Mat Mid-Term Review

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1) What is MAT?

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• Biomechanically based evaluation & treatment system.
• System of Checks & Balances. (Makes it different from anything)
• Structure dictates function & function dictates structure.
• MAT is a systematic approach that is reproducible.
• MAT provides a unique look at the muscular systems role in injury.
• MAT fills the void in conventional rehab protocols.
• ROM becomes indicator for muscle weakness, not tightness (tightness secondary to weakness). MAT looks at tightness as secondary to weakness, whereas most things look at TIGHTNESS as the issue. Analyze muscle weakness as priority over muscle tightness as a cause of muscle dysfunction.
• Systematic approach of analyzing the body and finding out where muscular imbalances exist and trying to correct them. Finding out where there is increased stress on certain tissues.
• MAT looks at the body as if it’s doing everything perfectly: given the body’s current state. The body adapts to whatever it is dealt with so that it can function to its best ability. MAT is discovering where the body is functioning less than OPTIMAL.
• The tools in MAT are not unique; MAT is unique in how those tools are used.
• Tightness is a protective mechanism. Why is the body not allowing you to go into that ROM?
• We treat what the body tells us to treat, not what we “think we need to treat.”

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2) Anatomy of Rotator Cuff Injury

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• Rotator Cuff Muscles (SITS): supraspinatus, Infraspinatus teres minor and Subscapularis. 3 attach on greater tubercle of humerus, 1 attaches on lesser tubercle of humerus.
• These muscles are considered to be part of a “cuff” because the inserting tendons of each muscle of the cuff blend with and reinforce the GH capsule.
• The rotator cuff consists of the tendinous insertions of the Subscapularis, Supraspinatus, Infraspinatus, and Teres Minor muscles. These tendons form a hood that surrounds the head of the humerus anteriorly, superiorly and posteriorly. Co-contraction of these muscles stabilizes the Glenohumeral joint during normal activities.
• The Glenohumeral joint lacks bony stability and relies on its capsular tissue, glenoid labrum, ligaments, and musculature about the shoulder joint for its stability.
• Would you start with scapular stability?
• Reported on 65 patients who had pain and discomfort for more than two years after initial acromioplasty for impingement syndrome without rotator cuff tear. It was noted that the diagnosis and operative procedure were correct in only 12 of the patients while the remainder either had diagnostic errors or operative errors. Subsequent operative intervention resulted in a 75% good to excellent rating. Of the diagnostic errors, 25% were because of instability of the shoulder not being recognized preoperatively before treatment was undertaken.

THE ROTATOR CUFF:

• Holds head of humerus in glenoid
• Depends on scapular stability!
• Pulls head of humerus down in abduction, counteracting the upward pull of the deltoid.
• All 4 muscles have separate divisions that have their own independent function.
• Are all of them doing their job?
• What is their role in internal impingement?
• Rotates humerus in elevation while pulling the humeral head downward to neutralize the upward pull of the deltoid.

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3) Patella Femoral Pain

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Patella-Femoral Syndrome:

• Transverse plane dysfunction
• Limited Dorsiflexion causing excessive hip translation.
• Check hip rotation
• “Strengthen VMO”
• “Quad vs. Ham ratio”
• Lateral leg muscles
• Lateral Release?

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4) Significance of ROM Exam

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• It’s our starting point!
• Tightness represents joint instability in extreme ranges. Tightness secondary to weakness.
• Indicator of limitations in motion that relate to muscle weakness.
• Huge piece of “checks and balances” did treating the muscle open up the range?
• ROM can help show a client they are being helped, some don’t recognize that they are getting positionally stronger, but many clients will notice an opening of ROM.
• You can show them that not only have they opened up a range, but they are also stronger as well.
• Potential muscles to test and treat.
• Sustaining treatment effectiveness.
• Can show client they have more range/flexibility in addition to stability.
• Must look at the relationship that each muscle has at each joint & must consider the muscles role in joints that it does not cross.

Joint ROM Exam: Law of Reciprocal Inhibition (reversed)

• Suggests that when a muscle is unable to contract due to limited Proprioceptive stimulation, the inhibitory response sent to the antagonist muscle is reduced.
• Identifies muscle weakness rather than tightness
• Correlating the ROM Evaluation: If limited motion is identified, the muscle that would contract to create that motion must be tested for weakness.

