CHARLES UNIVERSITY
Faculty of Physical Education and Sport Department of Physiotherapy
Case Study of Physiotherapy Treatment of a Patient with the Disc Herniation at L5/S1 with
Radiculopathy
Bachelor Thesis
Author: Deniz Demiryol Supervisor:
Mgr. Helena Vomačkova, Ph.D
Prague, May 2021 Instructor:
Bc. Aleš Nesvadba
Declaration
I hereby declare that this bachelor thesis was written by myself according to the knowledge that I had gained in these three years of my studies in UK FTVS based on Clinical Work Placement which took place in Beroun Rehabilitace Hospital, from the 18th of January until the 12nd of February, performed under the supervision of Bc. Aleš Nesvadba.
I declare that no invasive methods were used during the therapy period and an informative paper was signed by the patient after fully getting informed about the examinations and therapy applied.
Prague, 2021 Deniz Demiryol
Acknowledgments
With this bachelor thesis, I would like to express all my gratitude to my teachers in The Faculty of Physical Education and Sports of Charles University in Prague, for all the theoretical and practical knowledge they provided to me in my study period.
I would like to personally thank my supervisor Bc. Aleš Nesvadba for leading me during my case study and letting me work with the patient practice and letting me work autonomously.
Additionally, this work is dedicated to my parents and family for their great support and encouragement that they have been giving me all these years.
Abstract
Title: Case study of physiotherapeutic treatment about a patient with disc herniation with L5/S1 with radiculopathy.
Thesis goal: The thesis is divided into two parts, theoretical part and practical part.
The former presents an introduction to the anatomy, biomechanics and kinesiology of the lower back. The latter, the kinesiological examination of the patient (initial and final) and practical application in order to treat and cure the patient with disc herniation L5/S1 with Radiculopathy.
Method: In these 8 therapy sessions I was working with my patient along with the help of my supervisor Bc. Aleš Nesvadba. I was applying practically the knowledge I was taught during these three years on my patient. Therapy includes postural correction, soft tissue techniques according to Lewit, breathing exercises, stretching and relaxation by post isometric relaxation technique (PIR), PNF strengthening technique, and ADL training. For active exercises we used the help of specific tools such as over ball, gym ball, and medicine ball. These exercises were slipped into isotonic and isometric exercises. Afterwards, final kinesiological examination and the evaluation of the therapy results.
Result: Following 8 therapy sessions the patient could feel the relaxation of the restricted fascia of lower back and the decreased lower back pain. It was not fully relaxed. The patient was educated before of her condition but she is more aware about her condition after the sessions.
After the sessions, the patient has improved in her hip and knee range of motion in all the directions and with her walking pattern and coordination. Gait was the field where the patient improved the most because of the decreased lower back pain.
Keywords: lumbar disc herniation, range of motion, back pain, physiotherapy.
Abstraktní
Název: Kazuistika fyzioterapeutické léčby pacienta s výhřezem ploténky s L5/S1 s radikulopatií.
Cíl práce: Práce je rozdělena na dvě části, část teoretickou a část praktickou. První z nich představuje úvod do anatomie, biomechaniky a kineziologie dolní části zad.
Kineziologické vyšetření pacienta (vstupní a závěrečné) a praktická aplikace za účelem léčby a vyléčení pacienta s herniací ploténky L5/S1 s radikulopatií.
Metoda: V těchto 8 terapeutických sezeních jsem pracovala se svým pacientem za pomoci mého školitele Bc. Aleš Nesvadba. Prakticky jsem aplikoval znalosti, které jsem se během těchto tří let naučil, na svém pacientovi. Terapie zahrnuje posturální korekci, techniky měkkých tkání dle Lewita, dechová cvičení, strečink a relaxaci post izometrickou relaxační technikou (PIR), PNF posilovací techniku a trénink ADL. Pro aktivní cvičení jsme využívali pomoc specifických pomůcek jako overball, gym ball, medicinbal. Tato cvičení se sklouzla do izotonických a izometrických cvičení. Poté závěrečné kineziologické vyšetření a zhodnocení výsledků terapie.
Výsledek: Po 8 terapeutických sezeních mohl pacient pociťovat uvolnění omezené fascie dolní části zad a snížení bolesti dolní části zad. Nebylo to úplně uvolněné.
Pacientka byla o svém stavu edukována dříve, ale po sezeních je o svém stavu více informována.
Po sezení se pacientce zlepšil rozsah pohybu kyčle a kolena ve všech směrech, vzor chůze a koordinace. Chůze byla pole, kde se pacient nejvíce zlepšil kvůli snížení bolesti dolní části zad.
Klíčová slova: výhřez bederní ploténky, rozsah pohybu, bolesti zad, fyzioterapie.
