Pudendal Neuralgia and Lower Extremity (Feet) Biomechanics
ICS (International Continence Society) 2011, Glasgow, Scotland
29th August - 2nd September 2011
Spasticity is a velocity-dependent increase in muscle tone and exaggeration of reflexes caused by lesions in the pyramidal tract. It is characterized by hyper-excitability of stretch reflexes and occurs due to upper motor neuron syndrome. Spasticity can be caused by cerebral injuries or conditions like traumatic brain injury, stroke, or spinal cord injury. It is assessed clinically using scales like the Modified Ashworth Scale and mechanically by measuring torque. While spasticity can cause contractures and gait difficulties, it may also have benefits like preventing edema and aiding standing.
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
Common peroneal nerve lesions often present with foot drop and loss of sensation in the lower leg and foot. The common peroneal nerve is susceptible to injury where it passes between muscles in the leg and around the fibula bone. Injuries can occur from trauma, fractures, compression, ischemia or tight footwear and result in weakness of ankle dorsiflexion. Physical exams may show reduced foot movement and sensation loss while nerve conduction studies can identify injuries. Treatment focuses on bracing, stimulation, positioning and protective devices to prevent foot drop and sprains.
Classified according to design characteristics
Minimal motion control ……. Collars that encircle the neck with fabric, resilient foam, or rigid plastic.
The Philadelphia collar has mandibular and occipital extensions; sometimes used for upper cervical injuries
Maximum orthotic control of neck
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
The document describes various techniques used in physical therapy for neuromuscular re-education and facilitation including proprioceptive neuromuscular facilitation, neurodevelopmental technique, sensory integration, Brunnstrom movement therapy, and Rood's technique. It provides details on how each technique is applied and the receptors and responses targeted through different stimuli like stretching, traction, touch, and movement.
The posterior cruciate ligament (PCL) is one of the four major ligaments of the knee. It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. The PCL prevents the femur from sliding off the anterior edge of the tibia and prevents hyperextension of the knee. Injuries to the PCL typically occur from direct blows to the flexed knee, falling on the knee, or hyperextension injuries. Treatment involves rest, bracing, and physical therapy, with surgery required for complete tears.
Spasticity is a velocity-dependent increase in muscle tone and exaggeration of reflexes caused by lesions in the pyramidal tract. It is characterized by hyper-excitability of stretch reflexes and occurs due to upper motor neuron syndrome. Spasticity can be caused by cerebral injuries or conditions like traumatic brain injury, stroke, or spinal cord injury. It is assessed clinically using scales like the Modified Ashworth Scale and mechanically by measuring torque. While spasticity can cause contractures and gait difficulties, it may also have benefits like preventing edema and aiding standing.
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
Common peroneal nerve lesions often present with foot drop and loss of sensation in the lower leg and foot. The common peroneal nerve is susceptible to injury where it passes between muscles in the leg and around the fibula bone. Injuries can occur from trauma, fractures, compression, ischemia or tight footwear and result in weakness of ankle dorsiflexion. Physical exams may show reduced foot movement and sensation loss while nerve conduction studies can identify injuries. Treatment focuses on bracing, stimulation, positioning and protective devices to prevent foot drop and sprains.
Classified according to design characteristics
Minimal motion control ……. Collars that encircle the neck with fabric, resilient foam, or rigid plastic.
The Philadelphia collar has mandibular and occipital extensions; sometimes used for upper cervical injuries
Maximum orthotic control of neck
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
The document describes various techniques used in physical therapy for neuromuscular re-education and facilitation including proprioceptive neuromuscular facilitation, neurodevelopmental technique, sensory integration, Brunnstrom movement therapy, and Rood's technique. It provides details on how each technique is applied and the receptors and responses targeted through different stimuli like stretching, traction, touch, and movement.
The posterior cruciate ligament (PCL) is one of the four major ligaments of the knee. It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. The PCL prevents the femur from sliding off the anterior edge of the tibia and prevents hyperextension of the knee. Injuries to the PCL typically occur from direct blows to the flexed knee, falling on the knee, or hyperextension injuries. Treatment involves rest, bracing, and physical therapy, with surgery required for complete tears.
This document describes three upper limb tension tests (ULTT1, ULTT2, ULTT3) used to assess the cervical spine and brachial plexus. ULTT1 involves abducting, supinating, and laterally rotating the shoulder while extending the elbow and wrist. ULTT2 adds shoulder depression while extending the elbow and laterally rotating the arm. ULTT3 (ulnar nerve bias) assesses the cubital tunnel by having the patient flex their elbow while the examiner controls their hand and arm. Precautions are described and variations discussed, including assessing different angles of abduction. The tests aim to isolate tensions and identify symptoms to determine involved structures.
This document provides information on peripheral nerve injuries, including the structure of nerves, classifications of nerve injuries, common sites of injury for specific nerves like the ulnar and radial nerves, clinical features of injuries, and treatment approaches. It details Seddon's and Sunderland's classifications of nerve injuries, which range from neurapraxia to neurotmesis depending on the severity of axonal and neural sheath damage. Specific injuries like ulnar nerve entrapment at the elbow or Guyon's canal are discussed. Both non-surgical and surgical treatment options are presented.
Patellofemoral Pain Syndrome (PFPS), commonly known as runner's knee, is a condition characterized by anterior knee pain that is aggravated by activities involving the patellofemoral joint like climbing stairs, sitting with bent knees, or squatting. It is often caused by overuse injuries and biomechanical faults that cause abnormal tracking of the patella. Examination involves assessing for factors like patellar maltracking, tight muscles, and weakness. Treatment is primarily non-operative and focuses on exercises, bracing, taping, and orthotics to address biomechanical faults and strengthen the quadriceps muscles.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
This document discusses several theories of motor control including reflex theory, hierarchical theory, dynamical systems theory, motor programming theory, system theory, and ecological theory. It provides details on the key aspects and proposals of each theory as well as examples and criticisms of each approach to understanding human movement and motor control.
This document discusses shoulder impingement syndrome, including its anatomy, causes, symptoms, diagnosis, stages, and treatment approaches. It provides details on the rotator cuff muscles, signs and symptoms of impingement, external and internal factors that can lead to impingement, stages of the syndrome, common tests used for diagnosis, goals of treatment, and manual therapy, therapeutic exercise, and preventative measures used in treatment.
Sensory integration is a neurological process that allows individuals to make sense of sensations from their body and environment. Sensory integration disorder occurs when this process is not functioning properly, making it difficult for individuals to respond appropriately. Sensory integration therapy aims to stimulate the senses through activities involving movement, touch, sound, and vision to help brains better process sensory information. Research suggests this therapy can help brains of children with sensory integration disorder change and develop through rich sensory experiences.
این ارائه توسط دکتر خیاط زاده در کارگاه رویکرد جدید بوبات در توانبخشی کودکان مبتلا به فلج مغزی ارائه گردیده است.
برای مطالعه مطالب بیشتر در این زمینه، به وب سایت فروردین مراجعه نمایید.
https://www.farvardin-group.com
This scale is used to categrise spinal cord injury patients. it helps prognosticate the spinal cord injuires. it also helps define the treatment protocols for spinal cord injury patients. American Spinal Cord Injury Association made this scale so as to make a standardization in assesemnent technique in acute spinal cord injury patients.
The McKenzie Method is a classification system and treatment approach developed by Robin McKenzie for back, neck, and extremity pain. It involves assessing a patient's response to various movements and positions to determine the cause of their pain and develop an individualized exercise plan. The goals are to centralize or reduce pain. There are three main syndromes - postural, dysfunction, and derangement - each with different treatments like posture correction, mobilizing exercises, or movements to induce a directional preference. The McKenzie Method aims to actively involve patients to self-manage their pain.