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5) Pronation Vs. Supination



NOT SPECIFICALLY JUST IN THE FOOT:

• All movement is based upon the concepts of pronation & Supination, it occurs at each joint.
• Pronation & Supination in the foot are terms used to describe “composite” motions that have components of, or are coupled to, each of the cardinal motions.
PRONATION:
• PRONATION IN THE FOOT= Motion about an axis that results in coupled motions of Dorsiflexion, eversion, and abduction.
• Collapsing of the body.
• Generally flexion at all joints.
• Generally people don’t control pronation as well as they age.
• Works with gravity: effortless
• Creates storage of elastic energy.
• Occurs at each joint.
• Component of shock absorption.
• Eccentric muscle control regulate degree of Pronation (3X stronger eccentrically). EX. Driving a car 100 mph into a tree
• TRANSFORMATION KEY:
• Transformation is the key to all functional motion. A timing relationship: all joints must transform together (lunge). Trying to come out of this pronated position, into a supinated position. Normally one or more joints get stuck and stay in pronation, and that’s where most injuries occur.
• Ex. Hip going into Supination, knee is, but foot is stuck in pronation, you are trying to propel off of something that is loose. Or foot is going into Supination as well as the hip, but the knee doesn’t = injury.
• Golf swing there is simultaneous pronation and Supination. Transferring energy to opposite pronation and Supination. Its all about timing.

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Characteristics of Pronation:
• Flattened arch
• Internally rotated tibia
• Knee flexion/valgus
• Internally rotated femur
• Hip flexion/ant. Pelvic tilt
• Trunk flexion
• Protraction/forward shoulders

SUPINATION:
• SUPINATION IN THE FOOT = A motion about an axis that results in coupled motions of plantarflexion, inversion, and adduction.
• Movement against gravity.
• Extension through all planes. (Extension of the body)
• Works with gravity: requires effort
• Propulsion component
• Produces concentric force.
• Elastic Energy recoil.
• Propulsive phase of activity.
• Elastic recoil part the transformation. Store all the energy and rebound from it.

• Characteristics of Supination:
• High arch
• Externally rotated tibia
• Knee extension/varus
• Externally rotated femur
• Hip extension/post. Pelvic tilt
• Trunk extension
• Retraction/shoulders erect

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6) Is My Muscle Weak?

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• Dampening of neural input through the muscles full range (up to 50% strength loss) if a muscle is “weak”.
• Instability is a sign of muscle weakness
• Muscle weakness is going to show up in the shortened position.
• The muscle spindle must constantly be in a stretch when your muscle is contracting to the shortened position. The slow twitch fibers must take up the slack of the muscle spindle. The Alpha/gamma co-activation tells the slow twitch fibers to take up the slack and contract, the gamma motor neuron controls the slow twitch fibers.
• They are inhibited/weak: Not shut down or paralyzed. Muscles less than optimal = abhorrent.
• Muscle spindle must be on a stretch, slow twitch fibers must take up slack in shortened position, controlled by Gamma Motor Neuron.
• If a muscle is weak it doesn’t mean that it’s not working. It means that it’s not working at the extremes of the ROM & that its not working optimally through the entire range.
• Body has the ability to sense force via the muscular system, & when not every muscle is working properly, you’re functioning less than optimal.

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7) MAT as a Pre-requisite to Exercise

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• Identifies imbalances in order to not reinforce the imbalance (compensation).
• Strong gets stronger & weak stay weak, magnifying our own muscular imbalances (if the muscles aren’t working optimally). MAT prior to exercise is a way to prevent that.
• Potential prevention of injury.
• Restore efficient mechanics.
• Checks & balances (of person’s current status).
• MAT allows the trainer to assess the clients current state “joint by joint” to see what their status is, & what exercises would be safe & efficient for that individual to perform. Not over-doing what their body can handle.
• It’s like driving a car 90 mph across the country with bad alignment.
• Most trainers use the PAR-Q as a prerequisite to exercise to show if the client is able to perform exercise. All the PAR-Q shows is if the client will “die” if they do exercise. The PAR-Q doesn’t show anything about the current mechanical status of the client, it’s whether or not Im going to get sued if they exercise.

