Muscle Imbalance
Evaluation and Treatment
for the Low Back and Hip
Areas
Jose S. Figueroa, D. O.
Physical Medicine and Rehabilitation,
NMM/OMM
AOCPM&R, Fall 2013
1
Case Study
• In 1998 a 33 y/o gentleman presents with a 5
year history of right shoulder pain, which did
not stop him functionally, but significantly
affected his sleep.
• Diagnosed originally with biceps tendonitis,
and given some OMM treatments with good
but temporary relief.
• Dr. Greenman saw him and stated that he had
a muscle imbalance…
2
Objectives
• Learn concepts of neuromuscular imbalances and their
contribution to chronic musculoskeletal dysfunction in the
lumbar, pelvic and hip areas.
• Learn the muscles that commonly affect the low back, pelvic
and hip areas.
• Be introduced to the evaluation and treatment of muscle
imbalances of the lower quarter:
–
–
–
–
–
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Diagnose weak or pseudo-paretic muscles
Teach a home exercise prescription to address the tight/short and
weak or pseudoparetic muscles
– Follow-up for re-evaluations and exercise adjustments
– Teach patients how to self-treat certain common somatic dysfunctions
3
Most of the information in this
lecture is derived from the works
of
• Phillip Greenman, D.O.(he is the one in the
pictures)
• Dr. Vladimir Janda, a specialist in rehabilitation
medicine at the University of Charles, Prague,
Czechoslovakia, deceased in 2006
4
Road Map

•
•
•
•
•
•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
5
Muscle Balance
• The relationship between the strength
and the length of the muscles around a
joint or multiple joints.
• Ex. of muscles affecting one joint:
– Vastus medialis obliquus (knee joint), soleus
(ankle)
• Ex. of muscles Affecting multiple joints:
– Psoas (lumbar/SI/hip), hamstrings (knee/hip)
6
Muscle Imbalance Theory
• According to Dr. Janda, it is a malregulation by
the central nervous system (CNS) leading to:
– Some muscles becoming tight
– Some muscles becoming weak
– Loss of control of integrated muscle function
• Loss of Symmetry and Control
• Caused by some form of musculoskeletal
disturbance
7
Musculoskeletal Disturbance
• Can be caused by acute or chronic events.
Examples include changes in lifestyle, or poor
ergonomics, or trauma, or disease, etc.
• Examples: stress, participating in a poorly
designed exercise program, sedentary
lifestyle, joint and/or soft tissue disease or
trauma, spending too much time working in
front of a computer, loss of a limb, etc.
8
Articular
Receptors
1. Musculoskeletal
Disturbance
create
Reflexes at the level
of the:
Premotor Cortex
Motor Cortex
Brainstem
Spinal Cord
MUSCLE
IMBALANCE
CYCLE
Adds
to
Creation of Muscle
Imbalances which
maintain the wrong
positions of the
joints
Return to normal
muscle tone
Alteration in
muscle tone,
affecting joint
position and
function
Alpha Motor
Neuron
stimulates
muscle fiber to
contract.
Gamma
System:
stimulates
muscle
spindle to
adapt
9
Understanding Motor Control
• Movement: is performed by combined muscle
pull, which is very controlled in a very
complicated manner
– Controlled movements require many CNS signals
(afferent and efferent) with precise timing and
number
• CNS controls movement through
proprioception
– It produces useful movements that adapt to our
constantly changing environment
– Needs precise input from many receptors
10
Sit Up Straight, Please
• Pelvic Clock
• Helps to give you an awareness of the location
of the trunk when in postural balance
• Used in the supine, seated and standing
postures
• Let’s try the pelvic clock SEATED
• Work on the Sit
Stand Transfer, using
the pelvic clock
11
Functional Disturbance
• Injuries or diseases can cause muscles to react
differently than normal because of:
– Guarding joints or organs
– Inability to move properly due to tissue or nerve
damage
• Chronic vs. Temporary:
– When the injury is chronic, the changes are longer
lasting.
• Chronic poor posture re-trains the muscles in
patterns of movements that eventually
become incompatible with normal function
12
Muscle Function Disturbance
• Chronic articular or muscle dysfunction feeds the
afferent loop with more nociception and abnormal
mechanoreceptor information, perpetuating ongoing
aberrant muscle tone.
13
Muscle Imbalances
• Some muscles become tight (tonic)
• Some muscles become weak (phasic)
• Altered motor control (impaired proprioception)
– Either muscles do not contract when they are
supposed to, so they act as if they were weak
– Or muscles contract too early when moving
certain joints or too much when maintaining
certain postures
14
Road Map