Special test for dermatomes and myotomesTafzz Sailo
The document discusses dermatomes and myotomes, which are areas of skin and muscles innervated by specific spinal nerve roots. It provides detailed instructions for testing dermatomes using pinprick and light touch tests and myotomes using resistance tests of individual muscle groups to evaluate potential nerve root injuries. Key points include identifying the spinal nerve roots that innervate specific areas of the upper and lower limbs and correlating weaknesses to the likely injured nerve roots. Diagrams depict dermatome and myotome maps to guide the clinical tests.
This document provides an overview of how to evaluate the hand. It discusses the anatomy of the hand including bones, muscles, nerves and arteries. It describes taking a patient history and examining the hand for range of motion, deformities, palpation, observation, and functional assessment including grip strength and pinch tests. It also discusses evaluating the hand for conditions like edema and outlines tools used for various assessments.
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
A 47-year-old man presented with difficulty walking and weakness in his right foot for the past 3 months. He had been in a road traffic accident 4 months prior which resulted in a fracture of both leg bones on his right side, treated with a plaster cast. After cast removal, he noticed inability to lift his right foot and it dragged on the ground when walking. Examination revealed weakness and paralysis of muscles supplied by the common peroneal nerve on the right side, with loss of sensation on the lateral leg and top of the foot. The diagnosis is a common peroneal nerve injury at the level of the fibula neck due to trauma from the accident 4 months ago.
This document discusses principles of tendon transfers for restoring lost movement. It outlines key principles such as having supple joints before transfer, using a donor tendon with adequate excursion and strength, adhering to principles of synergy and straight line of pull. The timing of transfers depends on the likelihood of nerve recovery but can be done early to aid recovery. Contraindications include a lack of suitable donor muscles or transfers for joints with stiffness. Classification systems like Sunderland and Seddon are used to describe nerve injuries requiring tendon transfers.
Waddling gait- definition|role of muscle|gait analysis|kinematic and spatiote...jasna ok
This document discusses waddling gait, which is an abnormal gait pattern seen when there is bilateral weakness of the gluteus medius muscles, the primary hip abductors. During walking, individuals with waddling gait are unable to stabilize the pelvis and it drops on both sides, causing the trunk to laterally bend and the person to walk with a wide base like a duck. Treatment focuses on strengthening exercises for the hip abductors and gluteal muscles, gait training, and balance exercises. Physiotherapy aims to improve muscle strength, correct posture, and retrain a normal walking pattern.
Trigger points are hyperirritable spots within taut bands of muscle that are painful on compression and can cause referred pain patterns. They are commonly caused by overload, injury, lack of exercise, or poor posture in sedentary individuals between 27-55 years old. Trigger points have two types - active points that cause pain at rest and latent points that cause pain with direct pressure or muscle contraction. Electrotherapy can stimulate the body's endogenous opiate system to relieve pain by using low frequency stimulation below 10 Hz with long pulse durations to activate areas of the brain and spinal cord that inhibit nociception.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
Scapular dyskinesis refers to abnormal static positioning or dynamic motion of the scapula during arm elevation and is associated with shoulder injury. It has multiple potential causes including muscle weakness or imbalance. The document discusses the muscular attachments of the scapula, types of scapular dyskinesis, its effects on dynamic stability and shoulder strength, assessment methods, and rehabilitation treatments focusing on strengthening the lower trapezius and serratus anterior muscles to achieve optimal scapular positioning.
Este documento describe el síndrome de atrapamiento del nervio pudendo, una causa de dolor pélvico crónico. Explica la anatomía del nervio pudendo y los posibles mecanismos de lesión, así como los criterios para diagnosticar este síndrome clínicamente. También resume los enfoques de evaluación, tratamiento médico, infiltraciones, fisioterapia, neuromodulación y cirugía para abordar este tipo de dolor.
Interdisciplinary Management of Complex Pelvic Pain RevisedMark Conway
This document discusses complex pelvic pain that does not fit traditional paradigms of visceral pain. It describes how these patients are often labeled negatively after standard treatments fail to provide relief for their neuropathic pain. The document focuses on three specific nerves - the ilioinguinal, obturator, and pudendal nerves - outlining their anatomy, potential causes of injury/neuropathy, diagnostic techniques, non-surgical and surgical treatment approaches, and prevention strategies. Surgical techniques for decompressing the pudendal nerve transperineally or transgluteally are also reviewed.
This document describes three upper limb tension tests (ULTT1, ULTT2, ULTT3) used to assess the cervical spine and brachial plexus. ULTT1 involves abducting, supinating, and laterally rotating the shoulder while extending the elbow and wrist. ULTT2 adds shoulder depression while extending the elbow and laterally rotating the arm. ULTT3 (ulnar nerve bias) assesses the cubital tunnel by having the patient flex their elbow while the examiner controls their hand and arm. Precautions are described and variations discussed, including assessing different angles of abduction. The tests aim to isolate tensions and identify symptoms to determine involved structures.
This document provides information on peripheral nerve injuries, including the structure of nerves, classifications of nerve injuries, common sites of injury for specific nerves like the ulnar and radial nerves, clinical features of injuries, and treatment approaches. It details Seddon's and Sunderland's classifications of nerve injuries, which range from neurapraxia to neurotmesis depending on the severity of axonal and neural sheath damage. Specific injuries like ulnar nerve entrapment at the elbow or Guyon's canal are discussed. Both non-surgical and surgical treatment options are presented.
Patellofemoral Pain Syndrome (PFPS), commonly known as runner's knee, is a condition characterized by anterior knee pain that is aggravated by activities involving the patellofemoral joint like climbing stairs, sitting with bent knees, or squatting. It is often caused by overuse injuries and biomechanical faults that cause abnormal tracking of the patella. Examination involves assessing for factors like patellar maltracking, tight muscles, and weakness. Treatment is primarily non-operative and focuses on exercises, bracing, taping, and orthotics to address biomechanical faults and strengthen the quadriceps muscles.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
This document discusses several theories of motor control including reflex theory, hierarchical theory, dynamical systems theory, motor programming theory, system theory, and ecological theory. It provides details on the key aspects and proposals of each theory as well as examples and criticisms of each approach to understanding human movement and motor control.
This document discusses shoulder impingement syndrome, including its anatomy, causes, symptoms, diagnosis, stages, and treatment approaches. It provides details on the rotator cuff muscles, signs and symptoms of impingement, external and internal factors that can lead to impingement, stages of the syndrome, common tests used for diagnosis, goals of treatment, and manual therapy, therapeutic exercise, and preventative measures used in treatment.
Sensory integration is a neurological process that allows individuals to make sense of sensations from their body and environment. Sensory integration disorder occurs when this process is not functioning properly, making it difficult for individuals to respond appropriately. Sensory integration therapy aims to stimulate the senses through activities involving movement, touch, sound, and vision to help brains better process sensory information. Research suggests this therapy can help brains of children with sensory integration disorder change and develop through rich sensory experiences.
این ارائه توسط دکتر خیاط زاده در کارگاه رویکرد جدید بوبات در توانبخشی کودکان مبتلا به فلج مغزی ارائه گردیده است.
برای مطالعه مطالب بیشتر در این زمینه، به وب سایت فروردین مراجعه نمایید.
https://www.farvardin-group.com
This scale is used to categrise spinal cord injury patients. it helps prognosticate the spinal cord injuires. it also helps define the treatment protocols for spinal cord injury patients. American Spinal Cord Injury Association made this scale so as to make a standardization in assesemnent technique in acute spinal cord injury patients.
