One of my clients has osteoarthritis of the right knee and is awaiting surgery on the joint. She is also seeing an NHS physio who has advised her not to do the 4 sign exercises I gave her. When I do the screen she finds it difficult to place her ankle above the opposing knee (on both sides) and the bent knee is more than three hand-spans above the couch. Naturally she find it very difficult to get into the correct position to perform the exercise.
Please advise if the physiotherapist is correct and she should not be doing the 4 Sign and if there is any alternative? (I have also given her the leg press).
Also after four weeks I have not seen any noticeable improvements.
Yes the physio is correct. yes leg press will help. if there are arthritic changes in teh hip, its likely that is causing the spasm, so in that case the OA needs dealing wht then the spasm can be sorted. In some clincial cases, its the opposite way roiund - its not always the spasm that causes the injury, its the acute injury that causes hte spasm - not surprisingly. But what posiition can you get he hip and knee in to hit piriformis without loading the knee?
Martin, Is there a variation of the 4-sign exercise if clients cannot get there ankle just above the knee? , maybe doing the isometric contraction lying crook using the 20% principle but having the ankle below the knee on the tibia/fibula portion of the leg?
Good job, think of the attachements of piriformis, think of its different actions with the hip in different positions and look at a way that you can hit piriformis without the knee load. let me know what you come up with....
The piriformis is an abductor and lateral rotator of the femur. With the 4-Sign exercise you are starting from an abducted and laterally rotated position and are therefore isometrically contacting the antagonist muscles (I get a feeling I am getting this all wrong). Therefore can you isometrically contract the piriformis to anti-spasm it by:
Having the client sit on the floor with their back up against a wall with both knees in extension.
Ask the client to bend the leg (they are going to perform the anti-spasm on) till the plantar surface of the foot is flat against the floor.
Then with both hands hold the lateral side of the flexed knee.
Client then to push the knee into hands in a 20% isometric contraction. i.e.: if hands were not there client would be performing an lateral rotation and abduction of the femur dropping the knee to the floor.
In terms of using the same principle movement as taught:
Carry out point points 1. and 2. above.
Then client to drop the flexed knee to floor. Client now in similar start position as standard start position put as the foot/ankle of this leg it not on the opposing thigh (above knee) but next to it then it should mean less stress on knee ligaments particularly the LCL.
However apply the 20% isometric hold on the medial side of the knee replicating the 4-sign technique?....
This is getting confusing as when doing the normal 4-sign exercise the piriformis is not contracting isometrically if its job is to abduct and laterally rotate the hip, however I do understand that in the 4-sign exercise the piriformis will be elongated, but In the 4-sign exercise the piriformis would be an antagonist to the isometrically contracted adductor and internal hip rotator muscles right? surely the correct way to isometrically contract the piriformis muscle is to hold the isometric contraction on the lateral side of the knee whilst in the 4-sign exercise to target that muscle?..... unless our whole objective is to isometrically contract the antagonist muscles of the piriformis ?
Martin help Im going loopy
P.s, If things get complicated get your client to do the leg press and re-screen the pelvic area to see if there is an improvement.
OK, you're maing logical decisons, but the basis upon which they are calculated needs work.
Piriformis is a lateral rotator of the hip joint when the hip is below 70 degrees.
Above 90 degrees of hip flexion it is likely to be an internal rotator.
So now when you look at 4-sign, can you see that it is actually engaging piriformis as an internal rotator (as well as other muscels of course too)
Now when you're trying to take the load off the knee, think of how you can do that by working piriformis in a posiiton that does not work it as an internal rotator, which will iikely take the pressure off the knee - depending upon which exercise you go with.
Now have a think based upon that info as to which exervise you'd prescirbe the cleint to hit piriformis without loading his/her knee.
i'm off on holdiay now for a week so i'll look in again when i get back at the end of next week guys. have a great easter!!!!
Hi Martin and Alex, I hope you guys have had a great Easter,
RIGHT!, I've been thinking about this and I have taken into account what you have said Martin, the only thing I can think of alternatively to sitting is lying down the client on there front (face to floor) straighten both legs and then getting them to flex at the knee to 90 degrees and get them to externally rotate the hip while the trainer adds resistance to the clients ankle of the leg that is performing the anti-spasm for the piriformis.
Im guessing that would work the piriformis as the hip is in a extended position and we are not putting pressure on the knee. (I think)
I think your're on the right track but my concern with your solution is two fold:
You need a partner.
the ankle area being the point of resistant when trying to hit the hips. I may be wrong on this but it may be too distal a location to be very effictive as knee joint stabilisation would be required.
I was thinking of slightly modifying your suggestion but standing up against a door frame but client is move likely to do abduction than lateral rotation.
Client stands in doorway (facing door aperture) and places hands on either side of exteral surface of door-frame. i.e.: hands should be at shoulder height with an anterior facing palm (as in stop sign).
Client then moves whole body to the right till toes of right foot are touching door frame.
Client flexes right knee till right foot is a couple of inches above floor (right foot above left ankle).
Client then shifts about till lateral surface of flexed knee is flush against the door frame.
Client pushes flexed knee (right) into door frame with 20% maximal force for 20 seconds, etc.
Nav, unlike your solution mine does involve some hip flexion, but should be ok as below 70 degrees. Could move your prone position and replicate it against the doorway but my only concern from my experiments is a tendancy to abduct as well as lat. rotate and therefore highly unlikely most people would do it properly.
I think if you get your client to lay prone next to a wall then flex at the knee and then do an external rotation of 20% against the wall, that would work, which may also resist the urge for abduction at the hip , I think if you give a clear demonstration and explain exactly how you want this exercise to work you can get it done with 0% hip abduction.
As long as the hip is in less than 70 degrees of flexion and we are resisting lateral rotation, we're hitting piriformis (and the other external rotaors). so the door frame opiton or the prone laying opiton will both work with the corrcet instructions to the client.
We tend to lay the client down supine, and side on to a wall. flex knee to 40 degrees with their heel on floor. then press their knee into the wall. this lmiits knee load, hits piriformis as lateral rotator, encourages lateral rotation rather than abduction and doesnt need a partner.
Thanks for that Alex :) I was almost there haha , never thought of lying the client supine and applying the principle.
I guess as long as you understand the principle and muscle actions our Biomechanics exercise prescription can be altered in a safe way to exploit the 20/20 principle to some extent. Exciting.