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8) Stability & Mobility

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• You are only as good as the motion that you can control.
• Stability training: Instability + Instability = More Instability! Ex. Squatting on a ball. Mobility without Stability = Vulnerability
• You’re putting someone on an unstable surface to increase proprioception, yet you lose proprioception when you’re unstable.
• Stability training is only bad in the wrong environment: It would be good to do MAT as a prerequisite to stability training.
• If you increase motion you must make sure that you have stability through the new found range.
• Closing the gap between active & passive ROM. Can they get to the position actively??
• Symmetry.
• The body will only allow motion that it can control. As the body senses stability, it will give you the equal amount of mobility.
• Joint Stability Vs. Joint Mobility
• ROM IS GOOD: If its stable (Martial Arts)
• Mobility will be limited if there is no sense of muscular stability.
• Muscles support the joint
• Body will naturally protect the joint when muscles cannot support.
• Ligaments are 2nd form of protection: not tension regulator

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9) The Role of “Functional” Exercises with MAT

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• MAT is a pre-requisite to.
• “Functional” vs. Transfer.
• Use to reinforce what we have done through MAT.
• Use functional exercises.
• Cues don’t work to turn a muscle back on; cues only make the problem appear as if it is gone.
• Functional as integrated: If you do integrated exercise & already have a compensatory pattern then you are simply reinforcing those patters & teaching your body to compensate more! Through “functional” exercise, you are becoming LESS functional!
• Need to teach things to work together, but if they aren’t currently doing that then you are reinforcing dysfunction.

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10) Basis for Isometrics

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• Inhibited muscles have least Proprioceptive input in shortened position.
• Gamma Biasing, spindle under slack.
• Increase gamma input into spindle for more Proprioceptive feedback.
• Once joint senses stability in that position, it will allow it to move into that position.
• Isometrics: Work with the system.
• 15º carryover: If pain, move to position of no pain.
• Getting Alpha & Gamma co-activation. Looking for smallest of both fibers to fire simultaneously (neurons in intrafusal fibers).
• Place muscle in specific joint angle, maintain extreme of motion, patient activates into plane of weakness.
• Perform 6 contractions: hold 6 seconds with each contraction.
• Increase Force: 20%, 40%, 60%, 80%, 100% (2x’s).

Corrective Isometrics:
• Based on law of reciprocal inhibition. Need to activate agonist in order to inhibit antagonist.
• Least stressful and most controlled form of exercise when dealing with injury.
• Purpose: to recruit gamma motor neurons to develop internal stretch in the muscle spindles.
• Spindle sends feedback to the CNS based on tension.
• Since the spindle is under slack there will be less tension in the shortened position.
• Isometrics demonstrate less muscle spindle stretch lag and unloading effects and are more responsive to resistance. Over time this will increase impulse to brain, thus in turn will increase muscle strength.
• When attempt to re-educate a muscle through concentric training alone, the body will compensate.

30-60-90 Principle:
• 15º Carryover in isometric strengthening
• Reinforce 30º to each side of weakness
• Result: 60º Neurological gain.
• Use pain as a regulator!

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11) Relationship between the Suspension & support Systems

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• Suspension: Hips
• Support: Feet
• Valgus: Knee In
• Veras: Knee Out
• Weakness in hips: crashing down on the feet.
• Weakness in feet: Hip rotators hanging on for dear life.
• Consider all muscles that affect joint motion.
• Muscle doesn’t have to cross a joint to affect motion in that joint.
• Sometimes a foot problem can be a hip problem or vice versa.

Suspension System:
• The hip musculature (proximal)
• The foundation: most motion, largest muscles
• If suspension system gives out?

Reactive System:
• The knee (middle)
• Virtually a hinge joint, responding to hip and foot

Support System:
• The foot (distal)
• Gains foundation to the ground (mobile adapter into rigid lever).
• If support system gives out?

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12) Considerations for Hip DJD

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DJD: Hip
• Will lack total ROM in internal rotation
• Treat all muscles related to hip internal rotation
• Goal is to increase the surface area of weak to take away constant irritation.
• Consider the compensations being reinforced causing decreased muscle function.
• Goal is to increase surface area of wear.
• Limitations: flexion & rotation.
• Provide a better environment for healing.
• Abnormal mechanics.
• Decrease pain & progression of DJD.
• Restore mechanics, increase surface area, decrease pain, progression, & increase quality of life.
• Hardest thing to get back is hip flexion & internal rotation, adduction.