The McKenzie Method is a classification system and treatment approach developed by Robin McKenzie for back, neck, and extremity pain. It involves assessing a patient's response to various movements and positions to determine the cause of their pain and develop an individualized exercise plan. The goals are to centralize or reduce pain. There are three main syndromes - postural, dysfunction, and derangement - each with different treatments like posture correction, mobilizing exercises, or movements to induce a directional preference. The McKenzie Method aims to actively involve patients to self-manage their pain.
Special test for dermatomes and myotomesTafzz Sailo
The document discusses dermatomes and myotomes, which are areas of skin and muscles innervated by specific spinal nerve roots. It provides detailed instructions for testing dermatomes using pinprick and light touch tests and myotomes using resistance tests of individual muscle groups to evaluate potential nerve root injuries. Key points include identifying the spinal nerve roots that innervate specific areas of the upper and lower limbs and correlating weaknesses to the likely injured nerve roots. Diagrams depict dermatome and myotome maps to guide the clinical tests.
This document provides an overview of how to evaluate the hand. It discusses the anatomy of the hand including bones, muscles, nerves and arteries. It describes taking a patient history and examining the hand for range of motion, deformities, palpation, observation, and functional assessment including grip strength and pinch tests. It also discusses evaluating the hand for conditions like edema and outlines tools used for various assessments.
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
A 47-year-old man presented with difficulty walking and weakness in his right foot for the past 3 months. He had been in a road traffic accident 4 months prior which resulted in a fracture of both leg bones on his right side, treated with a plaster cast. After cast removal, he noticed inability to lift his right foot and it dragged on the ground when walking. Examination revealed weakness and paralysis of muscles supplied by the common peroneal nerve on the right side, with loss of sensation on the lateral leg and top of the foot. The diagnosis is a common peroneal nerve injury at the level of the fibula neck due to trauma from the accident 4 months ago.
This document discusses principles of tendon transfers for restoring lost movement. It outlines key principles such as having supple joints before transfer, using a donor tendon with adequate excursion and strength, adhering to principles of synergy and straight line of pull. The timing of transfers depends on the likelihood of nerve recovery but can be done early to aid recovery. Contraindications include a lack of suitable donor muscles or transfers for joints with stiffness. Classification systems like Sunderland and Seddon are used to describe nerve injuries requiring tendon transfers.
Waddling gait- definition|role of muscle|gait analysis|kinematic and spatiote...jasna ok
This document discusses waddling gait, which is an abnormal gait pattern seen when there is bilateral weakness of the gluteus medius muscles, the primary hip abductors. During walking, individuals with waddling gait are unable to stabilize the pelvis and it drops on both sides, causing the trunk to laterally bend and the person to walk with a wide base like a duck. Treatment focuses on strengthening exercises for the hip abductors and gluteal muscles, gait training, and balance exercises. Physiotherapy aims to improve muscle strength, correct posture, and retrain a normal walking pattern.
Trigger points are hyperirritable spots within taut bands of muscle that are painful on compression and can cause referred pain patterns. They are commonly caused by overload, injury, lack of exercise, or poor posture in sedentary individuals between 27-55 years old. Trigger points have two types - active points that cause pain at rest and latent points that cause pain with direct pressure or muscle contraction. Electrotherapy can stimulate the body's endogenous opiate system to relieve pain by using low frequency stimulation below 10 Hz with long pulse durations to activate areas of the brain and spinal cord that inhibit nociception.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
Scapular dyskinesis refers to abnormal static positioning or dynamic motion of the scapula during arm elevation and is associated with shoulder injury. It has multiple potential causes including muscle weakness or imbalance. The document discusses the muscular attachments of the scapula, types of scapular dyskinesis, its effects on dynamic stability and shoulder strength, assessment methods, and rehabilitation treatments focusing on strengthening the lower trapezius and serratus anterior muscles to achieve optimal scapular positioning.
Este documento describe el síndrome de atrapamiento del nervio pudendo, una causa de dolor pélvico crónico. Explica la anatomía del nervio pudendo y los posibles mecanismos de lesión, así como los criterios para diagnosticar este síndrome clínicamente. También resume los enfoques de evaluación, tratamiento médico, infiltraciones, fisioterapia, neuromodulación y cirugía para abordar este tipo de dolor.
Interdisciplinary Management of Complex Pelvic Pain RevisedMark Conway
This document discusses complex pelvic pain that does not fit traditional paradigms of visceral pain. It describes how these patients are often labeled negatively after standard treatments fail to provide relief for their neuropathic pain. The document focuses on three specific nerves - the ilioinguinal, obturator, and pudendal nerves - outlining their anatomy, potential causes of injury/neuropathy, diagnostic techniques, non-surgical and surgical treatment approaches, and prevention strategies. Surgical techniques for decompressing the pudendal nerve transperineally or transgluteally are also reviewed.
Kin191 A. Ch.4. Foot. Toes. Evaluation. Fall 2007JLS10
This document provides an overview of evaluating the foot and lower extremity for injuries. It outlines areas to inspect, palpate, and perform range of motion and special tests on including the toes, metatarsals, tarsals, and ankle. Neurological and vascular evaluations are also summarized. Key areas of focus include inspection for deformities, swelling, calluses; palpation of bones, joints, tendons; range of motion and ligament testing of the toes, tarsometatarsal joints, and midtarsal joints.
Apresentação congresso app 2009 sobre calcaneo stopAntonioRamos74
O documento discute pé plano, seus tipos, diagnóstico e tratamento. A maioria dos casos de pé plano flexível evolui espontaneamente para a normalidade, sem necessidade de tratamento. Cirurgia só é indicada nos casos adinâmicos ou hipodinâmicos funcionais que causam dor.
Ultrasound guided pudendal nerve pulsed radiofrequency in patients with refra...Jason Attaman
This document reports on 3 cases of patients with refractory pudendal neuralgia who underwent ultrasound-guided pudendal nerve pulsed radiofrequency. In each case, the pudendal nerve was located using ultrasound near the ischial spine and a needle electrode was advanced to deliver pulsed radiofrequency to the nerve. Fluoroscopy was used to confirm needle placement in the first case. In the second case an ultrasound image shows the needle positioned near the identified pudendal nerve and internal pudendal artery. These cases suggest ultrasound-guided pulsed radiofrequency may provide pain relief for pudendal neuralgia refractory to other treatments.
El documento describe el síndrome del piriforme, una causa común de dolor lumbar y ciática. El síndrome se produce cuando el músculo piriforme irrita el nervio ciático. Afecta más a las mujeres y suele causarse por ejercicio excesivo, posturas forzadas o traumatismos. El diagnóstico se basa en la exploración física y pruebas de imagen como ecografía o RMN. El tratamiento incluye antiinflamatorios, infiltraciones, fisioterapia y en casos graves, cirugía
This document discusses the anatomy of the small joints of the foot, including the forefoot, midfoot, and hindfoot. It describes the bones and ligaments that make up the Lisfranc joint, Chopart joint, subtalar joint, and plantar fascia. It also discusses common injuries to the Lisfranc joint such as fractures and dislocations that can occur from high-energy blunt trauma or indirect injuries like forced plantar flexion of the foot.
1. O pé chato e o pé cavo são variações anatômicas relacionadas ao formato do arco do pé e à área de apoio, podendo deixar a pessoa mais suscetível a lesões.