Contents
1. Preface 1
2. General Information 2
2.1 Vertebral Column 2
2.2 Spinal Curvature 2
2.3 Anatomy of Lumbar Spine 3
2.3.1 Vertebral bodies 3
2.3.2 Ligaments of the Vertebral Column 4
2.3.4 Spinal Nerves & Segmental Innervations 5
2.3.5 Fascia of Lumbar Spine 5
2.3.6 Muscles of the Spine 6
2.3.7 Diaphragm 7
2.3.8 Pelvic Floor 8
2.4 Biomechanics of Lumbar Spine & Intervertebral Disc 8 2.5 Kinesiology of Lumbar Spine & Intervertebral Disc 9
2.5.1 Extensors of the Lumbar spine 10
2.5.2 Lateral Flexors of the Lumbar Spine 11
2.5.3 Flexors of the Lumbar Spine 11
2.5.4 Rotators of the Lumbar Spine 11
2.6 Pathophysiology 12
2.6.1 Disc Herniation 12
2.7 Treatment 13
2.7.1 Surgical treatment 13
2.7.2 Nonsurgical treatment 13
2.7.3 Physiotherapeutic Approach 14
3. Special Part (Case Study) 16
3.1 Methodology 16
3.2.1 Status Presence 18
3.3 Initial kinesiological examination: 20
3.3.1 Postural examination: 20
3.3.2 Palpation of pelvis: 21
3.3.3 Breathing stereotype 21
3.3.4 Specific testing of posture 22
3.3.5 Modification of standing 22
3.3.6 Dynamic Spine Examination 22
3.3.7 Anthropometric Measurements of Lower Extremities 23
3.3.8 Gait Examination 23
3.3.9 Movement Pattern Evaluation according to Janda 24
3.3.10. Range of motion Examination 25
3.3.11 Muscle Length Test (According to Janda) 26
3.3.12 Muscle Strength Test (According to Kendall) 26
3.3.13 Muscle Tone Palpation 27
3.3.14 Joint play examination (According to Lewit): 28 3.3.15 Subcutaneous Tissues & Fascia Examination (According to Lewit): 28
3.3.16 Kibler`s Fold (cutis and subcutis): 28
3.3.17 Neurological Examination 29
3.4. Initial Examination Conclusion 29
3.5. Short term Plan 31
3.6. Long term Plan 32
3.7. Therapy Proposal 32
3.8. Therapy Progress 33
3.8.1 Session 1 on 18.01.2021 33
3.8.2 Session 2 on 19.01.2021 34
3.8.3 Session 3 on 20.01.2021 37
3.8.4 Session 4 on 21.01.2021 38
3.8.5 Session 5 on 22.01.2021 40
3.8.6 Session 6 on 25.01.2021 41
3.9 Final Kinesiological Examination 42
3.9.1 Palpation of pelvis: 44
3.9.2 Breathing stereotype 44
3.9.3 Specific testing of posture 44
3.9.4 Modification of standing 44
3.9.5 Dynamic Spine Examination 45
3.9.6 Anthropometric Measurements of Lower Extremities 46
3.9.7 Gait Examination 46
3.9.9 Movement Pattern Evaluation according to Janda 47
3.9.10 Range of motion Examination 48
3.9.11 Muscle Length Test (According to Janda) 48
3.9.12 Muscle Strength Test (According to Kendall) 49
3.9.13 Muscle Tone Palpation 50
3.9.14 Joint play examination (According to Lewit): 51 3.9.15 Subcutaneous Tissues & Fascia Examination (According to Lewit): 51
3.9.16 Kibler`s Fold (cutis and subcutis): 51
3.9.17 Neurological Examination 52
4. Evaluation 53
4.1 The Effect of Therapy 53
5. Conclusion 55
6. Bibliography 56
6.1 Literature References 56
7. Supplements 59
7.1 Figures List 59
7.2 Tables List 59
7.3 Abbreviations 59
1. Preface
My thesis work placement took place in Beroun Rehabilitace Hospital, from the 18th of January until the 12th of February. In this work placement the goal was understanding and testing my knowledge theoretically and practically. In Beroun Hospital I was assigned a patient with Disc Herniation of L5/S1 with Radiculopathy.
In this thesis I determined the detailed knowledge of the theoretical part which is the general part; anatomy, kinesiology and biomechanics of the lower back. In the practical part of the thesis I described the techniques and methods that I was applying on the patient in order to treat and cure the patient with disc herniation L5/S1 with Radiculopathy.
The conclusion of the study was successful as the pain was reduced, and posture was improved. According to this patient was able to perform the gait pattern much better.
2. General Information 2.1 Vertebral Column
The vertebral column is a structure composed of linked bones called vertebrae. It is consisted of approximately 33 vertebrae that are divided in 5 functionally separated parts; 7 cervical, 12 thoracic, 5 lumbar, 5 triangular ossified sacral and 4 fused elemental vertebrae consisting the coccyx [30, 16].
Each vertebra differs and shares characteristics among others. A typical vertebra consists of a ventral body, a dorsal arch extended by processes, a vertebral foramen engaged by the spinal cord, meninges and their vessels. There are 7 processes projecting per vertebral arch. Those consist of a spinous process, two transverse processes and two superior and inferior articular processes. On articular processes there is a smooth hyaline cartilage base joint, where the superior articular process of a vertebra articulates with the inferior articular process of the vertebra above it, to form the zygapophysial joint or facet [30, 16].
2.2 Spinal Curvature
There are three curves of the spine. The neck, or else the cervical spine, curves slightly inward. The thoracic spine curves outward. The low back, called the lumbar spine, curves slightly inward. An inward curve in the spine is called lordosis and an outward curve is called kyphosis. The kyphosis is shaped like a "C" with the opening in front. In cases of muscle disbalances and core instability we can see exaggerated positions of the spine with hyperkyphosis and hyperlordosis. [31]
Figure 1. Spinal curvature [1]
The spinal curves provide support, flexibility, stability and the needed stiffness of the spine. They distribute the vertical pressure on the spine, and bear the weight of the body. Ifthe spine was absolutely straight, it would be more likely to collapse under the pressure of the weight of the body [31].
2.3 Anatomy of Lumbar Spine
2.3.1 Vertebral bodies
The vertebral body serves as the primary weight bearing component of the spine [18]. The word “lumbar” comes from the Latin word “lumbus,” which means lion, and the lumbar spine deserves its name. It is constructed for both power and providing flexibility (flexion, extension, etc.) [6].
The lumbar spine consists of 5 (five) vertebral bodies that extend from the lower thoracic spine (upper back) to the sacrum (bottom of the spine). They are the largest out of all the vertebrae because the lumbar vertebrae are responsible for support of the weight bearing of the body due to gravity [26]. The five vertebrae of the lumbar spine (L1L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso [29].
Figure 2. Vertebral Bodies [2].
The lumbar vertebrae increase in size from L1 till L5. These vertebrae bear much of the body's weight and undergo biomechanical stress. Compared to those in the thoracic spine, the pedicles are longer and wider and the spinous processes are horizontal and more squared in shape. The intervertebral foramina are relatively large but nerve root compression is more common than in the thoracic spine [29].
The lumbar spine is connected to the sacrum at the lumbosacral joint (L5S1).
This joint permits considerable rotation, so that the pelvis and hips can swing during walking and running [12]. The lumbar spine’s lowest two spinal segments, L4 L5 and L5S1, which include the vertebrae and discs, bear the most weight and are therefore the most vulnerable to degradation and injury [29].
2.3.2 Ligaments of the Vertebral Column
Connective tissues are patterns of fibers that keep the cells of the body together. Ligaments are connective tissues that it is connects bone to bone. Several long ligaments connect on the front and back surfaces of the vertebrae. The anterior longitudinal ligament runs along the spine on the front of the vertebral bodies and prevents hyperextension of the spine. The posterior longitudinal ligament attaches on the back of the vertebral bodies [26].
In the spine there are three essential ligaments: Ligamentum Flavum, Anterior Longitudinal Ligament and the Posterior Longitudinal Ligament. The Ligamentum Flavum is a long elastic band that connects to the front surface of the lamina bones. Thick ligaments also connect the ribs to the transverse processes of the thoracic spine [26].