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13) Role of MAT Post Surgically

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• Trauma to tissue during surgery and due to trauma.
• Look at what caused the surgery in the first place.
• Intervene ASAP once cleared, the longer waited, the more compensation built and more time it will take.
• Use AROM as indicator: DO NOT muscle test.
• Wait until it is advised by a doctor or they are cleared for exercise/activity.
• Surgery is one of the biggest causes of muscle inhibition.
• Work away from the area operated on due to the body constantly protecting and the sensitivity.
• Gradually work toward the area of operation as they are ready.
• When people have surgeries & injuries we need to think: why did this happen

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14) Considerations for Lateral Release

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• Hypertonicity of lateral structures: Pulling patella lateral into condyle.
• Is it the train or the track?
• Regulate Pronation.
• The lateral release attempts to reduce patellofemoral contact pressure and correct a maltracking patella by decreasing the force component on the patella in the lateral and posterior direction particularly in the presence of contracture or adhesion of the lateral retinaculum. Lateral release procedures have a wide spectrum of outcomes and it has been shown experimentally that unpredictable and inconsistent effects on the patellofemoral contact pressure are produced.
• This procedure is most commonly necessary in a severely valgus knee is corrected but the contracted lateral retinaculum does not allow reduction of the patella into the femoral trochlea for smooth tracking. Although the appropriate bony cuts along with lateralisation of the femoral component and medialisation of the femoral component and slight internal rotation of the tibial compenent serve to aid tracking, it is still sometimes necessary to carry out a soft tissue release. This is carried out from inside-out, parallel to the patella with its tendons, and release kept as minimal as possible so as to avoid potential patellar devascularisation.
• Lateral Release:
• Like having an extra part when you fix the car
• Treating the symptom not the cause
• The problem is still there

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15) Considerations for Growing Pains

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• Bones grow faster than muscles, muscles placed on a stretch causing inhibition & pain.
• Longer lever arms require more force by muscles.
• Instability = muscle tightness.

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16) MAT with repetitive Ankle Sprains

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• Look at the lateral stabilizers of the hip. Could be due to a lack of lateral stability, if the lateral stabilizers are weak. (Ex. Gluteus Medius)
• Muscle that support the arch of the foot
• Lack of muscular systems role in lower leg to stabilize the ankle.
• When your foot is supinated, your foot is stable. Pronation: the foot is not locked.
• If you look just at the foot, you may miss something very important.
• Hip abductor weakness shifts body’s COG laterally.
• Cause vs. Effect
• Ligament laxity vs. muscular weakness.

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17) Shoulder Joint Motion & Mechanics relating to Humeral Flexion & Abduction:



Gleno-Humeral Joint:
• Very unstable joint
• Exhibits great ranges of motion in all 3 planes
• Glenoid: tiny
• Humerus contact: like a ball on a seals nose (makes it unstable). Depends on compression of humerus in the glenoid: Goal is to keep it centered.
• Centrification - Muscles preventing joints from transrotation of the axis = Rotator cuff stabilizes the head of the humerus in the glenoid.

Shoulder Motion:
• Stability comes from compression of humeral head on glenoid.
• The shoulder does not have true reciprocal muscular activities: most are active during all shoulder motions (always co-contraction of muscles).
• Alterations in the dominance or length of any one muscle can compromise the muscle balance.

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Clavicle:
• Elevates with humeral elevation.
• Clavicular elevation begins early and ends at 90-100º of humeral elevation.
• 4º of clavicular elevation w/every 10º of humeral elevation.
• Axis is at Sternal end of Clavicle.
• Acromioclavicular Joint: 2nd axis of motion. Allows for upward and downward rotation of the scapula from motion on the horizontal axis lying in the sagittal plane.
• Sterno-clavicular Joint: 1st & 3rd axis of motion. Allows length rotation of the clavicle about 50º total motion. This occurs during elevation of the arm and somewhat during protraction & retraction. Allows upward and downward swing of the clavicle during shoulder shrugging or elevation of the arm.
• Axis of motion changes.