2. O pé chato tem arco mais baixo e maior área de apoio, enquanto o pé cavo tem arco mais alto e menor área de apoio.
3. Esses tipos de pé podem ser classificados em 5 categorias e são normalmente hereditários, podendo ser tratados ou prevenidos com fisioterapia
Los atrapamientos del NP son más frecuentes de lo que pensamos y diagnosticamos. Pero su frecuencia real se desconoce.
Las especialidades involucradas (urología, ginecología, proctología, neurología,...) deben hacer un esfuerzo para la difusión de este
síndrome tan invalidante y tan poco conocido.
No debemos pasar por alto la importante relación entre el SANP y el Síndrome de dolor miofascial, pues muchas veces no sabremos quién
llevo a quién.
Los resultados de los tratamientos tanto conservadores como quirúrgicos son más que aceptables, pero siempre tendremos
presente comenzar por el menos invasivo.
O documento discute o pé cavo, definido como um pé com o arco plantar aumentado. Apresenta os tipos de pé cavo, exames para avaliação, principios do tratamento conservador e cirúrgico. O tratamento cirúrgico inclui procedimentos em partes moles como fasciotomias e em ossos como osteotomias para corrigir as deformidades.
The document discusses the arches of the foot, including the transverse and longitudinal arches. It describes flat feet and high arches, and related conditions like bunions, corns, and hammertoes. Tarsal tunnel syndrome is discussed as a nerve compression condition. Treatment options covered include orthotics, injections, and surgery. Posterior tibial tendon dysfunction is presented as a common cause of flat feet. Risk factors, other contributing conditions, and treatment approaches for flat feet are also outlined.
The arch of the foot is formed by bones, ligaments, and tendons that curve to distribute weight evenly. There are two longitudinal arches - the medial arch formed by more bones and joints that is resilient and mobile, and the lateral arch formed by fewer bones that is rigid. A transverse arch is also present. Together the arches maintain the foot's shape and enable movement and weight distribution. Conditions like flat feet or high arches can develop if the arches are weakened by injury or other factors.
The document summarizes the biomechanics of the ankle joint complex. It describes the anatomy and function of the talocrural joint (ankle joint), subtalar joint, and transverse tarsal joint. The ankle-foot complex consists of 28 bones and 25 joints that allow the foot to meet stability and mobility demands through dorsiflexion, plantarflexion, pronation, and supination movements. Key bones include the talus, tibia, and fibula. Ligaments such as the deltoid and tibiofibular ligaments provide stability to the ankle mortise.
The sciatic nerve is the largest nerve in the body, originating from the lower spine and extending down each leg. Foot drop is caused by weakness of the muscles that lift the front of the foot, usually due to injury or compression of the peroneal nerve branch of the sciatic nerve. Symptoms include inability to lift the foot and an exaggerated walking gait. Treatment depends on the underlying cause but may include bracing, physical therapy, nerve stimulation, or tendon transfer surgery.
Lesser toe disorders involve deformities of the 2nd-5th toes. Hammertoes cause flexion of the PIP joint while mallet toe flexes the DIP joint. Claw toe has MTP extension with PIP and DIP flexion. The deformities are often due to tight shoes weakening toe flexors/extensors. Evaluation examines toe range of motion and flexibility. Non-operative treatments use wider shoes and pads. Operations correct bony alignment and tendon imbalances. Bunionettes laterally deviate the 5th toe. Freiberg's infraction involves 2nd MTP osteochondrosis from trauma or vascular insult. Plantar keratosis forms under prominent metatarsal heads due to
This document discusses wrist drop, finger drop, and foot drop caused by radial nerve palsy. It provides details on the anatomy of the radial nerve and explains how injuries at different points can cause wrist drop or finger drop. For foot drop, it describes the anatomy of the leg and discusses how peroneal nerve injuries or issues with the sciatic nerve or L5 root can cause weakness of the dorsiflexors. It outlines the clinical features, diagnostic process, and treatment options including conservative care, physical therapy, splinting, and in some cases surgery.
This document provides an overview of evaluating low back pain. It discusses that most disc herniations occur at L5-S1 and 30% of asymptomatic people have disc protrusions. While MRIs often show spinal abnormalities, these findings do not always correlate with symptoms. The most common cause of low back pain is muscle imbalance leading to spasm. The document outlines approaches to evaluating patients with low back pain, including taking a history, performing physical exams, and assessing for red flags indicating serious underlying issues. Common lumbar spine conditions are described.
4 a adult acquired flat foot - Derek ParkDerek Park
The document discusses adult acquired flatfoot, caused by conditions like posterior tibial tendon dysfunction. It progresses through multiple stages as the deformity worsens. Early stages involve tendon repair/augmentation and osteotomies to realign the hindfoot and medial column. More advanced stages require fusions like triple arthrodesis or pantalar fusion to correct rigid deformities. Treatment aims to relieve pain and restore normal foot biomechanics through non-operative and surgical options depending on the stage of deformity.
This is the Presentation on the topic "Pathomechanics of Knee Joint".
The presentation includes images and a clip for proper understanding. The sentences are framed in the way that you can learn it in a easy way.
This document provides an overview of foot drop, including its anatomy, causes, symptoms, diagnosis, and treatment. Some key points:
- Foot drop is caused by paralysis of the muscles in the anterior and lateral compartments of the leg, resulting in inability to dorsiflex the foot.
- It can be caused by injury or entrapment of the common peroneal nerve, conditions that weaken muscles like polio or muscular dystrophy, or neurological issues such as stroke.
- Symptoms include difficulty lifting the foot and an equinus deformity. Treatment depends on the underlying cause but may include physical therapy, nerve stimulation, nerve grafting, or tendon transfers to restore function.
Steppage gait (High stepping, Neuropathic gait) is a form of gait abnormality characterised by foot drop or ankle equinus due to loss of dorsiflexion. The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking
Low back pain is usually caused by mechanical issues like lumbar spondylosis, herniated discs, or spinal stenosis. The lumbar spine consists of 5 vertebrae that are larger than other vertebrae to carry body weight. Between each vertebra is an intervertebral disc that acts as a shock absorber. Common causes of low back pain include lumbar spondylosis, herniated discs, and spinal stenosis. Lumbar spondylosis occurs from wear and tear on the joints between vertebrae and can cause pain from bone spurs and disc narrowing. Herniated discs occur when the gel-like center of a disc bulges out, pressing on nerves and causing pain. Spinal stenosis results
The document discusses various nerves of the lower limb including:
1. The femoral nerve which innervates the quadriceps and hip flexors and can cause paralysis of these muscles if injured.
2. The inferior gluteal nerve which innervates the gluteus maximus and injury causes inability to extend the hip.
3. The superior gluteal nerve which innervates hip abductors like gluteus medius and injury causes Trendelenburg gait.
4. The obturator nerve which innervates hip adductors. Injuries to the sciatic, tibial, common peroneal/fibular nerves can also cause muscle weakness, sensory loss
Congenital club foot is a rigid deformity present at birth characterized by equinus, hind foot varus, midfoot cavus, and forefoot adduction. It has multiple potential etiologies including genetic and environmental factors. Pathoanatomically, there is rotatory subluxation of the talocalcaneonavicular joint complex with talus plantarflexion and hind foot inversion. Higher Pirani scores, which assess midfoot and hindfoot contractures, are associated with greater treatment challenges including more casts and higher rates of tendon release procedures. Imaging can help evaluate severity and assess for atypical or syndromic cases.
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This document discusses various conditions affecting the ankle, including:
- Lateral collateral ligament injuries which can occur from ankle rolls and involve tears of the anterior talofibular ligament.
- Medial collateral ligament injuries which are stronger but can occur from eversion injuries and sometimes associated fractures.
