriptions of the TFL being a synergistic knee extender with the quadriceps or an externally rotator of the tibia can almost certainly be discarded. It is also doubtful that the TFL plays an active role in pulling the patella laterally. The most likely role the TFL has in knee patella stability is indirectly, through maintaining the tension in the fascia lata and thus the distal portion of the ITB that blends with the patella retinaculum(10).

The TFL As A ‘Fascial Tensioner’

It has been suggested that the TFL also acts on the fascia latae of the thigh by maintaining fascia tension during movement. Mike Benjamin in 2009 highlighted how extensive the fascia lata of the thigh is(7). It is a complex arrangement of fascial planes that have variable thickness and development over the thigh. It has a loose anterior and posterior layer, which cover the quadriceps and hamstrings respectively. The loose anterior superficial layer would most likely ‘bunch up’ during knee extension movements if there did not exist some manner of tensioning system for the fascia to maintain the fascial envelope. Similarly, the posterior fascia latae would most likely bunch up during knee flexion movements.

 

The most likely muscles to maintain this fascial tension during knee movement, based on their anatomical arrangement with the fascia lata would be the TFL anteriorly and superior gluteus maximus posteriorly. That is, the TFL would become slightly active in knee extension to gradually retract the fascia upwards whilst the knee extended – to prevent crimping and buckling of the anterior fascia. Similarly, the gluteus maximus can maintain fascial tension during knee flexion movements.

Femur Tensile Force

One of the most fascinating roles assigned to the ITB is the role it has in reducing the bending and tensile force on the lateral femur. Humans walk on two feet, and for a part of the gait cycle they are in one-leg stance. This can create large lateral femur tensile forces and medial femur compression forces, which if left unchecked, would create a varus effect of the femur and effectively ‘bow’ the femur.

 

In 1982, Jacob and Huggler (1982) investigated the function of the ITB and concluded that the varus bending forces on the femur could be partially relieved by tensioning the ITB(8). Even earlier than this, Rybicki et al (1972) looked at the stresses on the femur caused by the varus force on the bone and also found that by increasing the tension in the ITB the lateral tension force and the medial compression force on the femur would both be reduced(9). The attached musculature such as the TFL and gluteus maximus would further tension the ITB and reduce this lateral tension force on the femur.

 

Feto et al (2002) provide a comprehensive biomechanical review of the role that the ITB and associated muscles play on creating a ‘compression gradient’ along the lateral femur – effectively preventing distortion of the lateral femur due to the tensile effect of downwardly directed gravity on the varus forces acting on the femur(5).

TFL Dysfunction

For all the problems that the TFL poses to patients and therapists alike, almost nothing exists in the literature that highlights the role this muscle has in dysfunction. All theories and ideas are based on clinical reasoning and assumptions. The most interesting observation regarding TFL and dysfunction is the role it has in causing hip internal rotation/flexion during the stance phase of gait.

 

It is common and habitual for patients complaining of lower limb overuse injuries or low back/SIJ pain to demonstrate an exaggerated hip flexion/ internal rotation position during functional movements on one leg. That is, they demonstrate a positive Trendelenberg sign during one-leg stance (opposite side of pelvis drops down) and the stance hip assumes an internally rotated and flexed position. It appears as if they are ‘dropping out the back pocket’ on their stance leg.

 

This pathomechanic then creates a valgus collapse at the knee joint, and this has a direct mechanical influence on the ‘Q angle’ of the knee. With an increase in the ‘Q angle’ the patella has a tendency to drag laterally and compress against the lateral femoral condyle. This may then lead to patellofemoral pain at the knee.

 

The most plausible explanation for the Trendelenburg sign and the valgus knee collapse is that the TFL maintains pelvic stability in one-leg stance by initiating its abduction role. However if unchecked, the TFL will also exhibit its hip flexion/internal rotation role. The gluteus maximus and other hip external rotators should in theory check this flexion/internal rotation by providing and equal and opposite external rotation/extension role.

 

Gottschalk et al (1989) highlighted how the gluteus medius and minimus primarily act on the hip joint by providing a compressive and stabilising role. They do little to assist in maintaining a stable pelvic position. This role is assigned to the TFL and gluteus maximus(3).