This ligament makes the connection between facet joints and covers over the posterior openings of the vertebra. The anterior longitudinal ligament attaches to the anterior surface of each vertebra. This ligament runs along the spine (vertical or longitudinal). The Posterior Longitudinal Ligament runs up and down behind (posterior) the spine and inside the spinal canal [36].
When any two consecutive lumbar vertebrae are articulated, three joints are
formed. The first is composed between the two vertebral bodies and the other two are composed by the articulation of the superior articular process of one vertebra with the inferior articular processes of the vertebra above [27]. Intervertebral joint is the space that is located between two vertebras. Spine movement occurs in this space.
The vertebral body and the vertebral arch (the back portion) are the meeting points of the two spinal bones which form an intervertebral joint. Between the vertebral bodies, the intervertebral discs absorb any forces applied to them. Zygapophysial joints or else known as facets joints are synovial joints and they are located between superior and inferior articular processes on vertebrae. A thin articular capsule is attached to the margin of the articular facets and encloses each joint. In lumbar regions, the joint surfaces are curved and adjacent processes interlock, thereby limiting range of movement, though flexion and extension are still major movements in the lumbar region [36].
2.3.4 Spinal Nerves & Segmental Innervations
Spinal nerves are united ventral and dorsal spinal roots, attached in series to the sides of the spinal cord. There are 31 pairs of spinal nerves: 8 cervical (C1C8), 12 thoracic (T1 T12), 5 lumbar (L1L5), 5 sacral (S1S5), 1 coccygeal (Co1). The peripheral nerves emerge through the intervertebral foramina. All ventral rami excluding T2T12 are organized into nerve plexuses as they branching each other laterally to the vertebral column. Those plexuses are dividing into cervical (C1C5), brachial (C5T1), lumbar (L1 L4) and sacral (L5S3) according to their localization.
Practically, each spinal segment is functionally connected to a specific area of the skin (dermatome, see figure 4), the musculature (myotome), the skeleton (sclerotome), and the internal organs (enterotome). [28].
Figure 4 Skin Dermatomes [4]
2.3.5 Fascia of Lumbar Spine
The thoracolumbar fascia (lumbodorsal fascia) is a membrane which covers the deep muscles of the back of the trunk. It consists of three layers, the anterior, posterior and the middle. Posterior layer of thoracolumbar fascia is the thicker than
anterior layer [20]. In the lumbar region the fascia (lumbar aponeurosis) is in two layers, anterior and posterior. [29]
2.3.6 Muscles of the Spine
The muscles of the lumbar spine contribute to flexion and extension of the lower back. They play a key role in postural support and stability. [33]
There are two major groups of muscles in the back. The extrinsic back muscles include superficial (trapezious, latissimus dorsi, levator scapulae, rhomboids mm.) and intermediate muscles (serratus posterior mm.) that produce and control limb and respiratory movements. The intrinsic (deep) back muscles include muscles that act on the vertebral column, producing its movements and maintaining posture.
[26]
Figure 3. Muscles of Spine
The muscles of the vertebral column are arranged into two main layers;
superficial and deep. Themore superficial extrinsic back muscles are innervated by the ventral rami of the spinal nerves. The erector long spinae extends the spine, it is divided into three columns: Iliocostal is cervices, thoracic and lumborum, which extends, abducts and rotated the vertebral column. The deepest layers are the intrinsic back muscles; they are innervated by the dorsal rami of the spinal nerves and
interconnect the vertebrae: Multifidus, interspinales and intertransversarii muscles, rotators, longus colli and longus capitis. They act as synergists in extension and rotation of the spine as well as spinal stabilizers. The lateral group consists of quadratus lumborum which extends the trunk bilaterally and lateral flexes the trunk with ipsilateral contraction, and psoas major which flexes the trunk [19].
2.3.7 Diaphragm
The thoracic diaphragm is a dome shaped septum, composed of muscle surrounding a central tendon, which separates the thoracic and abdominal cavities.
The function of the diaphragm is to expand the chest cavity during inspiration and to promote occlusion of the gastroesophageal junction. The diaphragm is an important muscle to be considered here, which is widely considered as a respiratory muscle only, but it also has postural and stabilizing functions.
It originates from 3 different parts, all of which insert in the central tendon. The sternal part is that originating at the rectus sheath and xiphoid process, the costal part originates at the 6th12th ribs and indented with the transversus abdominis, while the lumbar part originates at the bodies
and transverse Figure 4. Diaphragm [2].
processes of the 1st through the 3rd lumbar vertebrae and the 12th rib. As its fibers
abdominal viscera, compressing the abdomen, while the costal part eventually elevates the lower ribs and flares them outwards [19].
2.3.8
2.3.8Pelvic Floor
There are two groups of muscles that ascend from the pelvis. Piriformis and obturator internus are considered as primarily muscles of the lower limb [23].
The pelvic floor is the final component of the burly mechanism of deep spinal stabilization, as it fortifies the pelvic visceral organs. The paramount muscles of the region for that purport are the levator ani and coccyges muscles. The levator ani muscle is composed by the pubococcygeus and iliococcygeus muscles, which originate at the inner pubic bone near the symphysis and ischial spine, and insert at the inner surface of the coccyx. The coccyges muscle originates at the ischial spine and inserts at the sacrum and coccyx [19].
2.4 Biomechanics of Lumbar Spine & Intervertebral Disc
The corresponding vertebral arches, the intervertebral joints composed by the facets, the transverse and spinous processes, and various ligaments make up the posterior section. The arches and vertebral bodies form the vertebral canal, which bulwarks the spinal cord [24, 39].
The intervertebral disk has no direct blood supply and relies on diffusion for its alimental needs. Kineticism is consequential for the diffusion process. Sustained loading has shown to impair diffusion, with a perpetuated instauration time needed for diffusion to return to unloaded conditions [26].