- Anterior shin splints which result from inflammation due to overuse and repetitive impact loading.
- Tibialis posterior tendinopathy which can occur from overuse and involves excessive pronation placing increased load on the tendon.
- Various assessments are described to evaluate range of motion, strength, and ligament integrity of the ankle. Treatment focuses on improving range of motion and strengthening without aggravating the
Muscle tone is the baseline tension present in muscles even when at rest. It is controlled by both spinal and supra-spinal mechanisms. At the spinal level, muscle tone is regulated by the stretch reflex involving muscle spindles, alpha and gamma motoneurons. Supra-spinally, various descending pathways from the brainstem and cortex facilitate or inhibit muscle tone. Abnormalities in muscle tone include hypertonia (spasticity or rigidity) and hypotonia. Spasticity results from upper motor neuron lesions and involves exaggerated stretch reflexes. Rigidity occurs in extrapyramidal conditions and is speed-independent. Hypotonia is decreased muscle tone. Clinical examination of tone involves assessing resistance to passive movement
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- Several classification systems are described including the Wiltse, Newman and Macnab classification based on etiology and topography.
- Risk factors for slip progression include developmental spondylolisthesis with lysis, isthmic spondylolisthesis from repetitive loading, and increased pelvic tilt.
- Treatment involves conservative care with bracing or exercise initially. Surgical options include direct repair of pars defect, decompression with or without fusion and instrumentation depending on the grade of slippage.
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This document discusses foot drop, which is the inability to lift the front part of the foot. It can be caused by nerve injuries, neurological conditions, muscle weakness, or injuries. Symptoms include difficulty lifting the foot and dragging it when walking. Treatment depends on the underlying cause but may include bracing, physical therapy, nerve stimulation, or surgery to repair nerves or transfer tendons.
LOW BACK PAIN. Dr Haki Selaj Residency in Kosovo QKUKHakiSelaj1
back pain is a very widespread pathology in the world. There are health and socioeconomic consequences. widespread both in the young and in the old. The causes are different. The overwhelming majority is mechanical pain without a specific cause, while the others are pain from disc, infections, tumors, fractures, metabolic.
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Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
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2. Overview
• Pudendal neuropathy
• Neurodynamics, the local and the global the
mechanical interface of the pudendal nerve
• The foot, gait and the foot’s relationship to
the hip and pelvis
• Abnormal foot biomechanics seen in patients
with pudendal neuropathy
• Recommendations for addressing foot
dysfunction
3. OBJECTIVES
• Encourage practitioners to consider and look for abnormal
biomechanics as a primary cause or perpetuator of impaired
neural dynamics in patients with pudendal neuropathy
• Encourage the practitioner to improve their very basic
understanding of how abnormal foot biomechanics could
contribute to the development of pudendal neuropathy
4. Pudendal Neuropathy
Symptoms
• (aggravated by prolonged
sitting)
• pain within and around the
peripheral nerve field
• numbness, hypersensitivity
and/or paresthesias within
the peripheral nerve field
• voiding dysfunction of the
bowels and bladder
• sexual dysfunction
Peripheral Nerve Field of the
Pudendal Nerve
5. Pudendal neuropathy
Mechanisms of injury
Compression
Tension or Traction
•prolonged sitting
•hypertonus PFM: pain, emotional stress,
postural muscle imbalance
•overdeveloped PFM: gymnastics, ballet,
wrestling
•fall(s) onto the buttocks
•cycling, horseback riding
•impaired biomechanics
•chronic constipation and straining
•extended vaginal delivery
•under-active PFM
•descending perineum syndrome
•squatting with excessive weight
•impaired biomechanics
Chronic aberrant nerve
stimulation (convergence)
Surgery related
•viscero-somatic reflexes
•somato-visceral reflexes
•somatic-somatic reflexes
•post-hysterectomy
•post-radical prostatectomy
•bladder suspension surgeries
7. ~ Impairments and pathological events that are
innocuous in isolation, in coexistence can
frequently give rise to complicated and severe
chronic pain and dysfunction ~
8. Pudendal Neuropathy
Compromised neural biomechanics or neurodynamics
pathomechanical
pathomechanical
impaired relationship between the
impaired relationship between the
musculoskeletal system and the
musculoskeletal system and the
nervous system (mechanical
nervous system (mechanical
interface)
interface)
patho(neuro)dynamic
patho(neuro)dynamic
s
s
pathophysiological
pathophysiological
abnormal physiological response
abnormal physiological response
of neural tissues
of neural tissues
9. Mechanical Interface (MI)
• Compromised neural biomechanics or neurodynamics
(neuro)pathomechanical
impaired relationship between
impaired relationship between
the musculoskeletal system and
the musculoskeletal system and
the nervous system
the nervous system
(mechanical interface)
(mechanical interface)
“where the nerves are presented with muscles, joints,
fascia and fibro-osseous tunnels, against which the neural
structures contact during daily movement and postures.”
Michael Shacklock, 1995
10. The LOCAL Mechanical Interface of the
Pudendal Nerve
Sites of PN Irritation Entrapment
11. The GLOBAL Mechanical Interface of the
Pudendal Nerve
GLOBAL MECHANICAL INTERFACE
Distally: Lower extremity structures that influence
hip and pelvic function: THE FOOT and ANKLE
LOCAL MECHANICAL INTERFACE
PIRIFORMIS
ALCOCK’S CANAL
LIGAMENTOUS CLAMP
12. The foot, gait and its relationship to the pelvis
The foot bone is connected to the
pelvic bone:
13. The Foot: Osseous Anatomy
rear
Subtalar
foot
Joint (STJ)
mid
foot
fore
foot
1st Ray
First
cuneiform
First
metatarsal
Talus
Calcaneus
First Ray
14. The Foot: Function:
• 3 main goals
– adapt to accommodate uneven terrain
– to absorb shock on impact
– form a rigid lever during push-off
15. The Gait Cycle
• STANCE PHASE (support)
– when the foot is in contact with the ground
– 60% of the gait cycle
– the phase in which the lower limb is particularly
susceptible to injury
• SWING PHASE (unsupported)
– when the foot is off the ground while swinging
forward
17. The Subtalar Joint (STJ)
• The key to
understanding how
abnormal foot function
relates to hip and pelvic
dysfunction is the
Subtalar Joint.
tibia
fibula
subtalar
joint
talus
calcaneous
22. Abnormal foot and ankle
biomechanics
• Can lead to:
– Disruption of connective tissue integrity and
fascial lines
– Inefficiency of the pelvic and hip muscles
– Impaired movement patterns
– Impaired joint alignment and mobility
– Dysfunction proximally or distally in the kinetic
chain
– Impaired ability to attenuate ground reaction
forces
23. EXCESSIVE PRONATION
(or abnormal control of pronation)
• Can lead to:
– Impaired foot, hip and
pelvic function
– Inefficient attenuation of
GRF on the contractile
and non-contractile
tissues of hips and pelvis
• Morton’s Toe
• Rear foot varus
• Forefoot varus
24. MORTON’S TOE
• What is a Morton Foot
Structure?
– characterized by a short 1st
MT relative to the 2nd MT.
• Why it is potentially a
problem?
