Knee pain and the the semitendinosis?

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

The semitendinosus hails from the posterior compartment.

During an ideal gait cycle, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off.

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain.

The semitendinosis is the most superficial of the hamstrings and originates between the biceps femoris, with which it shares a common tendinous attchment, which is anterior and slightly lateral and the semimembranosis which is just beneath it and slightly medial. It is fusiform and the muscle body ends about mid thigh, before becoming a long "piano string" and ultimately inserting most inferiorly of the trio, below the gracilis, on the pes anserine.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing. Look to this troublesome trio the next time you have recalcitrant medial knee pain.

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #gaitdysfunction, #thegaitguys, #pesanserine, #semitendinosis

Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SH. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013;26(3):249-54. 

Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 

Gray H:  Anatomy of the Human Body  Lea and Febiger, Phildelphia and New York 1918

https://www.anatomy-physiotherapy.com/knee/articles/systems/musculoskeletal/lower-extremity/knee/test-your-knowledge-the-pes-anserinus

 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011

Hamstring injuries and their gluteal relationship, the dialgoue.

Yesterday we talked about hamstring tears. One of the frequent findings we see in our hamstring injured clients is under performance of the gluteal group. We all are well aware that the hamstrings can be an assistive piece of the posterior chain hip extension pattern in gait. When the glutes are underperforming, under protecting hip stability or underperforming in pelvis control, that the hamstrings can be called upon to do more. The loads an move into the low back or into the leg, or both, when the glutes are underperforming. This study is supportive in an indirect manner.

Sagittal trunk flexion and extension in patients with chronic low back pain.
The study found the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Nothing new here for many of our followers, but it is always worth discussing.

We have talked about the fatigue factor and endurance factor of the paraspinals in low back pain in previous podcasts, maybe a year or two ago. But, in looking for something else in particular today, I came across this article from 2000.
It once again suggests the critical function of the glutes, all 3 divisions and that they do play multiple parts other than just hip stability and movement. We see plenty of clients who have poor development of the upper iliac and sacral divisions of the glute max. This could be from anterior pelvis tilt presentations, faulty movement patterning, or even failure to get to end range hip extension to work on developing that portion of the muscle. Regardless, this once again proves that we are an under-developed glute species and all this sitting is a problem, and even the standing desk trend, will not fix this. The body must move, it must be loaded through to the full range of motion and we must incorporate compound movements with load if we are to get even close to the opportunity to see folks with healthy glutes and thus healthy hips and spines.

"RESULTS:
During early flexion, lumbar paraspinal and biceps femoris were activated simultaneously before gluteus maximus. At the end of flexion and during extension all investigated muscles were activated and relaxed in order. Lumbar paraspinal and biceps femoris muscles were activated in a similar order in low back pain patients and healthy controls during flexion and extension. However, the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Active rehabilitation did not change the muscle activities of lumbar paraspinal and biceps femoris in the back pain patients, but in the measurements after rehabilitation the onset of gluteus maximus activity occurred later in flexion and earlier in extension."

"CONCLUSIONS:
The activity of the gluteus maximus muscle during the flexion-extension cycle was reduced in patients with chronic low back pain. The gluteal muscles should be taken into consideration in the rehabilitation of these patients." - Leinonen et al

Arch Phys Med Rehabil. 2000 Jan;81(1):32-7.
Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation.

Leinonen V1, Kankaanpää M, Airaksinen O, Hänninen O.
https://www.ncbi.nlm.nih.gov/pubmed/10638873

Building a Better Bridge

Using bridge exercises? Want to make it more effective? Here's one simple way: bend the weight bearing knee to 135 degrees rather than the traditional 90. It preferentially activates the g max and med more (relatively, compared to the hamstring ; the actual values for the max and med remained similar) and the hamstring significantly less (24% vs 75%)

CONCLUSION:

"Modifying the traditional single-leg bridge by flexing the active knee to 135 ° instead of 90 ° minimizes hamstring activity while maintaining high levels of gluteal activation, effectively building a bridge better suited for preferential gluteal activation.

Lehecka BJ, Edwards M, Haverkamp R, et al. BUILDING A BETTER GLUTEAL BRIDGE: ELECTROMYOGRAPHIC ANALYSIS OF HIP MUSCLE ACTIVITY DURING MODIFIED SINGLE-LEG BRIDGES. International Journal of Sports Physical Therapy. 2017;12(4):543-549.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534144/

How are your hammy’s?

Another tool for you, in addition to making sure the gluten are on line, to improve ankle rocker and hip extension.