The forms of kineticism in the spine are flexion, extension, rotation and lateral flexion. These forms of kineticism occur as a cumulation of rotation and translation in the following three planes of kineticism: sagittal, coronal and horizontal. Overall, the lumbar flexibility and disc pressures were more immensely colossal in flexion. Conversely, more sizably voluminous facet forces were computed in extension whereas flexion caused negligible contact forces. Unilateral and bilateral abstraction of L4L5 facets in extension minimized the stiffness and
incremented the disc pressure at the same level while the remaining levels were approximately unaffected. In contrast, more immensely colossal gap limit for articulation incremented stiffness, minimized disc pressure, and incremented loads on facets at all segmental levels. Disc fiber layers are most loaded in flexion and least loaded in extension. Astronomically immense tensile strains occur in disc fibers under flexion and lateral moments. This suggests the susceptibility of disc fibers to failure under forms of kineticism involving astronomically immense flexion and lateral rotations [38, 25].
The lumbar spine involute forms an efficacious load bearing system. When a load is applied externally to the vertebral column, it engenders stresses to the stiff vertebral body and the relatively elastic disc, causing strains to be engendered more facilely in the disc. The intervertebral discs are an essential biomechanical feature, efficiently acting as a fibrocartilage “cushion” transmitting force between adjacent vertebrae during spinal kineticism [38, 34, 1].
2.5 Kinesiology of Lumbar Spine & Intervertebral Disc
The lumbar spine and hip joints are responsible for the mobility of the body.
Lumbosacral junction and sacroiliac joint act as a transition zone between lumbar spine and the body. Lumbosacral junction has a very limited lateral bending motion, only 3 degrees, compared to upper segments, L1, L2, 6 degrees, and L3, L4, 8 degrees [3]. With the increase of flexion of the lumbar spine, intervertebral discs are compressed, and intervertebral disc pressure increases. To decrease the intradiscal pressure after the flexion, lumbar spine extension should be provided. Total lumbar spine lateral bending range of motion is approximately 30 degrees, and rotation is 10 degrees [3].
The lumbar spine is the most loaded part of the spine with immense five lumbar vertebrae forming the lumbar lordosis. The most distal end of the lumbar spine is linked to the pelvic thru the lumbosacral joint supported by massive ligaments running from the processes L45 to the iliac crest and sacral bone. These ligaments play a role of limiting the movement range of the lumbosacral joint, more
in the lateral flexion than in ventral flexion and extension. The lumbar spine, especially lumbosacral joint, carries the whole weight of the upper part of the body [31].
Mobility of the lumbar spine: Flexion of the whole spine in adults ranges between 4060 and extension varies within 3035. Flexion diminishes lumbar lordosis and extension increases it. Reduced mobility of one segment is compensated by increased mobility in the neighbor segment. The mobility of the spine can be reduced locally through the decrease of the range of movement in some segments [37].
The curves of the spine depend on the position of the pelvis. The backward tilt of the pelvis decreases the lumbar lordosis and influences the whole body bearing.
The forward tilt increases the lumbar lordosis. The sideward tilt causes a compensatory scoliosis of the spine. The flattening of spinal curves increases the occupancy of discopathy. If this posture is kept repeatedly for a long time such posture is fixed as a normally used holding pattern and becomes a coordinated posture even if causing problems. [21]
Often in chronic back strain (by excessive lumbar lordosis), in order to restore stability, it is important to eliminate the uneven distribution of weight and introduce exercises [2].
2.5.1 Extensors of the Lumbar spine
The posterior muscles of the trunk, function of these muscles is cognate to extension of the vertebral column, when the sacrum is finetuned they potently elongate the lumbar and thoracic vertebral column, at the lumbosacral and thoracolumbar joints.
Erector spinae is an astronomically immense musculotendinous mass which differs in size and composition at different vertebral levels. It consists of fascicles that surmise systematic annexations to homologous components of the skull, the cervical, thoracic, and lumbar vertebrae, the sacrum, and the ilium [7, 21].
Another extensor group of the back is called spinotransverse group which consists of muscles where the fascicles span between a spinous process and the transverse elements of vertebrae at sundry levels below which are rotatores, multifidus and semispinalis. All the spinotransverse muscles are extensors and they elongate the vertebrae from which they arise, or the head in the case of semispinalis capitis. The predominantly longitudinal orientation of their fascicles precludes any substantive action as rotators [7, 21, 16, 8].
The minimized contact pressure after sustained full extension may occur because the nuclear material is pushed forward and away from the neural tissues [31, 23].
2.5.2 Lateral Flexors of the Lumbar Spine
Second group of muscles is the lateral muscles of the trunk, composed of two main muscles, (quadratus lumborum and psaos major). One quadratus lumborum flexes the trunk ipsilateral and is helped in this movement by the internal oblique and the external oblique. The psaos has a main role leading the trunk to lateral flexion ipsilateral and rotation contralateral.
Transversus abdominis, quadratus lumborum and oblique abdominal muscles are in control of lateral flexion. [16]. The quadratus lumborum has no effect on the lumbar lordosis while the iliopsoas can influence it [31, 23].
2.5.3 Flexors of the Lumbar Spine
The flexors of the lumbar spine are composed of the iliothoracic and femorospinal muscle groups. Rectus abdominis, pyramidalis, external oblique, internal oblique and transversus abdominis that constitute the anterolateral muscles of the abdomen [21, 7, 16].
All these muscles play a paramount role in two main forms of kineticism.
Rotation and flexion of the trunk. The intervertebral joints have the propensity to resist when flexion movement is applied to the lumbar spine [31, 23].
2.5.4 Rotators of the Lumbar Spine
Almost all extensors of the lumbar spine can cause an oblique direction contraction producing a rotation movement. Rotation of the lumbar spine is defined by a multiregional diagonal motion caused by a unilateral muscle contraction. the spinotransverse muscles can act as rotators by reason of the longitudinal orientation of their fascicles [7, 16].
The forward tilt of the pelvis increases the lumbar lordosis, this position overloads the hip joint which over time can increase the risk of coxarthrosis.
The sideway tilt causes a compensatory scoliosis of the spine [31, 23, 9].
2.6 Pathophysiology 2.6.1 Disc Herniation
A herniated disk and spondylolisthesis are two potentially painful situations of the vertebral column, which contribute
negatively on the stability and function of the spinal column. While herniation affects the discs between the spinal bones (vertebrae), spondylolisthesis affects the bones themselves [2]. The protruded fluid disc matter, nucleus pulposus, becomes finetuned to the walls of the spinal canal and may rejuvenate here and pain may gradually vanish. The other way is disc matter may liberate movement in the spinal canal as a peregrine body exasperating steadily the meninges and nerve roots, which are genuinely painful. There are four types of herniated disc: bulging, protrusion, prolapsed and
sequestration [32]. Figure 4. Disc Herniation [3].