•
•
•
•
•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
15
Functional Disturbance
• There are two main ways that the muscles
react to functional disturbance:
• Some muscles become tight/short
– Usually the slow twitch fiber type muscles
• Some muscles become weak (or
pseudoparetic)
– Usually the fast twitch fiber type muscles
16
Slow-twitch Fiber Type
•
•
•
Oxidative metabolism, high capillary
density, greater endurance, characteristic
red color
Twitch speed is slow, making their function
more tonic or postural
Slow-twitch muscles react to functional
disturbance by shortening and tightening.
17
Fast-twitch Fiber Type
•
•
•
Glycolytic metabolic pathway, fatigue
rapidly, have low capillary density, whitish
color.
Twitch speed is fast and shorter lasting,
making their function phasic.
Fast-twitch muscles react to functional
disturbance by weakening or becoming
pseudoparetic
18
Table 1. Common upper and
lower extremity muscles and
their reaction to injury
19
Body Region
Function:
Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Pelvic and Hip
Region
Hamstrings
Iliopsoas
Rectus Femoris
Tensor Fascia Lata
Thigh Adductors
Vastus Medialis
Obliq.
Vastus Lateralis
Gluteus Maximus
Gluteus Medius
Gluteus Minimus
Piriformis
20
Body Region
Function:
Function:
Primarily
Primarily Phasic
Postural/Tonic
(Weak)
(Short and Tight)
Leg
Gastrocnemius Tibialis Anterior
Soleus
Peroneus
21
Body Region
Function: Primarily Function:
Postural/Tonic
Primarily Phasic
(Short and Tight)
(Weak)
Neck and Trunk
Erector Spinae
Group
-Lumbar Region
-Cervical Region
Quadratus
Lumborum
Scalenes
Sternocleidomastoid
Deep Cervical
Spine Flexors
Erector Spinae
muscles
-Mid-thoracic
Rectus
Abdominis
External
Obliques
Internal Obliques
Transversus
Abdominis
22
Body Region
Function:
Primarily
Postural/Tonic
(Short and Tight)
Shoulder Girdle Pectoralis Major
Levator Scapulae
Upper Trapezius
Biceps Brachii
Latissimus Dorsi
Function:
Primarily Phasic
(Weak)
Middle Trapezius
Lower Trapezius
Rhomboids
Supraspinatus
Infraspinatus
Triceps Brachii
Serratus Anterior
Deltoid
23
Stand Up, Please
• Static Active Stretch: muscle is put on a
passive stretch with little to no movement,
while its antagonist is being used to maintain
the position of the muscle stretched and to
reciprocally inhibit the muscle stretched.
Examples:
– Rectus Femoris
– Chest stretch
24
Road Map



•
•
•
•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
25
Causes of Muscle Imbalance
•
•
Noxious stimulus (due to acute or repetitive
trauma, chronic injury, arthritis, space
occupying lesion, neurologic injury,
metabolic disease, loss of a limb, etc.)
Prolonged postural disturbance (resulting in
a prolonged alteration of the center of
gravity, with mechanical responses requiring
long term muscle adaptations)
26
Causes of Muscle Imbalance
•
•
Excessive physical demands (usually chronic
overuse or under-use or chronic lack of restespecially stage IV sleep)
Emotional problems or other psychological factors
(tightness and fatigue that result when we are
"uptight" or stressed, anxious, depressed, etc.)
–
–
We show emotion with our muscles
Muscular action tends to create and/or accentuate
emotion
27
Reflex Pathways are involved in
maintaining muscle imbalances
• Co-Contraction:
– Lumbar erector spinae and psoas contracting to stabilize an
injured lumbar spine: What would someone look like who has
this?
• Reciprocal Inhibition:
– Psoas tightening causing weakness of gluteus maximus
– Pectorals tightening causing weakness of interscapular muscles
• Reciprocal Inhibition leading to Substitution
– Hamstrings doing most of the hip extension instead of the
gluteus maximus
• Still need to address the offending tight muscle: Iliopsoas
– Tensor fascia lata doing most of the hip abduction due to a weak
gluteus medius / minimus
• Still need to address the offending tight muscle: Adductor
28
Muscle Function Disturbance
• This vicious cycle can be interrupted and
reprogrammed through
• OMM
• Specific Exercises prescribed in the Proper Sequence
• Thus, the overall muscle tone and balance can be
returned to (and maintained in) a more normal
state.
29
1. OMM
2. Exercise Prescription
Articular
Receptors
create
Reflexes at the level of the:
Premotor Cortex, Motor
Cortex, Brainstem
Spinal Cord
1. Musculoskeletal
Disturbance
MUSCLE
IMBALANCE
CYCLE
Adds
to
Creation of Muscle
Imbalances which
maintain the wrong
positions of the
joints
Return to normal
muscle tone
Alteration in
muscle tone,
affecting joint
position and
function
Alpha Motor
Neuron stimulates
muscle fiber to
contract.
Gamma System:
stimulates muscle
spindle to adapt
1. OMM
2. Exercise Prescription
30
Functional Capacity!
• Despite the osseous pathology of his own
lumbar spine, Dr. Greenman used to
demonstrate all of the exercises in his text and
to his patients.
• This demonstrates the functional capacity in
the presence of significant osseous pathology.
• This demonstration was a powerful
motivational tool.
31
32
Kneel “Up” Straight, Please
• Pelvic Clock Kneeling
• Floor: sit to kneeling transfer
– From knees fully bent to knees at 900 flexion
• Kneeling to ½ kneeling maneuver
– One foot on the ground
– The other foot with the ball of the foot on the
ground
• ½ Kneeling to Stand transfer with or without
assistance
33
Road Map