“This study concludes that neural mobilization techniques are a useful adjunct to static stretching, without any risk of adverse events or injuries. Athletes or trainers can consider using one or both types of neural mobilization techniques to enhance muscular flexibility. Dosage of the neural mobilization as well as the proposed working mechanism behind the increase in hamstring flexibility can be found in the full text of the article.”

http://www.ncbi.nlm.nih.gov/pubmed/26482098

Phys Ther Sport. 2016 Jan;17:30-7. doi: 10.1016/j.ptsp.2015.03.003. Epub 2015 Mar 17.
Short term effectiveness of neural sliders and neural tensioners as an adjunct to static stretching of hamstrings on knee extension angle in healthy individuals: A randomized controlled trial.
Sharma S, Balthillaya G2, Rao R, Mani R .

Training out a crossover gait?

This gal came to see us with right-sided hamstring insertional pain. During gait analysis we noted that she has a crossover gait as seen in the first two sections of this video. In addition to making other changes both biomechanically (manipulation, gluteus medius exercises) and in her running style (“Rounding out her gait” and making her gait more “circular”, running with less impact on foot strike, extending her toes slightly in her shoes) she was told to run with her arms at her sides rather than across her body. You can see the results and the third part of this.

Because of her bilateral gluteus medius weakness that is seen with the dipping and lateral shift of the pelvis on the footstrike side, she moves her arms across her body to move her center of gravity over her feet.

Yes, there is much more work that needs to be done. This is one simple step in the entire process.

The Mighty Quadratus Femoris→

Ishial tuberosity pain that looks like a hamstring but is not responding? Think QF.

We have always have found the quadratus femoris is one of, if not the, 1st hip muscle to become dysfunctional in hip pain patients. Perhaps it is due to it being the southern most stabilizer of the deep 6. Long known as an adductor, but also external rotator, we find it is employed eccentrically when the foot the planted and people rotate to the same side as weight bearing, or people take a “sudden stumble” while running. It often mimics an insertional hamstring strain with regards to location. We were happy to see it is getting some of the attention it deserves : )

When is a hamstring strain not a hamstring strain?

We have always have found the quadratus femoris is one of, if not the, 1st hip muscle to become dysfunctional in hip pain patients. Perhaps it is due to it being the southern most stabilizer of the deep 6. Long known as an adductor, but also external rotator, we find it is employed eccentrically when the foot the planted and people rotate to the same side as weight bearing, or people take a “sudden stumble” while running. It often mimics an insertional hamstring strain with regards to location. We were happy to see it is getting some of the attention it deserves : )

http://www.anatomy-physiotherapy.com/articles/musculoskeletal/lower-extremity/hip/1528-function-of-the-quadratus-femoris-and-obturator-externus

A cause of ishial pain?

How many of us treat runners on a regular basis? Most of us I would say. While lecturing, I had an epiphany about recalcitrant hamstring insertional pain, that does seem to respond to conventional therapy. Take a look at the trigger point referral pattern for the semimembranosis/ semitendonosis. Note that in closed chain, these are external rotators of the thigh. Thinking about this, they would eccentrically contract (theoretically) to decelerate internal rotation of the thigh (such as with excessive midfoot pronation at initial contact and loading response.

Now look at when these guys fire during running gait. The left side of the graph (up to TO)  represents the stance phase of running gait (Mann 1986). The right side represents swing (or float) phase. Note that the medial hamstrings should fire from about foot descent to mid support (or midstance), with a little blast after the foot leaves the ground (asumed eccentrically) to assist in slowing the leg.

Now think about if the foot is a poor lever and remains on the ground just a little longer and rotates medially a little too far (overpronation); this muscle could conceivably be over worked and result in the trigger point referral pattern seen above on the ishial tuberosity.

Ah, but how to fix it? 

We could dry needle it and rehab it (better train it eccentrically, since that is how it is working), but it is already overworked, and in my cllinical experience, only provides temporary relief of the symptom. What other muscles seen in the chart could help? Hmmm… Take a look at the tibialis anterior (dorsiflexor/inverter), gastroc (medial) (plantarflexor/inverter), foot intrinsics and glute max/ posterior fibers of the glute medius. All external rotators (save for the foot intrinsics, which should fire from midstance to toe off) and a bonus pronatory decelerator for the tibialis anterior and able to slow an excessively internally rotating lower leg. You better check and make sure they are all on line before just treating the area of the chief complaint!

The Gait Guys. Keeping it real and giving you the tools to do a better job at what we all love to do : ) .

Just when do those hamstrings fire anyway? In a follow up to mondays post, check out what the EMG studies say..

Hamstring Reverse Engineering:

The biceps femoris is an internal rotator of the thigh? You heard correctly. Think of how the lower extremity works in closed chain, not open. Check out this quick video with Dr Ivo on “reverse engineering”

Reciprocal Inhibition anyone? Thanks to The Manual Therapist (Erson Religioso) for this great post.