Lumbar disc herniation results from several transmutations in the intervertebral disc including minimized dihydrogen monoxide retention in nucleus
pulposus, incremented type 1 collagen ratio in the nucleus pulposus and inner annulus fibrosus, ravagement of collagen and extracellular material, and an upregulated activity of degrading systems such as matrix metalloproteinase expression, apoptosis, and inflammatory pathways. Ultimately, resulting in a local increase in mechanical compression applied by the protruding nucleus pulposus on the exiting nerve. The pressure exerted by the herniated disc on the longitudinal ligament and the vexation caused by the local inflammation results in localized back pain. The lumbar radicular pain arises when disc material exerts pressure or contacts the thecal sac or lumbar nerve roots, resulting in nerve root ischemia and inflammation. The annulus fibrosus is thinner on the posterolateral aspect and lacks support from the posterior longitudinal ligament, making it vulnerable susceptible to herniations. Due to the proximity of the nerve root, a posterolateral herniation is more liable to result in nerve root compression [38, 15, 22]. Lumbar disc herniation is the most mundane spinal disk condition that incites the symptoms of low back pain and very often with the coexistence of radicular pain. Depending on how the hernia is compressing the nerve root it can cause the symptoms such as radicular pain, paresthesia, dysesthesia and anesthesia [17, 5].
A herniation can cause direct pressure on the nerve root, the nerve root elongates down the leg and any type of pinching or pressure on the nerve on the lower spine can cause pain, numbness, tingling or impotency that radiate along the path of the nerve down the leg [15, 12].
2.7 Treatment
2.7.1 Surgical treatment
Intervertebral disk herniation can be treated conservatively or surgically. If there are serious motor deficits arising from migrated disk fragments or large bump surgery is needed. There are several types of surgical procedures for intervertebral disk herniation. Lumbar discectomy and microdiscectomy are the most common and less contagious approaches. If the patient is suffering from lumbar stenosis laminectomy is the surgical approach [4, 13, 34]. If the patient is diagnosed with
signs of neurological deficit or cauda equine syndrome then surgical approach will be needed. Otherwise, surgery is the last option. Surgical treatment for a herniated disc includes three main surgical treatments that are commonly used; the standard lumbar discectomy microendoscopic lumbar discectomy and laminectomy with or without a foraminotomy with the use of tubular retractor systems [22, 10, 27].
2.7.2 Nonsurgical treatment
Physiotherapy, rest and medications are some of the nonsurgical approaches.
For lumbar disc herniation, one of the most effective and classic treatment is bed rest. Bed resting effects are related to a decrease in the intradiscal pressure and relaxation of the paraspinal muscles. Bed rest is useful during the first few days of lumboradicular symptoms. The bed should be hard enough and the position in the bed is up to the patient whichever position reduces the lumboradicular pain but preferably supine and hips, knee flexed because of the tension. The prone position should be avoided because if it continues occurring then it exacerbates lumboradicular pain.
Due to herniated disc, lumbar radiculopathies and acute cervical are getting treated by conservative treatments. In case there are not severe neurological deficits such as marked muscle weakness, impaired gait or cauda equine syndrome, conservative treatment is the first choice. Antiinflammatory medications can be used to relieve pain NSAIDs and physical therapy with specific exercises and appropriate rehabilitation plans can restore the muscles balance [11, 35].
2.7.3 Physiotherapeutic Approach
Lumbar disc herniation treatment is applied individually. Except for severe neurological symptoms such as progressive loss of strength, urinary and fecal incontinence, it is not a condition that requires emergency surgical treatment.
Generally, a very large proportion of patients can be treated without the need for surgical intervention. The first step in the treatment of herniated disc is rest.
However, since it has been understood in recent years that longterm rest can have negative effects in the treatment of herniated disc, keeping the rest and movement
restriction as short as possible is important for the success of the treatment. Although short term bed rest can be given in very painful cases, rest is mostly in the form of restricting the movements that put a load on the spine. Whether the patient goes to work or not is evaluated by the doctor depending on the work the patient does.
Painkillers and muscle relaxants are usually administered during this period. In some cases, steroid therapy can be administered in a controlled manner. It can be used for a short time when bracing is required. Physical therapy methods have an important place in the treatment of lumbar hernia. For this purpose, heat applications, ultrasound, laser, pain relief current treatments, massage, mobilization, manual therapy, dry needling, taping, traction (classical and vertical traction vertetrac) are the most commonly used treatment methods. In some cases, epidural injections and nerve blocks can be applied to the lumbar region to relieve pain. Exercise practices should be arranged early by the therapist and should aim for the ADL which includes posture exercises, stretching without triggering the pain.
The intensity of the exercises is adjusted according to the clinical condition of the patient and it is aimed to return to daily life and work activities as soon as possible. Spinal Surgery for herniated disc is the last treatment option used in cases with severe and progressive neurological losses and ineffective treatment despite all treatments. If necessary, physical therapy and rehabilitation can be performed in the postoperative period [4, 11, 35].
Exercise prescriptions for mechanical low back pain generally commence with the goal of ameliorating alignment and posture. The rectification of posture as an initial goal is paramount for several reasons. One is that exercises are more efficacious if they are done from a position of opportune alignment that promotes optimal joint function and kineticism patterns. Virtually all patients will spend much more time in habitual postures such as sitting and standing than exercising. The reason lies that if these habitual postures can abbreviate anomalous tissue strains, there is a better change of abbreviating pain and setting a good prognosis for more expeditious regeneration [11, 12].
3. Special Part (Case Study) 3.1 Methodology
My thesis work placement took place in Beroun Rehabilitace Hospital, from the 18th of January until the 12th of February. In this work placement the goal was understanding and testing my knowledge theoretically and practically. In Beroun Hospital I was assigned a patient with Disc Herniation of L5/S1 with Radiculopathy.
The total amount of hours of my practice was 80. Beroun Hospital is equipped with a room for hydrotherapy, one for magnetotherapy and one fully equipped gym. I was able to work with RedCord, gym balls, medicine balls, different intensity Thera Bands, and soft balls. I used mostly my hands for the examination and therapy.
