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Client Overview
The client in this study is a 29 year old female, who weighs 10 stone 2 pounds and height is 5ft 2 ins, she takes part in regular exercise consisting of cardiovascular and resistance training 2-3 times a week. The client works part-time as a retail assistant which includes the client being on her feet and active for the most of the day, she has previously participated in sports such as ballet from the age of 10-16 years and football from the age of 11-17years. The client is currently suffering from patella joint pain, this could potentially be due to genu valgum as she is showing signs of valgum from the postural analysis assessments. The aim of the corrective exercise for this client is to analyse the clients posture, to find any compensations of genu valgum and prevent the injury from becoming worse. Using corrective exercises such as PNF stretching, self myofascial release and muscle strengthening exercises using resistance bands and the F.I.T.T principles to increase joint range of motion (ROM) and improve any muscular imbalance the client may have.
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Anterior Cruciate Ligament (ACL) Injury in females
Recent studies indicate that altered lower-extremity neuromusculoskeletal control imbalances can increase the risk of acute injuries such as ACL ruptures (Baumher et al 1995). Women have demonstrated a lower relative knee flexor torque during landing in comparison to men, women also presented greater side to side differences in normalised hamstring complex peak torque (Hewitt et al, 1996).
Insufficient neuromusculoskeletal control of lower limb biomechnics, particularly frontal plane control of the knee, leads to high-risk patterns in female athletes during executution of common albeit potentially hazardous, movements (Hewett et al, 2005).These differences in values measures (ligament dominance) and limb to limb asymmetries (leg dominance) reflect neuromusculoskeletal control deficits that may be indicative of decreased dynamic knee joint control in female athletes (Ford et al, 2003).
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Static postural analysis Q Angle
The NASM, (2010) illustrated that malalignment of the patella within the femoral trochlea is commonly associated with an excessive Q Angle. The Q angle is formed by a line drawn from the anterior superior iliac spine, to the centre of patella and a second line is drawn from the centre of the patella through the tibial tubercle.
Holmes and Clancy, (1998) describe the Q angle as “an attempt to measure the vector forces applied to the patella” and is responsible for guiding the patella within the femoral trochlea during the knee flexion and extension. A large q angle is believed to facilitate a excessive lateral tracking of the patella, which can develop into Patellofemoral pain (PFP) (Huberti, 1984).
According to Powers, (2003) the underlying origins of an excessive Q angle consist of femoral anteversion, external tibial torsion, genu valgum and foot hyper pronation. Muscle activation of the quadriceps which attaches to the patella may aslo influence patellar alignment and potentially PFP.
Researchers have suggested that the oblique fibres of the vastus medialis must activate earlier or at the same time as the vastus lateralis because a delay in the vastus medialis oblique activation may lateralize the patella leading to suboptimal tracking influencing intensified stress on the patellar surface, cartilage damage and pain (Voight & Wieder, 1991).
According Rencher et al, (2015) to it appears there is no published research on the acute effects of corrective exercise and whether or not it can improve standing postural alignment, however this study only uses college ages males which suggests the results are not generalizable to other individuals. Rencher et al, (2015) also suugest further research is needed to discuss how much and to what extent corrective exercise can minimize musculosketal pain, improve functional movement patterns and enhance activities of daily living.
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Static Posture Analysis
Postural analysis of client A.
Posterior view: The Q angle.
Left hip to knee ratio shows an angle of 21 degrees.
Right hip knee ratio shows an angle of 19 degrees
Postural analysis of client A.
Anterior view: The Q angle.
Left hip to knee ratio shows an angle of 21 degrees.
Right hip to knee ratio shows an angle of 19 degrees.
Using the NASM, (2010) continuum for knee assessment and observations, using a static posture assessment to identify genu valgum. Looking for pronation distortion syndrome (PDS), tibial and femoral adduction, also internal rotation, this positioning of the kneecap place excessive stress on the muscle and connective tissue involved in the joint during dynamic movement.
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Over head squat analysis
The NASM, (2010) continuum for movement posture analysis suggests using the overhead squat analysis if the knee moves adducts and internally rotates or if the knee abducts and externally rotates, this could also suggest potential menu valgum.
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Anterior view of the overhead squat analysis used to observe potential postural distortion syndrome.
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Posterior view of the overhead squat analysis used to observe potential postural distortion syndrome.
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After analysing the clients overhead squat analysis it was clear there was reason for applied corrective exercises to be implemented as the client shown a clear inwards rotation on the left leg and an outwards rotation on the right leg. The clients arms also lean forward during the overhead squat analysis however this is difficult to observe due to the camera angle the recording is taken at.