– when the first MT is short,
the second MT takes on the
job of weight acceptance and
the function of the foot is
impaired
– can lead to abnormal pronation
26. VARUS DEFORMITIES
REARFOOT VARUS
Uncompensated
FOREFOOT VARUS
Uncompensated
Compensated
Compensated
Posterior View
(left foot)
STJ
pronation
STJ
pronation
• Rear foot inverted
• medial side of the HEEL elevated
• rear foot normal
• medial side of FOREFOOT elevated
• compensatory STJ pronation, excessive and happening at the wrong time
• leaves the foot in an unstable position propulsive phase of gait
27. Identifying RF Varus
• medial bunion (1st MTPJ)
• Tailor’s Bunion (on the 5th
MTPJ)
• hammer toes
• callus under 2nd MTPJ,
• Haglund's deformity (heel
bump due to movement of
heel against shoe)
28. Identifying Forefoot varus
• Hallux abducto valgus –
abducted great toe
• bunion medial side 1st MTPJ
• hallux limitus/rigidus
• overlapping toes especially 2nd
• A history of heel pain and or
Plantar fascia pain.
29. Global mechanical interface affects
the local mechanical interface
• Consequences of abnormal pronation due to Morton’s Toe,
Rear/Forefoot Varus
–
–
–
–
The problem: improper timing and excess pronation at the STJ
STJ pronation = the lower leg internal rotation
the hip and or sacroiliac joints absorb the extra internal rotation
piriformis and the obturator internus muscles undergo tremendous
strain at both origin and insertion
• neuromuscular and myofascial dysfunction develops in in the piriformis
and obturator internus muscles
30. Global mechanical interface affects
the local mechanical interface
• Consequences of abnormal pronation due to Morton’s Toe,
Rear/Forefoot Varus
– foot should be supinating during the mid-stance to support weight of
the body and keep pelvis level
– Excessive pronation leaves the foot unstable which compromises the
muscles responsible for pelvic stability
• Muscle dysfunction can occur in gluteus medius, piriformis, TFL,
adductors and psoas
– impaired dynamic stability and impaired functioning in the pelvic-hip
complex
– Strains passive support structures of the pelvis – ligaments and bony
structures
31. 46 y.o. – PNE, post-op bilateral PN decompression AND bilateral
PN decompression revision with tendon reconstruction
- multiple TPI for recurring, piriformis, obturator internus,
ongoing complaints of anal pain
Morton’s Toes
Moderate Rear foot
an Mild Forefoot
Varus
Subtalar Joint
Pronation
Pump
bump
32. UNDERPRONATION
(The Supinatory Foot)
• Can lead to:
– Impaired foot, hip and
pelvic function
– Decreases ability of foot
to absorb GRF
– Puts excessive strain on
contractile and noncontractile tissues of the
hips and pelvis
• The PLANTAR FLEXED
1ST RAY with
REARFOOT VARUS
33. THE PLANTAR FLEXED 1ST RAY
•
•
•
Less common but still
prevalent in patients with
long standing pudendal
neuralgia –
characterized by a fixed and
plantar flexed (closer to the
ground – dropped)
overtime because of its
position closer to the ground
normal STJ pronation is
inhibited and causes rear
foot varus
Compensated
STJ
supination
Dropped 1st
MT
Posterior View
(left foot)
34. Underpronation –
The supinatory foot pattern
•
•
•
the STJ does not pronate to
compensate because the
great toe is already too close
to the ground
No STJ pronation = LE
Internal rotation
Consequently, entire kinetic
chain experiences less hip
internal rotation ROM
52 y.o. patient with >30 yrs. Left
sided symptoms related to
PN – limited left hip IR,
ongoing piriformis and O.I
dysfunction, fall on tailbone
was initial injury.
High arch
35. Identifying the supinatory foot
•
•
•
•
foot structure characterized by a higher arch
1st MT lies below the plane of the others
calluses beneath the head of the first MT and the great toe
the “peek-a-boo heel sign in which the medial heel fat pad
can bee seen from the front
• c/o painful iliotibial bands and hip pain, and posterior leg pain
- usually due to myofascial dysfunction in the piriformis
and/or obturator internus
36. The supinatory foot
The plantar flexed 1st ray
• A greater problem …
– an underpronating supinated foot does not allow
the subtalar joint to unlock
– foot stays rigid and unable to absorb GRF
– effects in the proximal kinetic chain – increase
load on proximal ligaments - sacroiliac joint
hypermobility and dysfunction
37. Supinatory Foot – Plantar flexed 1st Ray
• > 3 years of bilateral pudendal neuralgia and dysfunction
• - 2/5 gluteus medius MMT
Peek-a-boo heel sign
High arches
Rear foot varus
38. The plantar flexed 1st ray and dysfunctional
Hallux Limitus
And another problem …
• Hallux Limitus
– When the great toe looses
extension ROM necessary for
normal gait
– A stiff great toe can result in
profound abnormal
biomechanics in the lower
kinetic chain.
Hallux Limitus
39. Hallux Limitus
•
Pertinent to the situation of pudendal
neuropathy
– loss of hip extension and concurrent
relaxation of the hamstring muscle and
sacrotuberous ligament during midstance
– interferes with proper sacral nutation and the
inherent locking mechanism of the SIJ
– puts the sacrotuberous ligament under
increased strain and structural changes and
can increase the load on the piriformis and
psoas
– May lead to SIDJ/hypermobility
41. TREATMENT
•
•
•
•
address range of motion impairments, restore muscular strength, balance
and proprioception to the foot/ankle complex
weight-bearing closed-chain exercises are more suitable as this is the
functional realm of the foot
if necessary, foot orthoses can be prescribed that help to ensure correct
foot and therefore, limb and pelvic alignment.
Recommendations:
– Start looking at the feet of your patients with symptoms of Pudendal
neuropathy.
– Look for bunions, deviated toes, abnormal callus patterns, toeing out gait
pattern, the peek-a-boo heel sign, claw and hammer toes, etc.
– Ask about history of foot or ankle dysfunction
– Stay tuned, there is still more to learn on this front
– Find and refer to a or Physical Therapist who specializes in foot and ankle
rehabilitation and orthotic fabrication
– Refer to podiatry
42. •
So while the condition of PN is likely a result of coexisting dysfunctions, of
which abnormal biomechanics are just one, ignoring faulty biomechanics
and their influence on abnormal neurodynamics, myofascial pain and joint
function that can result in neural irritation may result in prolonged
dysfunction and incomplete resolution of the problem.
43. Thank You
The central nervous system, presumably, has
an overriding biological mandate that
locomotive efficiency dominates over
anatomical integrity. Erl Pettman, MCSP, MCPA, FCAMT
Editor's Notes
Original itention
It’s really ironic ...
I think my avoidance stems from that fact that feet mechanics are just really very complex, the feet are riddled with genetic deformities and the load on them is tremendous, in addition to that there isn’t really any agreement on how to treat foot dysfunction or even on the terminology used to describe foot dysfunction.
So, I had to laugh when I went to leave the clinic one night…
My first thought was, “I sure hope not!” At any rate, I started taking a closer look at feet and two issues have emerged.
over 80% if not 90% of our patients with Pudendal nerve issues have this relatively short 1st metatarsal that characterizes the Morton Foot Structure. I’ve since then learned that a Morton foot structure in isolation doesn’t always seem to be problematic, but when it exists with additional abnormal foot mechanics, can become a problem.
treating the feet seems to correlate with faster healing times.
**
CAUSES: Pudendal Neuropathy as with many neuropathies, is thought to be a consequence of trauma from compression, traction, or chronic aberrant nerve stimulation as a result of convergence and the associated abnormal reflexes and with surgery related traumas less common. It’s my experience that it’s rare to see a patient in whom just one of these conditions can be implicated as the sole mechanism of PN irritation or injury. More commonly, my evaluation process nearly always confirms events and conditions that fall into two if not three of these categories.