•
•
•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
34
Diagnosis of Muscle Imbalances
Three Specific Types of Clinical Testing
•
Evaluate Proprioception
–
•
Through balance testing
Evaluate the sequence of muscle contraction
(muscle “firing” patterns) during specific
movements to evaluate which muscles contract out
of sequence, acting as if they were weak
Evaluate asymmetry in muscle lengths
•
–
Muscles are isolated as much as possible and then
tested for symmetry in their lengths and compared with
estimations of normal
35
Treatment of Muscle Imbalances
General Principles:
• Goal: restoration of proper muscle length, strength
and control of muscle function
• Start with OMM
• May need a home exercise prescription (HEP)
• HEP should address muscle control (i.e.,
proprioception re-training)
• When treating muscle imbalances: Quality of movement is
more important than quantity
36
General Treatment Sequence
1. Establishing a process of re-evaluations to
monitor progress
2. Establish a level of patient commitment to
follow through
3. Re-training proprioception
– home exercises (single leg stance)
– PT (more advanced intervention)
37
General Treatment Sequence
4. Stretching the tight muscles
– manual stretches in the office (Dr. or PT)
– home stretches (self-stretches)
5. Re-training or strengthening late contracting
(pseudoparetic) or weak muscles
– home “strengthening” exercises
6. Teaching the patient how to self-treat
specific recurring somatic dysfunctions on
their own
38
Road Map





•
•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
39
HANDS-ON SESSION
DIAGNOSIS AND TREATMENTS OF
COMMON MUSCLE IMBALANCES
OF THE PELVIS AND LOW BACK
40
Treating Impaired Proprioception
• Retrain balance with bare feet on a carpeted
surface in order to stimulate the
propioceptors of the sole of the foot
• Practice “shortening the foot”-also stimulates
the proprioceptors of the soles
• Goal: the capacity to symmetrically stand on
one leg with arms crossed and eyes closed for
30 seconds
– Do the best possible if unable to reach goal
41
42
Look to your feet, Please
• Remove your shoes
• See if you can shorten one of your feet now
• Let’s test each other’s SINGLE LEG standing
balance
43
Treating Impaired Proprioception
• Bilateral exercises that help increase
proprioception and increased body
awareness:
– Walking, Swimming (may need mask/snorkel)
– Properly taught Pilates
– Bilateral Martial Arts movements like some of the
ones found in Tai Chi, Choi Kwang Do, etc.
44
Road Map






