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Foot function and low back pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Sep 29, 2007.

  1. musmed

    musmed Active Member

    Dear All
    A very good example is those poor souls who use those silly MBT (or what ever) rocker bottomed soled shoes.

    No extension, walk like an ape with time. chin out, dropped shoulders, no arm swing no leg extension
    Regards
    musmed
     
  2. Dananberg

    Dananberg Active Member

    Eric,

    You wrote

    "I agree with Dave's point about the psoas firng as you approach zero speed. "

    So, are you saying that from a standing start...there is less psoas activity than during a 3.5mph gait? What happened to Newton's 3rd Law regarding momentum...a body in motion tends to stay in motion?

    As far as the hard wired aspect to swing phase, your remarks about the cat miss the point and only confuse the discussion. We are discussing level walking...and yes, swing phase is absolutely hardwired. Of course walking up or downhill changes the characteristics, but it doesn't negate the consistency of swing phase on level terrain.

    Following a classic podiatric protocol of posting the rear foot to control STJ pronation only limits internal rotation of the hip during contact and fails to address the sagittal plane issues associated with hip extension mechanics. The more hip extension present, the more pre-swing motion becomes available to permit efficient swing phase with the least amount of muscular involvement. When accompanied with ankle push (which is occurring during pre-swing), the requirement of the psoas are clearly reduced. Since the psoas originates from the intervertebral disks of the lumbar spine, the intervertebral septa and the disks themselves, the greater the psoas strain, the more likely for lumbar spine issues to develop as a repetitive strain injury.

    Howard
     
  3. Dananberg

    Dananberg Active Member

    Eric,

    You wrote

    "I agree with Dave's point about the psoas firng as you approach zero speed. "

    So, are you saying that from a standing start...there is less psoas activity than during a 3.5mph gait? What happened to Newton's 3rd Law regarding momentum...a body in motion tends to stay in motion?

    As far as the hard wired aspect to swing phase, your remarks about the cat miss the point and only confuse the discussion. We are discussing level walking...and yes, swing phase is absolutely hardwired. Of course walking up or downhill changes the characteristics, but it doesn't negate the consistency of swing phase on level terrain.

    Following a classic podiatric protocol of posting the rear foot to control STJ pronation only limits internal rotation of the hip during contact and fails to address the sagittal plane issues associated with hip extension mechanics. The more hip extension present, the more pre-swing motion becomes available to permit efficient swing phase with the least amount of muscular involvement. When accompanied with ankle push (which is occurring during pre-swing), the requirement of the psoas are clearly reduced. Since the psoas originates from the intervertebral disks of the lumbar spine, the intervertebral septa and the disks themselves, the greater the psoas strain, the more likely for lumbar spine issues to develop as a repetitive strain injury.

    Howard
     
  4. musmed

    musmed Active Member

    Dear All

    I thought the psoas fired as we approach zero speed simply because the 'system' is anticipating that we are going to stand still ie stop.

    We start from 'stop' go to walking phase and go to 'stop'.
    we then either stop still or continue the process all over again and again until we stop.

    I have yet to read that there is a walking pattern for walking and a walking pattern that ends up in stopping.

    The foot goes from a stationary position to the walking position to the stationary position for each step (repeats if one continues walking) so I cannot see that the rest of us possess a different method of locomotion.
    Basically the system is anticipating that we are going to stop and prepares the body to do so.

    from damp Dunedin NZ
    musmed
     
  5. efuller

    efuller MVP

    Not that I'm counting, intertia/momentum is Newton's 1st law. And Newton's 2nd law F=Ma. If an object is at zero velocity a force has to be applied to it for it to accelerate. The stance leg becomes the trailing leg. At this point in gait the leg is moving slower than the rest of the body. The trailing leg has to be accelerated by something to catch up and pass the rest of the body. That something could be hip pull (illeopsoas) or ankle push. So, it is possible that illeopsoas activity could be greater than or less than when initiating gait.