Also worth noting, is that while impaired biomechanics are often listed as a situation unto itself, a closer look at this reveals impaired biomechanics as an underlying component in many of these mechanisms.
On that same note, it’s my experience these patients frequently present with not one, but a remarkable collection of clinically significant and interrelated findings coexisting in multiple layers of the body.
Very commonly these conditions include, pudendal neuropathy, pelvic floor muscle dysfunction, connective tissue dysfunction, impaired biomechanics, myofascial pain, visceral pain & dysfunction, central sensitization, history of trauma, impaired neurodynamics.
**What I believe this coexistence of findings implies is simply this ~
Impairments and pathological events that are relatively innocuous in isolation, in coexistence, can frequently give rise to complicated and severe chronic pain and dysfunction.
Biomechanics are just one piece of this puzzle and subject to the same implication.
For example, it is unlikely that a structural problem in lower extremities, like excessive foot pronation, alone will cause Pudendal Neuralgia. However, when a structural problem, such as excessive foot pronation co-exists with a history of recurrent bladder infections and discomfort induced, reactive pelvic floor muscle guarding, the likelihood of a myofascial problem at the very least may increase. Adding, a fall on the tailbone, a surgery or just emotional stress into this mix (which is a very common scenario in my practice) can quickly escalate the severity of the problem.
Compromised neural biomechanics or neurodynamics are usually the primary feature of pudendal neuropathy. Pathodynamics describes combination of pathomechanical and pathophysiological events in take place when there is injury to the nervous system - with pathomechanical referring to an impaired relationship between the musculoskeletal system and the nervous system or the mechanical interface (MI) and pathophysiological referring to the abnormal physiological response of neural tissues.
For my purposes here pathomechanics and specifically, the musculoskeletal piece of the MI is the focus. “where the nerves are presented with muscles, joints, fascia and fibro-osseous tunnels, against which the neural structures contact during daily movement and postures.”
The MI of the pudendal nerve essentially includes the piriformis muscle, the ligamentous clamp formed by the sacrotuberous and sacrospinous ligaments, Alcock’s canal within the obturator internus muscle and the pelvic floor muscles – all structures that could be referred to as the local mechanical interface of the pudendal nerve and that have been implicated as sources of pudendal and sacral nerve root irritation and entrapment.
Beyond the local MI of the pudendal nerve lie the structures that could easily be referred to as the global mechanical interface. And as is the case with most systems, global events affect local events. This global MI of the pudendal nerves essentially includes any structures the lower extremities and their associated movement patterns that influence hip and pelvic function.
**The Foot: Osseous Anatomy
The tarsal bones make up the rear and mid-foot.
The talus and the calcaneus make up the rear-foot their articulation forms the subtalar joint which is part of the functional unit that allows for pronation and supination of the foot.
The rest of the tarsal bones make up the mid-foot
The metatarsal bones, and the phalanges (the toes) make up the forefoot.
Together the 1st cuneiform and the 1st MT make up the first ray, the functional unit of the forefoot that creates power for pushing off the ground to propel the body forward during gait. – This is also the structure that can become dysfunctionally hypermobile with a Morton type foot structure as well as with other foot pathomechanics.
3 main goals
adapt to accommodate uneven terrain
to absorb shock on impact
form a rigid lever during push-off
when the foot fails to meet these goals, structures both proximally and distally can be affected
The foot’s connection to the pelvis can be understood through its role in walking and the kinetic chain. The detailed mechanics of walking, very far exceed what I will cover here, but none-the-less a little is necessary…the gait cycle of each leg is divided into a STANCE (support) PHASE, (when the foot is in contact with the ground which makes up 60% of the gait cycle and is the phase in which the lower limb is particularly susceptible to injury and the phase that is of concern here) and a SWING (unsupported) PHASE (when the foot is off the ground while the swinging forward).
The stance phase is further divided into heel strike, midstance and push-off phases of gait. The rear-foot, mid-foot and forefoot all influence how the foot adapts to and pushes off from the surface it’s walking on.
The key to understanding how abnormal foot function relates to hip and pelvic dysfunction is the Subtalar Joint. The motions of this joint alternate between pronation and supination during the stance phase of gait.
Pronation unlocks the mid-foot allowing the foot to become a flexible adaptor to uneven terrain, and very importantly also to absorb ground reaction forces.
Supination transforms the foot from a flexible adaptor into a rigid lever in preparation for push-off.
In normal gait, during heel strike the foot immediately begins to pronate, converting the foot into a mobile adaptor in order to accommodate variances in terrain. During this phase the weight is shifting from the lateral foot to the medial foot toward the first ray and great toe. From mid-stance to push off the foot begins to re-supinate, a motion is crucial for the foot to function as a rigid lever in preparation for push off. During the push off phase of gait, the foot continues to supinate, and weight is shifted to the medial side of the foot supported by the strength of the 1st ray and the great toe.
**In the lower extremity kinetic chain when the distal segment is fixed, the proximal segments move. In gait, because the STJ and the hip are inextricably linked, movement patterns of the feet and ankle are reflected through the kinetic chain to the pelvis through the hips.
Specifically, the lower extremity internally rotates with subtalar joint pronation and externally rotates with subtalar joint supination. Furthermore, synchronized activation of the hip adductors as hip internal rotators and the Obturator Internus as a hip external rotator, supports sacral nutation and counternutation, sacroiliac joint compression and decompression, and anterior and posterior pelvic tilt.
SKIP: Abnormal biomechanics of the foot can lead to disruption of connective tissue integrity and fascial lines, inefficiency of the pelvic and hip muscles, impaired movement patterns, impaired joint alignment and mobility, dysfunction proximally in the kinetic chain, and impaired ability to attenuate ground reaction forces.
The problem of excessive pronation or poorly timed pronation:
A certain amount of pronation at the correct time during the stance phase of gait is imperative for normal foot, hip and pelvic function and in order to attenuate the forces put on the contractile and non-contractile tissues of hips and sacroiliac joints.
What exactly is a Morton Foot Structure?
A Morton Foot structure is characterized by a short first metatarsal in comparison with the adjacent second metatarsal. It can be problematic because normally, during the stance phase of gait, the pressure on the foot should move toward the first metatarsal so that the very powerful great toe flexors can facilitate push-off and propel the body forward. When the first MT is shorter, the second MT takes on the job, of weight acceptance, for which it is not well-suited and the function of the foot is impaired.
Due to complex changes in foot function, these abnormal mechanics can lead to abnormal pronation and subsequent hypermobility of the first ray. When this functional unit loses stability, the great toe can deviates away from midline (Hallux Valgus), bunions develop, and the stability needed to “push off” during walking is lost.
Ensuing weakness develops in the muscles involving the foot, calf, and back leg, including the gluteus medius and maximus, all of which play and important role in the health of the pelvis. In theory then, muscle imbalance within this group of muscles may then also lead to excessive stress and possible instability of the SI joint.
There is no agreement in the science about whether or not it should be seen as a problem. Using toe pads under the 1st MT is definitely not the answer for all patients with this foot type, and yet has shown to be extremely effective for some. What I do know, is that the prevalence of Morton toe is high among patients with Pudendal Neuropathy and seems to make matters worse when it coexists with other foot pathologies.
Two other foot types that I very commonly see in patients with diagnosed PN are Rear foot and forefoot varus, which are different foot types but they both can result in compensatory and abnormal pronation. With rear foot varus foot the calcaneus is more inverted than normal so that the medial side of the heel is farther from the ground.
With a forefoot varus has normal rear foot orientation the medial side of the forefoot higher or further from the ground than the lateral side.