Scapula:
• Muscular attachments create stability.
• Position is vital for proper Glenohumeral joint motion.
• Movement impairments of scapula typically cause humerus to anteriorly and superiorly glide. Must be stable.

Scapula Motion:
• Scapulo-humeral rhythm:
• 1:2 ratio: upward rotation (60º Scapular vs. 120º Humeral = 180º of motion.
• Scapular Elevation:
• 0º - 90º: of elevation there is a 2:1 ratio of humeral elevation to scapular rotation (60º Humeral = 30º Scapular). Axis: Superior angle of scapula. Inferior angle moves outward and AC moves upward. Lag up to 30º abduction (more humeral).
• 90º - 150º: of elevation there is a 2:1 ratio of humeral elevation to scapular rotation (20º Scapular = 40º Humeral). Axis of rotation shifts to Acromial end due to tension on acromion-clavicular ligaments.
• 150º - 180º: of elevation the axis shifts back to the superior angle of scapula to complete the final phase of motion (10º Scapular = 20º Humeral).
• What the specific scapula muscles do in rhythm (muscle function/weakness slides).
• Muscle involvement (Muscle Function/Weakness slides)
• Scapula Motions: None of the movements are true moments, all have rotation.
• Retraction = Component of downward rotation.
• Protraction = Component of upward rotation.
• Elevation = Component of upward rotation.
• Depression = Component of downward rotation.

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18) Considerations for Impingement

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• Impingement: Joint Structure & Function:
• When the Subacromial space is narrowed, the likelihood of impingement of the rotator cuff tendons and Subacromial bursa during elevation of the arm increases. Narrowing of the space can be caused b changes in the shape of the acromion inferiorly, changes in the slope of the acromion etc. Abnormal scapular or humeral motions can also functionally reduce the size of the Suprahumeral space.
• Inadequate posterior tipping or upward rotation of the scapula during arm elevation or abnormal superior or anterior translation of the humeral head on the glenoid fossa brings the humeral head and rotator cuff tendons in closer proximity to the humerus and increases the risk of impingement.
• Abnormal anatomic factors and motion abnormalities have been identified in persons with impingement, as well as a reduction in the available Subacromial space during arm elevation.
• Rotator cuff muscles that have something to anchor off of.
• Scapular stabilization.
• Thoracic spine extension.
• Check supinators last, relative to shoulder muscles.
• Move into cervical spine.
• Last resort: Look at pronation.
• Impingement, Tendonitis can each be a result of mechanical imbalances.

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19) What is the difference between Muscle Weakness & Inhibition?

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• Does something that’s weak have to be inhibited? No. Is something that’s inhibited, weak? It all depends on how long it’s been shut off.
• The reason things continue to shut back down, is because they are not only inhibited, they are also weak.
• What shuts something down, or inhibits a muscle? Stress trauma & overuse
• Stress trauma & overuse is different for every group of muscle and different people. Sometimes that part of the body can’t even handle everyday life.
• It is very possible to jumpstart a muscle and turn everything back on & a muscle to be so weak that everyday life activates end up inhibiting the muscle again. You have to regress them in their activity, and do microprogression to get that muscle strong again where it doesn’t fall back into inhibition.
• You are only as strong as your weakest link.
• Something that’s weak will get overused a lot quicker and become inhibited.
• IDENTIFYING MUSCLE WEAKNESS: Feel for instability (slow or sluggish vs. quick to respond). If question, retest 3 times. An innervated muscle will get stronger with each test.
• Muscle Inhibition:
• Due to stress, trauma, overuse, dehydration, or vitamin/mineral deficiencies, muscles will lose gamma stimulation
• Intrafusal fibers unloads: as muscle moves into shortened position, spindle sensitivity decreases
• Muscle becomes less efficient in all of its characteristics
• Lose inhibitory affect: allows the antagonist muscle to tighten up
• Law of reciprocal inhibition: in reverse
• Agonist muscle lose ability to perform its function
• Lack of proper communication from the brain
• Antagonists become hypertonic
• Synergists become more involved, acting as prime movers (synergistic dominance).
• Neutralizers may not counteract actions of other muscles (impingement)
• Leads to compensation and alterations in length tension relationships of muscles
• Sacrifice joint integrity.
• Inhibition/compensation is similar to cancer in the body, it will spread if not treated.