Goniometers, measurement tape, and a neurological hammer were the tools that I used for the examination procedures. My supervisor during the practice was Bc. Ales Nesvadba. I first met my patient on the 18th of January and immediately performed my initial examination on her. I started the therapy session on the 19th of January, through January the 27th for a total of 6 therapy sessions with my patient. On the 26th of January, I took notes for my final examination with her as our programmed therapies came to an end. Each therapy session my patient and I had lasted 30 minutes. In addition to the therapy my patient was having hydrotherapy, electrotherapy, motomed letto, massage and gym exercises every day in the week. I was not responsible for this as the patient was carefully followed by other physiotherapists or hospital staff. Only in the gym sessions I was observing and correcting the patient. For my therapy, I mainly focused on regaining the reducing pain that my patient has low back pain on the left side due to her Disc Herniation. I performed my therapy mainly in the individual room for each patient and therapist with softball, gym ball, and medicine ball but mostly manual therapy. The patient was fully aware of the procedure we were following and she was informed about the exercises we were doing each and every session. The patient was informed and agreed to participate in this project. She signed the agreement approved by the Ethics Committee of the Faculty of Physical Education and Sport at Charles University.
3.2 Anamnesis
Examined person, gender: H.U. Female
Year of birth: 1977
Diagnosis: Disc herniation of L5/S1 with Radiculopathy. (Left side)
The patient was suffering from chronic low back pain due to her lifestyle.
Since she is a saleswoman in confectionery she was overloaded to her lower back region due to her work in postural and repetitive patterns. It causes inflammation and pain in the lower back region. Her pain goes from her left side (hip) through the buttocks to the posterior lateral side of the thigh and to the toes (first and fifth). She mentioned that constant cramps in LLE, blunt stabbing pain, intermittent burning like “whipped with nettle.” on track of S1 (left side) after prolonged exertion. She mentioned that she was not able to change positions in the bed during the night due to lower back pain. In the morning she wakes up and goes to the toilet and she starts having pain due to the position in the toilet which is bending forward and sitting. The pain level on a scale of 110 (10 is maximum) she mentioned 8 in acute situations.
Current History: 44 years old patient was admitted for repeated rehabilitation for prolonged exacerbation of chronic radicular syndrome L5/S1 left. Sensitive outbreak symptomatology, without motor deficit, without the caudal syndrome. According to MRI 3/11/2020 in L4/5 region medial disc protrusion 5 mm, regression of S1 and S2 root pressure by the left side of sequestration compared to MRI 5/2020. According to EMG 11/2020 lighter chronic neurogenic lesion S1 left, repeated infusion therapy, caudal blockage (therapy), CT PRT without major effect. 9/12 consultation in neurosurgery Dr. Kasik, where a conservative approach was recommended considering the regression found on the MRI examination. From Autumn 2020 gradual progression of the problem. Irradiation to left lower extremity, relief position is lying on the abdomen, intermittent also lying on the right side. Symptoms are significantly worsened while sitting and walking. In a short distance, the patient walks without help but with the antalgic stereotype. In greater distances with 2 french crutches, occasionally needs to flex the trunk after approximately 5 minutes. The
patient walks until severe pain in the lower extremity. Pain goes from the left hip through the buttocks to the posterior lateral side of the thigh and to the toes (first and fifth toe). Reduced sensitivity throughout the lower left extremity. The patient has constant cramps in LLE, blunt stabbing pain, intermittent burning like “whipped with nettle” in the track of S1 after prolonged exertion. She can sit only on the right buttock because of back pain. The patient negates chest pain and burning when urinating and negates breathing difficulties.
History: The patient first came to Beroun Hospital on January the 8th. She had already 5 therapy session with my supervisor. I met with her 18th of January in Beroun Hospital.
Status Presence Objective
Height: 178 cm Weight: 92 kg BMI, somatotype: 29
Subjective
● Chief complaint: Constant cramps and intermittent burning feeling on the low back.
● Family Anamnesis: Mother is healthy and the father has rectal cancer.
● Medical History (Injuries and Surgeries):
● Laparoscopic gynecologic surgery, surgery of extrauterine pregnancy.
● Frozen shoulder (right), chronic migraine, chronic gastritis, chronic bulbitis (duodenitis), tuberculosis (1981)
● Medications:
● Zoloft 100 mg 100
● Neurontin 600 mg tbl. 111
● Indometacin 100 mg
● Topiramat 25 mg 101
● Allergy: None
● Occupational anamnesis: Saleswoman in a confectionery.
● Social Anamnesis: The patient lives with her family, 2 children (25 and 15 years old). The patient socializes in her workplace and most of her friends are from there.
● Functional anamnesis: The patient is a saleswoman in a bakery, she wakes up every morning at 7 AM, she goes to work by walking. Every day walks for about 1 hour every day. She lives with family so they share the household activities. She has 2 children, one of them is 25 and the other one is 15 years old. She sleeps for 67 hours each day, standing for about 45 hours a day.
● Gynecological Anamnesis: She gave one birth, 4x spontaneous abortion, one extra uterine pregnancy, followed by in vitro fertilization, regular doctor controls.
● Diet: None
● Abuses: Nonsmoker, alcohol abstinent.
● Sport: She is not doing any sport.
● Hobbies and leisure activities: No hobbies.
Prior rehabilitation:
10 years ago the patient had therapy for a frozen shoulder.
Indication for rehabilitation:
● Soft tissue techniques
● Manual therapy
● Activation and strengthening of deep stabilization system
● Correction of the gait pattern
● Strengthening and conditioning exercises
● Strengthening of weak muscles
● McKenzie exercises
● Relaxation and stretching of shortened muscles
● Strengthening of core muscles
● Increase core stability
3.3 Initial kinesiological examination:
3.3.1 Postural examination:
Posterior view:
● The base of support: Narrow
● Shape of the heels: Symmetrical
● Shape and position of the ankle joint: Symmetrical
● Achilles tendon: Thickness and shape are symmetrical
● Contour of the calf muscles: Symmetrical
● Position of the knee joint: Both knees are not fully extended, left knee more flexed, no valgusity or varusity of the knee joint
● Popliteal lines: Symmetrical
● Contour of thigh muscles: Symmetrical
● Gluteal muscles: Right is more prominent
● Position of the pelvis: Slightly tilted to right
● Position of the scapula: Ventrally prominent on the right scapula.
● Position of the shoulder: Right shoulder is higher than the left shoulder.
● Position of the head: Slightly rotated to the right side.
Anterior view:
● Base of support: Narrower than physiological
● Arches: Slightly medially collapsed, both symmetrical
● Weight distribution: Slightly medially
● Shape and position of the knee: Both of the patellas faces slightly medially
● Contour of calf muscles: Symmetrical.