According to the NASM, (2014) the knee moving inward during the overhead squat (excessive compensatory pronation) could possibly be indicative of calf, tensor fascia latae, and adductor tightness. This compensation may also be due to anterior tibialis, posterior tibias and gluteus medium and maximus weakness.
This compensation could be due to lower leg or possible hip dysfunction, it may benefit to use the modified version of the overhead squat with the heels being elevated, this could determine where the initial cause is coming from, whether it is the lower leg or hip.
The NASM, (2014) also suggests that an outwards tilt during the overhead squat assessment, may be indicative of tightness in the lateral gastrocnemius and soleus, performs and bicep femoris, as these will contribute to external rotation of the tibia and femur. A weakness in the adductors and medial hamstring complex, this may influence internal rotation of the tibia and femur.
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Anterior view of the gait analysis of the client showing signs of flat feet and inwards rotation of the ankle and patella joint, also a slight lateral hip shift.
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Nueromusculoskeletal control imbalances are often evident in adolescent female athletes, which include ligament dominance (a lower - extremity frontal plane stability), quadriceps dominance (decreased relative strength or recruitment of the posterior chain musculature). to target ligament dominance deficits, the health and fitness professional should instruct the individual to use the knee as a single - plane (sagittal) hinge joint allowing flexion and extension, not values and varus motion at the knee. The health and fitness professional should also use training movements that will facilitate both identification and correction of knee motion on the sagittal plane may be achieved through progressive exercises that challenge the nueromusculoskeletal system. (Myer, 2004).
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Goniometer Test
According to Webster, (2018) the medical definition of a goniometer is an instrument for measuring angles (as of a joint or the skull).
According to Nussbaumer, (2010) a study conducted on Range of Motion (ROM) suggested that the goniometer was liable for overestimating results, however this particular study only used 15 participants which is considered quite small and all of which were sex and age matched suggesting a small differentiation in the results were likely to be significant.
However Lea & Gerhardt, (1995) suggest the advantages of goniometry are the simplicity in assessing ROM, the direct measurement of joint angles without any data reduction process and the low cost of the instrument. The two-arm goniometer is still the most commonly used, economical and portable device for the evaluation of ROM.
On the contrary using goniometric measurements to test for menu valgum is suggested by the NASM, (2010) decreased dorsiflexion (less than 15degrees) or decreased knee extension in a 90/90 position (hamstring complex - biceps femurs)
The goniometer illustrated the client’s Q angle on the left leg to be an angle of 21°.
The goniometer test illustrated the clients Q angle on the right leg to be an angle of 19°.
According to Horton and Hall, (1989) consider the normative data for the Q angle in females varies from 15.8 degrees and 20.3 degrees. suggesting the client in this study is still considered to have a large q angle and should be considering corrective exercises to prevent any injuries occurring such as PFP and ACL injuries.
However Davies and Larson, (1978) Do not state a normal value range for the Q angle but describe anything above 20 degrees to be excessive, suggesting the client in this study is considered to have an excessive q angle on the left leg as it is above 20 degrees.
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Self myofascial release
Self myofascial release is a flexibility technique that focuses on neural and fascial systems in the body. Self myofascial release concentrates on alleviating myofascial trigger points and areas of hyperirritability located within a band of muscle. This style of stretching includes the concept of autogenic inhibition to improve soft-tissue extensibility. after a sensitive region has been identified, hold the foam roller on that area for a 30 seconds to release tension in the muscle band (Youdas et al, 2003)
Sutton, (2016) defined self myofascial release as “A type of soft tissue therapy used in osteopathy to release physically restricted musculoskeletal groups. It is believed that chronic tension and trauma cause the fascia, which envelop muscle, to become fixed in a particular position, known as a myofascial restriction. Manipulation of the myofascial group is believed to resolve the restriction”.
Macdonald et al, (2013) has illustrated self myofascial release to increase acute flexibility to last for atleast 10 minutes post intervention. However Jay, et al, (2014) found that there were no significant differences in flexibility at 30 minutes post intervention between FR and a control.
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Video 1: Self myofascial release on the peroneals holding on tender areas for 30 seconds as suggested by Youdas et al (2003) to improve soft tissue extensibility and release tension in the muscle band.
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Video 2: Self myofascial release on the gastrocnemius/soleus holding on tender areas for 30 seconds as suggested by Youdas et al (2003) to improve soft tissue extensibility and release tension in the muscle band.
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