•
•
•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
45
Evaluating Muscle Firing Patterns
of
Lower Quarter Muscles
46
PELVIC CLOCKS
• Three dimensional evaluation of function of
the lumbar spine and pelvis.
• Used diagnostically and therapeutically.
47
Testing: PELVIC CLOCKS
Clock Orientation
Start Position
48
Testing: PELVIC CLOCKS
12 O'clock
Problems: pubic dysfunction,
iliosacral dysfunction, sacral
dysfunction (base posterior), lumbar
extended dysfunction, tight psoas,
tight paraspinals, weak abdominals
6 O’clock
Problems: pubic dysfunction,
iliosacral dysfunction, sacral
dysfunction (base anterior), lumbar
flexed dysfunction
49
Testing: PELVIC CLOCKS
3 O’clock
Problems: Lumbar rotation to the
left, sacral torsion to the right , weak
abdominal obliques, transversus
abdominis
9 O’clock
Problems: Lumbar rotation to the
right, sacral torsion to the left, weak
abdominal obliques, transversus
abdominis
50
Testing: HIP EXTENSION FIRING
PATTERN
51
Testing: HIP EXTENSION FIRING
PATTERN
•
•
•
•
Hamstrings.
Gluteus maximus.
Contralateral lumbar erector spinae (low).
Ipsilateral lumbar erector spinae (low).
• Contralateral lumbar erector spinae (high).
• Ipsilateral lumbar erector spinae (high).
Significant finding is late firing of the gluteus
maximus.
52
Other Firing Patterns
• Hip Abduction Firing Pattern on Sidelying
– Normal: Gluteus medius, Tensor fascia lata (TFL),
Quadratus lumborum (QL) and Erector Spinae
– Abnormal: substitution with weakness of gluteus
medius and early firing of TFL (causing IR and flexion
of the hip) and QL. Worst scenario is that the motion
is initiated by the firing of the QL.
• Pelvic Tilt Heel Slide
• Pelvic Tilt with Hip Abduction and External
Rotation
• Active Trunk Rotation
53
Road Map








•
•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
54
Evaluating and Treating
Muscle Length Asymmetry
of
Lower Quarter Muscles
55
Stretching: PSOAS & RECTUS FEMORIS
56
Manual Stretching of Muscles
• Manual Stretching done at the clinic is very
important because it can significantly increase
the muscle lengths further than self-stretching
alone can.
– “Supercharges” the patient’s home stretching
routine
• Sustained Stretch: 20-30 secs, 2 or 3 reps.
• Muscle Energy: Post-isometric Relaxation and
Stretch
57
Stretching: RECTUS FEMORIS
PRONE
58
Stretching: PSOAS PRONE
• Anterior Hip Capsule Stretch
59
SELF STRETCH: PSOAS
60
SELF STRETCH: RECTUS FEMORIS
61
Stretching: ADDUCTORS
62
Stretching: ADDUCTORS (Long)
63
Stretching: ADDUCTORS (Short)
64
SELF STRETCH: ADDUCTORS
65
Stretching: PIRIFORMIS
66
Stretching: PIRIFORMIS
• Above 90 degrees
67
Self Stretch: PIRIFORMIS
Above 90 degrees
Below 90 degrees
68
Self Stretch: PIRIFORMIS (Prone)
69
Stretching: LATISSIMUS DORSI
70
Stretching: LATISSIMUS DORSI
Manual Stretch
71
Self Stretch: LATISSIMUS DORSI
72
Road Map









•
Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
73
Strengthening / Retraining
of
Lower Quarter Muscles
74
Strengthening/Retraining:
GLUTEUS MAXIMUS
• Prone hip extension.
• Bridging.
75
Strengthening/Retraining:
GLUTEUS MAXIMUS
1. Contract Gluteus.
2. Contract Gluteus
& hold knee.
76
Strengthening/Retraining:
GLUTEUS MAXIMUS
3. Isometric hold.
4.Concentric contraction.
77
Strengthening/Retraining:
GLUTEUS MAXIMUS BRIDGING
1. Contract transversus
abdominus or
maintain a slight 12
o’clock pelvic tilt.
2. Use two legs to
bridge and contract
buttocks.
3. Single leg bridge.
78
Strengthening/Retraining:
GLUTEUS MAXIMUS BRIDGING
79
Strengthening/Retraining:
ABDOMINALS
• Sit backs.
• Curl ups.
• Supine leg slides with stable transversus or
posterior pelvic tilt.
• Norwegian exercise.
80
Strengthening/Retraining:
ABDOMINALS
Rectus abdominus
Transversus abdominus
81
Strengthening/Retraining:
ABDOMINALS
• Oblique abdominals
82
Strengthening/Retraining:
ABDOMINALS Sit Backs
• Performed in three stages, arms in front, arms
crossed, and hands behind neck.
• Maintain a lumbar lordosis throughout.
• Strengthens transversus abdominus in
subconscious mode.
• Strengthens abdominals in a lengthened
position.
83
Strengthening/Retraining:
ABDOMINALS Sit Backs
• Start position.
Level one.
84
Strengthening/Retraining:
ABDOMINALS Sit Backs
• Level Two
• Level Three
85
Road Map










Muscle Imbalances
Muscles commonly affected by imbalances
Causes of Muscle Imbalances
Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Home exercise prescription (HEP) for the tight/short muscles
HEP for the weak or pseudoparetic muscles
Part Two
86
Pause shortly. Then move on to
the second part of the program.
Questions
??????????????
87