As a result the STJ compensates for the structural impairment of the calcaneus and the forefoot by pronating , in order to assist the medial side of the calcaneus or the forefoot to the ground.
The result is too much pronation, too soon in the gait cycle.
For complicated reasons related to abnormal control of pronation, but as a means of identifying the problem, individuals with a rear foot varus frequently have a Tailor’s bunion (on the 5th MTPJ), hammer toes, a plantar callus under 2nd MTPJ, and a Haglund's deformity or heel bump due to movement of heel against shoe.
* Symptoms
o Leg fatigue and nocturnal leg cramp.
o Low back pain or fatigue.
o Lateral ankle sprains.
Individuals with a forefoot varus foot structure very frequently have hypermobility of the 1st ray evidenced by the laterally deviated great toe (Hallux abducto valgus), may or may not have a bunion of the 1st MTP, hallux limitus/rigidus (a stiff great toe), overlapping toes especially 2nd, a history of heel pain and or Plantar fascia pain
* Symptoms
o Hallux bursitis.
o Generalized forms of metatarsalgia.
o Chronic low back pain.
o Inferior calcaneal bursitis or plantar fasciitis.
o Severe fatigue.
The problems associated with Morton’s toe and varus deformities of the rear and forefoot are related to improper timing and excess pronation at the STJ. Due to the foot’s compulsory relationship with the proximal kinetic chain, whenever the STJ pronates the lower leg must internally rotate. Because the knee has very little capacity for rotation, the hip and or sacroiliac joints almost always absorb the extra internal rotation.
If the femur is internally rotating to accommodate the excessive pronation, while the pelvis is reversing direction to move forward with the swinging leg, the piriformis and the obturator internus muscle due to their bony attachments inside the pelvis and femur, both undergo tremendous strain at both their origin and their insertion.
As a consequence, neuromuscular and myofascial dysfunction and poor functionality can develop in the piriformis, obturator internus as well as the Gluteus maximus and the SS and ST may also be subject to greater strain. A very common set of finding in my practice in patients with these types of structural foot problems and pudendal neuropathy.
Additionally, the foot should become stable (an effect of supination) during the mid-stance phase in order to effectively support the full weight of the body and keep the pelvis level. Excessive pronation leaves the foot unstable and therefore compromises the muscles responsible for pelvic stability.
Consequently, the gluteus medius in particular can become fatigued, weak and develop myofascial trigger points and tender points indicative of neuromuscular dysfunction in hips and SIJ. In their compensatory role in stability, the piriformis, TFL, adductors and psoas undergo even further strain and overtime can become painful and loose functionality.
The impaired muscle function can very likely contribute to impaired dynamic stability and overall impaired functioning in the pelvic-hip complex adding strain to the passive support structures of the pelvis, the ligaments and bony structures
UNDERPRONATION – THE SUPINATORY FOOT
Can lead to:
Impaired foot, hip and pelvic function
Decreases foots ability to absorb GRF
Puts excessive strain on the joints, contractile and especially the non-contractile tissues of the pelvis
The plantar flexed 1st ray is another problematic structural problem I see in patients with long standing pudendal neuralgia –
characterized by a fixed and plantar flexed (closer to the ground) position the first MT relative to the other metatarsals which overtime because of its position closer to the ground inhibits STJ pronation and results in rear foot varus. Except in this condition, the STJ does not pronate to compensate because the great toe is already too close to the ground. This lack of STJ pronation then interferes with the normal internal rotation of the lower leg during the stance phase. Consequently, the entire kinetic chain experiences less hip internal rotation.
When the hip doesn’t experience hip internal rotation ROM during gait, severe muscle imbalances can result in the proximal hip muscles, especially, the piriformis, Obturator internus and gluteus maximus muscles.
Identifying the supinatory foot
foot structure characterized by a higher arch
1st MT lies below the plane of the others
calluses beneath the head of the first MT and the great toe
the “peek-a-boo heel sign in which the medial heel fat pad can bee seen from the front
c/o painful iliotibial bands and hip pain, and posterior leg pain - usually due to myofascial dysfunction in the piriformis and/or obturator internus
A greater problem is that an underpronating supinated foot does not allow the subtalar joint to unlock leaving the foot rigid, and unable to absorb ground reaction forces efficiently. which leads to additional effects in the proximal kinetic chain. Ground reaction forces that are normally absorbed in the pronated and unlocked foot are forced proximally and can in combination with weakness of the SIJ stabilizers can contribute to the development of sacroiliac hypermobility.
As a sequel to both a plantar flexed 1st ray and the previously described excessively pronating feet is a stiff great toe. In this condition the great toe loses extension ROM needed for normal gait.
A stiff great toe can result in profound abnormal biomechanical effects of the lower kinetic chain.
Pertinent to the situation of pudendal neuralgia
loss of hip extension and concurrent relaxation of the hamstring muscle and sacrotuberous ligament during midstance
interferes with proper sacral nutation and the inherent locking mechanism of the sacroiliac joint SIJD
puts the sacrotuberous ligament under increased strain and can increase the load on the psoas and piriformis
The list of dyfunctions that are related to these basic foot abnormalities is extensive and these are just the very basic foot abnormalities, but they do in some ways represent the ends of a very interesting continuum of human architectural forms.
In general, however, patterns do exist. The problems associated with varus deformities of the rear and forefoot due to the foot’s obligatory relationship with the proximal kinetic chain, impart impaired biomechanical stresses on the hips and sacroiliac joints and specifically the structures involved in health of the pudendal nerve. More specifically, all of the foot abnormalities here result in excessive and poorly timed rotational stresses on the hip internal and external rotators - piriformis and obturator internus, gluteus medius, maximus - contributing to the formation of neuromuscular dysfunction in the form of myofascial trigger points, pain and weakness, subsequent length tension dysfunction and overall poor functioning of the pelvic-hip complex.
Weakness of the gluteus and the resulting weakness in piriformis and Obturator internus muscles known to contribute to stability of the sacroiliac joint may be the basis of some cases of sacroiliac instability, leading to subsequent strain and remodeling of the ST and SS ligaments. All of which are conditions which have been implicated in the development of pudendal nerve irritation.
an appropriate rehabilitation plan is necessary to address range of motion impairments, and to restore muscular strength, balance and proprioception to the foot/ankle complex
weight-bearing closed-chain exercises are more suitable as this is the functional realm of the foot
if necessary, foot orthoses can be prescribed that help to ensure correct foot and therefore, limb and pelvic alignment.
Recommendations:
Start looking at the feet of your patients with symptoms of Pudendal neuropathy.
Look for bunions, deviated toes, abnormal callus patterns, toeing out gait pattern, the peek-a-boo heel sign, claw and hammer toes, etc.
Ask about history of foot or ankle dysfunction
Stay tuned, there is still more to learn on this front
Find and refer to a or Physical Therapist who specializes in foot and ankle rehabilitation and orthotic fabrication
Refer to podiatry
So while the condition of PN is likely a result of coexisting dysfunctions, of which abnormal biomechanics are just one, ignoring faulty biomechanics and their influence on abnormal neurodynamics, myofascial pain and joint function that can result in neural irritation may result in prolonged dysfunction and incomplete resolution of the problem.
Again, it’s my opinion, based on 1) what I see in practice, and 2) generally accepted ideas about biomechanics and the kinetic chain of the lower extremity, that biomechanics is important. Even in the presence of a discernibly distinct cause of Pudendal Neuropathy, such as a traumatic vaginal delivery, pelvic fracture or surgical trauma, faulty biomechanics should be explored as a reason for the exacerbation or perpetuation of symptoms.