● Shape of the thigh muscles: Symmetrical.
● Position of the pelvis: Slightly tilted to the right side.
● Symmetry of abdominal muscles: Symmetric in both sides.
● Position of umbilicus: Shifted to the right side.
● Position of collarbones: Right supraclavicular hole is deeper than the left one.
● Position of the shoulder girdle: Right shoulder is higher than the left shoulder.
● Position of the head: Slightly rotated to the right side.
Right lateral view:
● Weight distribution: Slightly shifting to the medial part of the foot.
● Shape of ankle joint: Physiological.
● Position of the knee joint: Both knees are not fully extended. Left knee is more flexed than the right knee.
● Position of the pelvis: Anteriorly tilted.
● Shape of the spine: Slightly kyphotic posture on thoracic spine and slight increase of lumbar lordosis.
● Position of the shoulder: Protracted.
● Position of the head: Protracted and rotated to the right side.
Left lateral view:
● Weight distribution: Slightly to the medial part of the foot.
● Shape of ankle joint: Physiological.
● Position of the knee joint: Both knees is not fully extended. Left knee is more flexed than the right knee.
● Position of the pelvis: Anteriorly tilted.
● Shape of the spine: Slightly kyphotic posture on thoracic spine and slight increase of lumbar lordosis.
● Position of the shoulder: Protracted and elevated.
● Position of the head: Protracted and rotated to the right side.
3.3.2 Palpation of pelvis:
● Anterior superior iliac spines: Left side is slightly higher.
● Posterior superior iliac spines: Right side is slightly higher.
● Iliac crests: Left side is slightly higher.
Conclusion: The anterior superior iliac spine are lower than the posterior superior iliac spine. According to this result, anteversion of the pelvis is slightly visible and slightly torsion to the right side.
3.3.3 Breathing stereotype:
● Standing position: Involves the upper abdominal wall.
● Sitting position: Involves lower thoracic part.
● Lying position: Upper abdominal wall.
● The activation of abdominal muscles and diaphragm is weak.
3.3.4 Specific testing of posture:
● Romberg test: I, II, III: All negative.
● Single leg stance test: On both sides, slightly correction.
● Trendelenburg sign: On both sides, negative.
● Velè test: Negative
3.3.5 Modification of standing:
● Standing on tiptoes: Able.
● Standing on heels: Able.
3.3.6 Dynamic Spine Examination
Backwards: While performing extension, spine was stiff and restricted in all regions.
Motion was not fluently done and only minimal movement was on the ThL junction.
Patient performed the movement without any pain.
Sideways:
Right: While performing lateral flexion, the movement was not fluent. Movement took place on the lower Th region and no curve on the lumbar spine. Patient was having limited ROM with slight rotation of the trunk to the left side. Patient performed the movement without any pain.
Left: While performing lateral flexion, the movement was not fluent. Movement took place on the lower Th region and no curve on the lumbar spine. Patient was having limited ROM with slight rotation of the trunk to the right side. Patient performed the movement without any pain.
Forward: While performing flexion, the movement was not fluent. Patient was performing the movement mostly from her hip joint. While ThL region was flat, we could observe the
motion on the C spine and upper Th region. Upper Th region has hyper kyphosis during the motion. Patient performed the movement and she felt slight pain in the L spine region.
3.3.7 Anthropometric Measurements of Lower Extremities
Right Left
83 cm
The length of whole lower extremity (Anatomical)
83 cm
88 cm
The length of whole lower extremity (functional)
88 cm
42 cm The length of the thigh 42 cm
31 cm The length of the middle leg 31 cm
22.5 cm The length of the foot 22 cm
45 cm The circumference of the thigh 10 cm above the patella
45 cm 47 cm The circumference of the thigh 15 cm above the
patella
47 cm 33 cm The circumference of the knee joint 34 cm
31 cm The circumference of the calf 31 cm
23 cm The circumference of the ankle 24 cm
21 cm The circumference of the foot 21 cm
Table 1. Anthropometric Measurements of Lower Extremities
3.3.8 Gait Examination
Patient walks a short distance, without any help but with the antalgic stereotype. In greater distances and in the morning, patient use 2 french crutches, occasionally needs to flex the trunk after approximately 5 minutes due to her cramps in the lumbar region. Patient has a narrow base of support, short steps with slow
feet and both of the arches are slightly collapsed medially. The heel strike was absent in both feet. She wasn’t performing the full knee extension on both sides. The patient has no flat foot, valgusity or varusity in knee and ankle. The patient is unable to keep an erect posture while walking due to her lower back pain, she was walking with a slightly flexed torso. She spends more time on her right leg so the rhythm of gait is not as expected. The stride length is good but not rhythmical. The motion of upper extremities is fluent, it follows rhythmically the contralateral lower extremities. She has a minimal movement of the pelvic. The trunk stayed in the ideal position in which no lateroflexion or rotation were absorbed. Her shoulders are slightly elevated and protruded forward more on the right side, slight protraction of the head and rotation to the right side. She performed walking with pelvis rotation without loss of balance.
While walking backwards, there was limited hip extension due to weakness of Gluteus maximus. Patient while walking on the tiptoes and heels, no pathological signs related to L4, L5 and S1. Squat position was not optimal for the patient to perform squat walking. Overall stability was poor while walking.
3.3.9 Movement Pattern Evaluation according to Janda:
Hip extension: Movement started with the anteversion of the pelvis but activation of the muscles is not physiological.
Hip Abduction:
Left: Patient starts the movement with flexion of the knee and following activation of quadratus lumborum. Fluent movement was not visible due to her weak muscles of hip abductors.
Right: The muscle activation is better if we compare it to the right side. Elevation of pelvis is not observed and the motion mainly happens at the hip level.
Trunk Flexion (Curl up):
Initial activation was done by the abdominals. During the first degrees of the motion, the lower extremities lost contact with the bed which shows us the result of a positive test with the greater activation of the iliopsoas and the absence of abdominal muscle
activation.