    A hard wired gait would imply that the muscles function the same across all people all of the time. This is inconsistant with studies that added mass to the leg in running. With added mass the legs swung with essentially the same velocity yet they worked harder. A hard wired swing phase would not be able to adapt to the added mass of shoes.

    Swing phase is consistant, in my educated guess because, the gait that we see is the most efficient. Any of the walks from the ministry of funny walks would be impossible if swing phase was hard wired. There may be some reflexes, but they can be overcome.

    I completely agree with your last sentence. :drinks

    However, having more preswing motion available is not necessarily the cause of efficient gait. I would bet that it correlates with efficient gait, but is not causitive. It could be that the mind lets the hip extend more because it can comfortable do this if there is sufficient ankle push to allow a comfortable foreward swing.

    Regards,

    Eric Fuller
     
    Last edited: Oct 17, 2008
  6. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Bilateral and unilateral increases in calcaneal eversion affect pelvic alignment in standing position
    Rafael Z.A. Pinto, Thales R. Souza, Renato G. Trede, Renata N. Kirkwood, Elyonara M. Figueiredo and Sérgio T. Fonseca
    Manual Therapy; Volume 13, Issue 6, December 2008, Pages 513-519
     
  7. GavinJohnston

    GavinJohnston Member

    This comes at no suprise to me as a physiotherapist,except I thought the angles may be greater.
    To help me catch up on the research side of kinetics Vs Kinematics debate what is the major study or peramiters used that swung the podiatry profession towards the current kinetic theory.?
    Regards
    Gavin j (physio)
     
    Last edited: Nov 2, 2008
  8. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The mechanical relationship between the rearfoot, pelvis and low-back.
    Duval K, Lam T, Sanderson D.
    Gait Posture. 2010 Oct 1. [Epub ahead of print]
     
  9. Don't that just beat all!

    Hard to know what to think when you get some studies show one thing and others show something quite different!!
     
  10. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Near the start of this thread:
    and now:
    :bash:
     
  11. Here's fun.

    Classical kinematic chain theory (kinetic chain theory is far to complex for a simpleton like me) states that the obligate triplanar nature of the sub talar joint converts frontal plane motion in the foot into transverse plane rotation in the leg.

    The ratio of frontal / transverse motion depends on the sagittal plane inclination of the sub talar axis. A horizontal axis would create no rotation, a vertical nothing BUT rotation, in the middle, about 1:1 (if we take manters 42 degrees as average).

    I could not see a number for the subjects in the last study. Could it be, if numbers are small, that they had generally lower axial inclinations, frontal planal dominance, and as such less tranverse plane rotation? Could that have skewed the data?

    Regardless, the data on rotation of the leg and lordosis is interesting. Would have been great to have that data for dynamic gait as well.
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effects of calcaneal eversion on three-dimensional kinematics of the hip, pelvis and thorax in unilateral weight bearing.
    Tateuchi H, Wada O, Ichihashi N.
    Hum Mov Sci. 2011 Apr 1. [Epub ahead of print]
     
  13. efuller

    efuller MVP

    I wonder where they were getting 10 degrees of calcaneal eversion. I doubt that 1 in 100 people have 10 additional degrees of calcaneal eversion to the leg in stance. They might get 10 degrees of calcaneal eversion if the leg everts too. No wonder they are getting wierd upper body tilt results with the wedging, it's going to be really hard to balance if your leg is tilted that much.

    Eric
     
  14. musmed

    musmed Active Member

    Dear Eric
    I could not agree more
    I will make up a 10 degree wedge stand on it and X-Ray my calcaneus.
    I am willing to bet the only thing that moves is the fat pad because that is what it is there for.
    Regards
    Paul Conneely
    www.portaleducation.com
    i will let you know
     
  15. Yet another study on kinematic chain which works with induced pronation. Almost all of them do. A cynic might be cynical.