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20) Integrated Exercise

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• You are only as strong as your weakest link.
• Supposed to work everything as a chain?
• If you are going to perform “integrated” exercise, you can only work as hard as the weakest part of your body can handle. Everything has to work together and the second you “over do” what the weakest link can handle; your body begins compensation patterns.
• If you did isolated things, you might be able to work everything individually according to what it can handle, until the strength of your “weakest link” improves.
• This is not saying that isolated exercise is better. You eventually want to be able to begin “integrated exercise” and work everything out at the same intensity, but until you improve the strength of your weakest link, “functional exercise” will only cause DYSFUNCTION!

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21) Muscle Weakness Vs. Muscle Tightness

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• Hip flexor weakness/Hip Extensor Tightness
• Hip Extensor tightness/Hip Flexor Weakness
• Internal rotator weakness/External Rotator Tightness
• Trunk rotator weakness/trunk rotator tightness
• Dorsiflexor weakness/Plantarflexor tightness

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22) Muscle Testing:

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• Figuring out which muscles have the MAd (mechanical advantage).
• Not testing muscles, testing positions.
• Neurologically: weaknesses will be found in the shortened position since it takes longer to develop sensory feedback: basis for muscle testing.
• Muscle spindle is most receptive to sensory feedback in lengthened positions (when a muscle is in the shortened position, the spindle should be lengthened).
• Bringing muscles into the shortened range of certain positions & seeing if the spindle is tight or slack.
• Neuro-Proprioceptive Response Testing: The response-ability of a muscle to a specific and consistent applied force over TIME.
• Pain = lack of proprioception, more nociception

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23) LowerBody Injuries:



Shin Splints:
• Tearing of the muscle away from the bone.
• If the muscle was torn from the bone, how can it be repaired instantly?
• Potential: Pronating when you should be supinating or vice versa.
• Differentiate position of pain: anterior, posterior or localized.
• Consider shock absorption: ability to pronate.
• Lower leg rotation
• Switch to softer surfaces?

Achilles Tendonitis:
• Transverse plane dysfunction.
• Role with femoral rotation (hip rotation).
• Eccentric control of tibia moving forward over fixed foot: Tight hip flexors/weak extensors or Tight hamstrings/weak abdominals

Patellar Tendonitis:
• Sagittal plane dysfunction
• Inability to eccentrically control knee flexion
• Lower leg rotation
• Locked up talocrural joint

IT-Band Syndrome:
• “Tight IT-Band”
• Look at tibial rotation
• Excessive pronation
• Biarticular muscle: increases complexity
• TFL & Gluteus Maximus relationships

DJD: Knee Joint:
• “Bone on bone”
• Alignment problem
• Must increase the surface area of wear
• Consider lower and upper leg rotation
• All components of normal motion at the hip and lower leg

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Greater Trochanter Bursitis:
• Attachment to medius and minimus is on the greater trochantor.
• A muscle shut down becomes hypersensitive
• Are lateral hip muscles weak or are they placed at a mechanical disadvantage?
• Need lateral stability throughout

Piriformis Syndrome:
• A generalized diagnosis
• Cause or Symptom?
• Treat what you see
• Check ROM in hips and lower leg
• Suspension system vs. support system
• Popliteus does wonders
• Other deep rotators.

Cortisone:
• Treating a symptom
• Takes away ability to display problem
• Weakens tissue in the long run

Fusion:
• Taking away normal function of the joint
• Body will have to go somewhere else to get motion
• Must understand the mechanism of joint motion to understand how the body will be forced to compensate.

ACL Repair:
• What is the status of their function
• When trauma has affected tissue: must re-stimulate
• Many repeat surgeries
• Hip and foot may play a major role
• Isolated strength vs. integrated strength

Plantarfascitis:
• Lack of arch support
• Suspension vs. support system
• Is it primary or secondary?
• Consider previous orthodics

Neuroma:
• Compression on nerve ending between 2nd & 3rd toe
• Unstable 1st ray causing torsional stress through metatarsals

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Muscle Activation Techniques Mid-Term Review

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M.A.T. Mid-Term