3.3.10 Range of motion Examination
Left Lower Extremity Right Lower Extremity
Movement Active Passive Active Passive
Hip flexion (knee extended)
85° 90° 85° 90°
Hip flexion (knee flexed) 100° 110° 100° 120°
Hip extension 10° 15° 10° 15°
Hip adduction 10° 10° 10° 15°
Hip abduction 35° 40° 35° 40°
Internal Rotation 25° 30° 20° 30°
External Rotation 40° 45° 40° 45°
Knee flexion 110° 120° 110° 120°
Knee extension 5° 5° 5° 5°
Table 2. Range of motion
3.3.11 Muscle Length Test (According to Janda)
Tested muscle Right Left
Pectoralis major & minor 1 1
Iliopsoas 1 1
Hamstrings 1 1
Gastrocnemius 0 1
Soleus 0 1
Rectus femoris 0 0
Tensor fasciae latae 0 0
Table 3. Muscle length test according to Janda
*Scale according to Janda: 0 no shortness, 1moderate shortness, 2 marked shortness.
3.3.12 Muscle Strength Test (According to Kendall)
Tested muscle Left Right
Quadriceps Femoris 4+ 4+
Adductors 4 4
Abductors 4 4
Gastrocnemius 4 4
Hamstrings 4 4
Gluteii 4 4
Tibialis anterior 4 4
Table 4. Muscle strength test according to Kendall
3.3.13 Muscle Tone Palpation
Left side Right side
Muscle Tonus Pain Trigger
Point
Tonus Pain Trigger Point Rectus
Abdominis
Normal No No Normal No No
Erector Spinae Thoracic
Normal No No Normal No No
Erector Spinae Lumbar
Normal No No Normal No No
Quadratus Lumborum
Hypertonic Slight Painful
No Hypertonic No No
Gluteus Maximus
Hypotonic No No Hypotonic No No
Gluteus Medius Normal No No Normal No No
Piriformis Hypertonic Slight Painful
No Hypertonic Slight Painful
No
Iliopsoas Hypertonic Slight Painful
No Hypertonic Slight Painful
No
Quadriceps Normal No No Normal No No
Hamstrings Hypertonic No No Normal No No
Gastrocnemius Normal No No Normal No No
Soleus Hypertonic No No Normal No No
Tibialis anterior Normal No No Normal No No
Peroneus Longus
Normal No No Normal No No
Table 5. Muscle Tone Palpation
3.3.14 Joint play examination (According to Lewit):
Examined joint: Left: Right:
Patella:
Caudal and cranial direction: Restricted
Medially and laterally: No restriction
No restriction.
Head of fibula: Medially slightly restricted.
Medially slightly restricted.
Talocrural: No restriction. No restriction.
Subtalar: No restriction. No restriction.
Talocalcaneonavicular:
No restriction.
No restriction.
Tarsometatarsal (Lisfranc):
No restriction.
No restriction.
Transvers tarsal (Chopart): No restriction. No restriction.
Table 6. Joint play examination according to Lewit
3.3.15 Subcutaneous Tissues & Fascia Examination (According to Lewit):
There were restrictions in the cranial and caudal direction of the lumbar region.
3.3.16 Kibler`s Fold (cutis and subcutis):
It was unable to form the fold along the paravertebral in ThL and L regions.
Left side was more restricted than the right side.
3.3.17 Neurological Examination
The patient is lucid, orientated, collaborates, without malfunction of speech, right handed, bulbs are in the middle position, no mystagmus. Innervation of the both branches of Nervus facialis is normal, arches elevate symmetrically. The tongue crawling in the middle.
Upper extremity: Passive and active movements are adequate, tone and muscle strength is normal, reflex of C5C8 is symmetrical, no tremor.
Lower extremity: While examining the hip joint there was a pain reaction.
There is a tendency to hypotonia. Laseque manoeuvre is performed and it is positive which is on the left side in 30 degrees and on the right side 50 degrees. In reverse Laseque manoeuvre, left side is positive but on the right side is negative.
The patient has L2L4 (Patellar) hyperreflexia, L5S2 (Achilles tendon) hyperreflexia. Also the patient mentioned that throughout the LLE hyperesthesia and dysesthesia.
3.4. Initial Examination Conclusion
The patient was admitted for repeated rehabilitation for prolonged exacerbation of chronic radicular syndrome L5/S1 left. Sensitive outbreak symptomatology, without motor deficit, without the caudal syndrome. According to MRI 3/11/2020 in L4/5 region medial disc protrusion 5 mm, regression of S1 and S2 root pressure by the left side of sequestration compared to MRI 5/2020. According to EMG 11/2020 lighter chronic neurogenic lesion S1 left, repeated infusion therapy, caudal blockage (therapy), CT PRT without major effect. 9/12 consultation in neurosurgery Dr. Kasik, where a conservative approach was recommended considering the regression found on the MRI examination.
The patient is lucid, orientated, collaborates, without malfunction of speech, right handed, bulbs are in the middle position, no mystagmus. Innervation of the both branches of Nervus facialis is normal, arches elevate symmetrically. The tongue
Upper extremity: Passive and active movements are adequate, tone and muscle strength is normal, reflex of C5C8 is symmetrical, no tremor.
Lower extremity: While examining the hip joint there was a pain reaction. There is a tendency to hypotonia. Laseque manoeuvre is performed and it is positive which is on the left side in 30 degrees and on the right side 50 degrees. In reverse Laseque manoeuvre, the left side is positive but on the right side is negative.
• Patient has muscle disbalance due to her weakness of LE muscles which are Hamstrings, abductors and adductors, gastrocnemius and tibialis anterior.
• Hypertonicity and tension is present in her LLE muscles which are Quadratus lumborum, piriformis, iliopsoas, soleus, erector spinae mm. (lumbar region).
• In the direction of flexion and extension of the hip and knee joint of the left lower extremity, patient has decreased ROM.
• Tension of the soft tissue in the left side mostly. In cranial, caudal, medial and lateral directions, the patient has a restricted barrier which is in left calf and thigh muscles, fascia of thoracolumbar and paravertebral m.
• Hamstrings, iliopsoas, gastrocnemius, soleus mm. have shortness.
The patient has L2L4 (Patellar) hyperreflexia, L5S2 (Achilles tendon) hyperreflexia. Also the patient mentioned that throughout the LLE hyperesthesia and dysesthesia.
Patient walks a short distance, without any help but with the antalgic stereotype. In greater distances and in the morning, patient use 2 french crutches, occasionally needs to flex the trunk after approximately 5 minutes due to her cramps in the lumbar region. Patient has a narrow base of support, short steps with slow speed while walking. The weight distribution happens on the medial aspect of the feet and both of the arches are slightly collapsed medially. The heel strike was absent in both feet. She wasn’t performing the full knee extension on both sides. The patient