    I strongly, strongly doubt that they are getting 10 degrees of calc eversion from the pre wedge state. Having said that if they are measuring it as an absolute, from a vertical, then they may well have acheived 10 degrees eversion because it would be dependant on where they drew the initial line. Worth remembering that they are not measuring calc eversion. They are measuring eversion of a line they drew on the skin.

    That said, I think the body of evidence showing changes on proximal bony alignment from induced pronation is substantial enough to indicate that a lateral wedge will produce some actual calcaneal eversion in some subjects.
     
  16. efuller

    efuller MVP

    This study was done standing on one leg. What they are measuring is the motions that the brain decided to induce to maintain balance. This is behavior, not some purely mechanical effect.

    Eric
     
  17. nmedipem

    nmedipem Member

    This study observed a mean 1.571 anteversion of the pelvis with mean calcaneal eversion of 7.51 and 8.361 at the right and left sides respectively.

    This study did not report mean values but instead showed graphs to represent their data.
    [​IMG]
    It did not reach the degrees of eversion achieved in the above study but I still see a slight trend of calcaneal eversion with anteversion of the pelvis, although the errors were large enough to be statistically insignificant.

    Recognizing this may happen, they also rotated the legs internally and externally to 40 degrees each to exaggerate the effects seen at the pelvis and reported this:

    "Internally rotating the legs induced an anterior tilt of the pelvis
    particularly at the extreme range of internal rotation. The effects
    on the pelvis were more pronounced when internally rotating the
    legs than when externally rotating the legs. It was possible that we
    did not see a response when externally rotating the feet because
    the limit of the range of external femoral rotation was not reached.
    When the feet are in contact with the ground, the femur is a fixed
    structure upon which the pelvis rotates. Thus when both heads of
    the femur internally rotated to the extreme of the normal range of
    motion, as was the case when participants were in-toeing by 40
    degrees, the femoral heads pushed backwards against the
    acetabulum. The pelvis responded to this backwards push by
    tilting forwards.
    Based on the anatomical relationship between the pelvis and
    lumbar spine, it is generally accepted that extreme changes in the
    inclination of the pelvis affect the degree of lumbar lordosis
    [14,15]. However, previous studies that have focused on small
    changes in pelvic posture have not been able to establish a
    statistically significant relationship between pelvic tilt and lumbar
    lordosis [19–21]. The degree of pelvic tilt at which low-back
    posture is affected has not been identified but it seems this limit
    was not reached with the manipulations used in the current study.
    It could be argued that the soft tissues connecting the pelvis to the
    spine offer some independence between the two segments before
    the movement of one segment affects the other. Thus, the changes
    that occurred at the pelvis in this study were not large enough to
    trigger a detectable change in lumbar posture [22]."

    [​IMG]

    Internal rotation of the hip affected pelvic tilt, but did not affect the lower back. I'm wondering, how did these people tilt their pelvis anteriorly to about 10 degrees and have no increased lumbar lordosis? Since the researchers didn't include hip flexion angle, do you think hip flexion could have been the accomodation?
     
  18. WTF?!

    I didn't spot that!

    Well that is certainly the weirdest idea I've seen this year. We might argue the relevance of static standing to dynamic function but unilateral static standing?

    Odd. Very odd.
     
  19. nmedipem

    nmedipem Member

  20. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Very interesting discussion on the suggested link between foot motion and pelvic position.

    In a study I published in the JAPMA in 2006 in which I linked foot driven pronation, due to a structurally unstable foot structure, (as opposed to Hip Driven Pronation expounded by Inman and Close) to an anterior rotation of the innominates.

    Similar findings were published in later years by Khamis and Yizhar (2007) and Pinto, Souza, Trede, Kirkwood et al (2008).

    Postural Imaging Analyses demonstrates this automatic and almost instantaneous link when appropriate insoles are used underneath the feet (See Brief Case Study). This link, to my knowledge was first published on, what is now referred to as the Righting Reflex or Lovett Reactor.