What they are doing here is taking advantage of what Sherrington know many years ago. Activating a muscle (agonist for a movement) will inhibit the muscle with the opposite action (antagonist for a movement), through a disynaptic, post synaptic pathway. It is a great way to gain additional movement and remove or reduce muscular inhibition. Try it!

Prior hamstring injuries

Previous hamstring injury is associated with altered biceps femoris associated muscle activity and potentially injurious kinematics.

“Previously injured athletes demonstrated significantly reduced biceps femoris muscle activation ratios with respect to ipsilateral gluteus maximus, ipsilateral erector spinae, ipsilateral external oblique, and contralateral rectus femoris in the late swing phase. We also detected sagittal asymmetry in hip flexion, pelvic tilt, and medial rotation of the knee effectively putting the hamstrings in a lengthened position just before heel strike.”
http://onlinelibrary.wiley.com/d…/10.1111/sms.12464/abstract

Stretching out Plantar Fasciitis→

Neuromechanics Weekly: Look to the hammy’s???

“These findings show that while we always consider the tightness of the gastrocnemius/soleus complex and the subsequent restricted ankle motion from this equinus, we also need to consider the role of the hamstrings,” said Jonathan Labovitz, DPM, lead author and associate professor at Western University of Health Sciences, Pomona, CA.

this article from Lower Extremity Review, concludes “After controlling for covariates, participants (86 of 210 feet) with hamstring tightness were 8.7 times as likely to experience plantar fasciitis (p < .0001) as participants without hamstring tightness. Patients with a BMI >35 were 2.4 times as likely as those with a BMI <35 to have plantar fasciitis.”

The question is why?

They go on to say “ If you can’t get dorsiflexion at your talo-crural joint, this often drives dorsiflexion at other joints and that is going to cause collapse of the longitudinal arch of the foot, loading the plantar fascia with increased tensile stress.”

So, loss of ankle rocker leads to increased midfoot pronation, which loads the plantar fascia. That sounds pretty logical to us. We are sure you are thinking a loss of hip extension may do the same thing. Correct. Or you may say ” The calves may be tight so the medial gastroc can invert the rearfoot to correct for too much midfoot pronation and the foot can be supinated"…and you would be correct again.

So why are the tight hammys driving the bus? Or are they?

We remember the hams are a 2 joint muscle, and with the foot in a closed chain position (ie, on the ground); they flex the thigh on the lower leg and tilt the pelvis posteriorly (ie reduce the lordosis). They are FLEXORS which are active from late swing phase, just prior to heelstrike (initial contact) and a little nudge just prior to toe off (preswing) to help extend the thigh. 

The tricep surae are FLEXORS and are supposed to be active from loading response till almost pre swing, with a burst of activity at heel lift (terminal stance). 

So they take turns, and are not firing (normally) at the same time (or maybe have a small overlap). Going from heel strike to heel strike, the hammys fire 1st.

So IF the two are related, it could be a neurological sequencing issue. How often does that happen? The literature says (and there aren’t many studies) that you can change the order of recruitment of motor units ( the nerve and the muscle fibers it innervates), but not (usually) individual muscles. So probably not.

OK, how about plan B?

The hams and tricep surae are all flexors, correct? What is the innervation to the hamstrings and tricep surae? Hmm….Hamstrings, mostly tibial branch of the sciatic nerve, short head of biceps femoris is the common peroneal: L5-S2. How about the tricep surae? Tibial nerve, mostly S1-S2. I think I see a trend here. Common neurological overlap of FLEXOR muscles.

So are the hams driving the bus? Probably not, but neither are the gastroc/ soleus. The FLEXORS are driving the bus, and excitation of that common neuronal pool is probably causing the tightness

Ivo and Shawn….Uber footgeeks of the web. Dicing and slicing through the literature so you don’t have to.

More Gait Guy Gait Gaffs: What it would look like if “The Flash”, ran with heel strike ? click here. Note the excellent anterior compartment use (nice ankle dorsiflexion and toe extension at terminal swing/ pre-impact) but heavy, nasty, heel strike. What is interesting here is that he has adopted a nice forward lean (ala. natural or chi running style) but when combining this with a heel strike gait you end up with an anterior pelvic tilt (which begins inhibition of the lower abdominals) and you then have to begin the power through phase in early-mid stance phase with the hamstrings. You need tremendous lower abdominal strength, and hamstring length and strength to run this way (go ahead, get up and try it running through your office ! let out a great “Yaulp” from the ensuing hamstring pull (ala Robin Willliams in Dead Poets Society) when you find out your abdominals are not strong enough to lean that far forward and still heel strike, without enough hamstring length (on second thought, just trust  us……although i know now we have challenged some of you). This is a medical disclaimer, dont do it !