REHABILITATION KEY POINTS

■ the brain recognises movement, not individual muscles ■ movement is a sensory experience as much as a motor experience ■ by re-training correct movement, the necessary muscles are automatically activated

■ repetition of aligned and controlled functional movement automatically “strengthens” muscles

■ aligned static positions form the foundation for dynamic movement ■ incorrect movement, repeated over time can cause pain ■ pain can be relieved by re-training aligned and controlled functional movement

■ integrated into daily activities of sitting, standing, and walking makes it functional and more meaningful to the patient and enables them to use it throughout the day. This increases compliance and motivation.

pronation will lead to midfoot collapse in midstance while hallux valgus will be seen as unstable push-off, with reduced plantar flexion of the ankle, causing shock absorp- tion to be transmitted up to the SIJs and lumbar spine. Increased pelvic rotation and side flexion may be used to achieve swing through of the legs. Swing of the upper limbs may be restricted and there will be loss of the primary control (Fig. 9).

Running - resulting shortened hamstrings and calves influence the biomechanics of the lower limb kinetic chain in the runner. They will land with increased knee flexion and thus more dorsiflexion (DF) is needed to position the body over the planted foot. DF will occur quickly at the talocrur- al joint and further ankle range will be achieved by pronating at the subtalar joint. This increases the valgus force vec- tor, increases the dynamic Q angle and increases PFJ compression forces (25).

The above descriptions clearly demon- strate the concept of use, structure, and function (Fig. 1). The client’s habitual lor- dotic standing posture (use) results in tight hamstrings and calves (structure) which affects gait and running (function).

RE-EDUCATION OF A SYMMET- RICAL STANDING POSTURE Optimal posture is a combination of min- imal joint loading and minimal muscle work (26). It is recommended to start with foot alignment as the feet provide the CNS with an abundance of afferent information (ascending pattern).

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Feet ■ equal weight bearing on left and right ■ parallel like train tracks

Visualise a square on the calcaneus. STJ neutral can be achieved by encouraging the patient to raise one heel and replace it with emphasis on the postero-lateral aspect contacting the ground first while the first ray remains on the ground (Fig.10). Weight should be evenly spread through the foot in all planes, with good contact of the calcaneus on the ground. A symmetrical foot posture reveals to the client the extent of the lower limb biome- chanical alignment (Fig.11).

Knees ■ soft knees (letting go of the hyperex- tension not standing with quadriceps contracted)

■ patellae should be facing anteriorly (“12 o’clock”). Where femoral internal rotation is seen, external rotation of the distal femur is necessary. Clients usually take a while to appreciate that this is not achieved by tightening the gluteals and may experience difficulty dissociating the tibial and femoral components.

Hips, pelvis and trunk ■ hip-knee-foot alignment - anteriorly, drop an imaginary plumb-line from the hip joint, (midway between the greater trochanter and the symphysis pubis). This should run through the centre of the patella and through the second/ third ray. Ribcage should be symmetri-

cal. Laterally, centre of gravity should fall just in front of the calcanei.

■ ask the client to visualise the spine being a stack of one pound coins and you want them to create space between each coin by growing tall

■ ask the client to simultaneously let go and lengthen the lower back. This is achieved by asking them to visualise the tail dropping towards their heels and letting go of the erector spinae (not by tucking under, which will over activat- ing the rectus abdominus at the front).

Head and neck ■ the thought of lengthening the spine will cause some to extend the cervical spine and pull back at the occiput. The back of the neck must remain length- ened to keep the occipital condyles engaged on the atlas; the thought is of the occiput gently moving forwards and up. This finally engages the primary control mechanism and is responsible for keeping the deep postural muscles activated. Loss of this control results in other superficial muscles taking over the role of keeping the body upright and moving. This increases pain and decreases efficiency.

A re-assessment of the ‘new and unfamil- iar’ aligned standing posture will reveal a neutral spine, decreased activity of the shortened muscles and increased activa- tion of the stabiliser muscles (Fig.12).

In this early cognitive stage of motor skill learning, the verbal, tactile and environ-

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