    B Rothbart
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Influence of foot positions on the spine and pelvis.
    Betsch M, Schneppendahl J, Dor L, Jungbluth P, Grassmann JP, Windolf J, Thelen S, Hakimi M, Rapp W, Wild M.
    Arthritis Care Res (Hoboken). 2011 Dec;63(12):1758-65.
     
  22. Dananberg

    Dananberg Active Member

    The key to understanding how gait style relates to LBP involves the ability to extend the thigh on the hip. In a 2001 paper I published, subjects with LBP had an average of 7.5 degrees of hip extension prior to CFO treatment and a f/u range of 13.5 degrees with CFO modified to manage
    1st ray function. Measuring arch height misses the sagittal plane contribution to lower back dysfunction.

    Dananberg, HJ, “Gait Style and Its Relevance in the Management of Chronic Lower Back Pain”, In Proceedings, 4th Interdisciplinary World Congress of Low Back & Pelvic Pain”, Ed, Vleeming, A, Mooney. V, Gracovetsky, S, Lee, D, etal, November 8-10, 2001, pp 225-230

    Howard
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The relationship between foot motion and lumbopelvic-hip function: A review of the literature.
    Barwick A, Smith J, Chuter V.
    Foot (Edinb). 2012 Apr 12.
     
  24. Dananberg

    Dananberg Active Member

    The two papers below are outcome studies I performed to describe the effects of foot orthotics on CLBP as well as the functional changes in the hip joint as a direct result of the use of FFO. I would strongly suggest that looking at this problem from a sagittal perspective creates a far better understanding of the cause:effect relationship between gait style and chronic lower back pain.


    Dananberg, HJ, Guiliano, M, “Chronic Lower Back Pain And It Response to Custom Foot Orthoses”, Journal of the American Podiatric Medical Association, 89:3 March, 1999 pp109-117

    Dananberg, HJ, “Gait Style and Its Relevance in the Management of Chronic Lower Back Pain”, In Proceedings, 4th Interdisciplinary World Congress of Low Back & Pelvic Pain”, Ed, Vleeming, A, Mooney. V, Gracovetsky, S, Lee, D, etal, November 8-10, 2001, pp 225-230


    Howard
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    EMG activation of trunk and upper limb muscles following experimentally-induced overpronation and oversupination of the feet in quiet standing
    Theodoros Ntousis, Dimitris Mandalidis, Efstathios Chronopoulos, Spyros Athanasopoulos
    Gait and Posture; Article in Press
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain
    Colin B. O'Leary, Caroline R. Cahill, Andrew W. Robinson, Meredith J. Barnes, Junggi Hong
    Journal of Back and Musculoskeletal Rehabilitation
     
  27. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain.
    O'Leary CB, Cahill CR, Robinson AW, Barnes MJ, Hong J.
    J Back Musculoskelet Rehabil. 2013 Jan 1;26(2):117-23.
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Influence of second-degree flatfoot on spinal and pelvic mechanics in young females
    Neveen Abdel-Raoof, Dalia Kamel, Sayed Tantawy
    International Journal of Therapy and Rehabilitation, Vol. 20, Iss. 9, 05 Sep 2013, pp 428 - 434
     
  29. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Here's another

    Rothbart BA, Liley P, Hansen, el al 1995. Resolving Chronic Low Back Pain. The Foot Connection. The Pain Practitioner (formerly American Journal of Pain Management) 5(3): 84-89


    Professor Brian
     
  30. The Cairo study, very nice. Shame people who have no understanding of correlation vs causality will misquote it.

    RE Brian's, is there any experimental data in your reference or is it just you stating your opinion again. Just so I know if it's worth finding the abstract.
     