 

The underlying principle behind why the TFL is such an influential muscle in pelvic dysfunction, is that the TFL has the greatest mechanical advantage to influence the pelvis and hip joint. It is the most anterior muscle at the front of the hip. It therefore has the greatest leverage advantage to induce a flexion posture or an anterior tilt of the ilium. Viewing the hip from in front, the TFL is also the most lateral muscle on the hip. It also therefore has the greatest leverage to affect abduction of the hip. This explains why such as small muscle can have such a large influence.

Management

Assessing tightness in the TFL can be performed using an ‘Ober Test’ or a ‘Thomas Test’.

Ober test (see figures 2a and 2b)

Start position – The client is positioned in side-lying, with the unaffected side down. The pelvis and spine are in neutral alignment, with the bottom leg flexed for support. The uppermost leg is extended and needs to be above the horizontal. The hip is laterally rotated and extended, as far as no lumbar extension occurs.

 

Movement – The client actively flattens the waist towards the floor and holds the leg in slight abduction and lateral rotation. He/she client is then instructed to slowly lower the leg towards the floor until the TFL-ITB hangs on the greater trochanter and cannot lower any further. The key to an accurate test is not letting the pelvis move, either into lateral tilt, anterior tilt or rotation. As the leg lowers, the hip should not flex or medially rotate. It’s essential to maintain the laterally rotated position of the hip. Ideally, the leg should lower into at least 10 to 15 degrees adduction without loss of proximal control of the pelvis or hip. The TFL-ITB lacks extensibility if the leg does not adduct sufficiently.

Thomas test (see figure 3)

On a plinth, the patient lies supine, with the untested leg held in hip flexion. The tested leg is then forced into extension and adduction. If the tested leg is unable to attain a horizontal alignment and is held in flexion and/or abduction, this is indicative of tightness in the TFL.

Managing Tightness In The TFL

Managing the overactive/tight TFL comes with 2 important criteria: it must be stretched and it must be massaged/ manipulated. The most effective stretch for the TFL is in the knee-down hip flexor stretch (see figure 4). If you are stretching the left TFL:

 

1. Kneel on the left knee with the right leg at 90 degrees hip flexion and knee flexion.

 

2. Push the left hip forward until the slack is taken up (this takes up the flexion component).

 

3. Place your hands on the right thigh and twist the trunk around to the right whilst the pelvis remains facing forward (this induces an external rotation of the hip which adds to the rotation component of the stretch).

 

4. If you have any slack left, push the left outwards (this takes up the abduction component).

 

5. Finally, isometrically contract the right hamstring by attempting to drag the left heel backwards (this induces posterior pelvis tilt that takes up the anterior tilt component).

 

To self massage or trigger the TFL (figure 5), have the client lie on their side and place a trigger ball/Muscle Mate/Posture Pro under the TFL and apply gentle pressure. The hip, knee and ankle need to stay in a straight line with the body. This can be performed as a rolling type movement or as sustained pressure to relieve the trigger points within the muscle.

Conclusion

TFL is a muscle that acts both on the hip joint to create hip/pelvic dysfunction and it also acts on creating tension in the fascia latae and its specialised portion known as the ITB. Overactivity in this muscle can create a direct mechanical effect that creates excessive lateral tension on the patella and thus patellofemoral pain and it can also be implicated in low back syndromes that are caused by excessive anterior pelvic tilt and lumbar spine extension. It is a muscle that needs regular massage and stretching.

 

References
1. Journal of Bone and Joint Surgery. 1981. 63: 1457-1471
2. Journal of Bone and Joint Surgery. 1958. 40: 817-832
3. Journal of Anatomy. 1989. 166: 179-189
4. J of Anatomy. 2006. 208; 309-316
5. J Orthop Sci. 2002. 7:724–730
6. Journal of orthopaedic & sports physical therapy. 2013. 43(2); 54-65
7. Journal of Anatomy. 2009. 214: 1-18
8. Jacob HA, Huggler AH. In vivo investigations of the mechanical function of the tractus iliotibialis. In Huiskes R, von Campen DH, de Wijn JR, editors. Biomechanics, principles and applications: selected proceedings of the 3rd
General Meeting of the European Society of Biomechanics, Nijmegen, The Netherlands, January 1982. The Hague: Nijhoff; 1982
9. J Biomech. 1972;5:203–15
10. Journal of Arthroscopic and Related Research. 2007. 23(3): 269-274

Dr. Alex Jimenez's insight:

Chiropractor, Dr. Alexander Jimenez examines the relevant anatomy and biomechanics of the tensor fascia latae. 

For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900

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