  31. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Pain Profiles, PreTx vs PostTx (one year) published in the American Journal Pain Management (peer reviewed journal published by the American Academy of Pain Management)

    Professor Brian
     
  32. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Foot posture, foot function and low back pain: the Framingham Foot Study
    Hylton B. Menz, Alyssa B. Dufour, Jody L. Riskowski, Howard J. Hillstrom, and Marian T. Hannan
    Rheumatology first published online September 17, 2013
     
  33. Fair play! This is a real study. Not a very good one, but it is experimental data! Here’s the link
    http://www.rothbartsiteDOTcom/uploads/Chronic_LBP.pdf

    The main problem here is of course the lack of a control group. An improvement in LBP over a year is fairly likely if you pick the patients, based on regression to the mean, placebo effect, hawthorn effect etc. Likewise the hypothesis that this suggests a causal link between LBP and foot function is flawed. If I took a sample of 200 LBP sufferers and asked them if they ate bread I suspect that 96% of them would, that does not establish a link between bread and back pain.

    What I found very interesting however is that the study talks about forefoot varus being measured in degrees, using a biovector. It talks about catagorizing treatment based on 0-10mm, 10 – 19mm etc. It talks about microwedging (a varus post only extending under the first met head). All the stuff mentioned in Brian’s later work.
    Now more than once, we’ve run around the stump of whether “Rothbarts foot” is actually an Unreported foot type.

    Brian Described this, in an article in Podiatry Review, thusly
    In a later critique in the same journal, I wrote
    Now in light of that, this 1995 study is VERY interesting.

    In 1995 Brian was describing the situation wherein the forefoot is off the ground by 10mm< caused by talar torsion as forefoot varus and prescribing something called a PCO (posture control orthotic), a device with a varus wedge under the first met head.
    By 2005 Brian was describing the situation wherin the forefoot is off the ground by 11mm< caused by talar torsion as a PREVIOUSLY UNREPORTED foot type called rothbarts foot, and prescribing something called a PCI (posture control INSOLE), a device with a varus wedge under the first met head.

    Answers the question I’d never actually managed to get an answer from from Brian, whats the difference between a PMS and a forefoot varus. Answer, there is none, and back in the day Brian himself described the inverted forefoot caused by talar neck torsion as, yes, forefoot varus.
     
  34. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Robert,

    There is a vast difference between PMS and forefoot varus. It is clearly delineated when one studies the ontogenetic development of the lower limb bud between the 5th and 8th week of embryogenesis.

    Succinctly, forefoot supinatus (what Podiatrists refer to as forefoot varum) cannot exist without calcaneal supinatus. If you want the long reason, review your embryology. The short answer is that the ontogenetic development occurs central to peripheral. That is, the calcaneus (and with it, the lateral embryological column) always starts its ontogenetic unwinding before the talus (and with it the medial embryological column).

    Therefore, forefoot varum, as a foot type, for an embryological point of view, can not exist. What can exist is forefoot varum, concurrently with calcaneal varum - a foot type I describe as the PreClinical Clubfoot Deformity.

    Primus Metatarsus Supinatus occurs when there is a retention of talar torsion. This talar torsion cascades all the way down the embryological medial column into the 1st metatarsal and hallus. Clinically what we see is an elevation and inversion of the 1st metatarsal and hallux when the subtalar joint is placed in joint congruity.

    If you want to read a more complete description of the embryological development of PMS, I refer you to my paper below.

    By the way, in the mid 1990s, I thought I was dealing with a forefoot varum foot type. Further research into the 21st century, I discovered the PMS foot structure.

    Professor Rothbart

    Rothbart BA, 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal of Bodywork and Movement Therapies (6)1:37-46
     
  35. 1. Podiatrists (or at least the even moderately well read ones) don't refer to forefoot supinatus as forefoot varum. They are two entirely different things. You made that up.

    2. What's calcaneal supinatus? Are you postulating an inversion deformity of the calcaneus as it articulates with the cuboid?

    3.
    Quite possibly true. Also impossible to test.
    Wait, what? So you're saying forefoot varum as described (rotation of the talus) can't exist without calcaneal varus...
    4.
    Then going on to say that an inversion deformity of the forefoot caused by talar rotation DOES exist, and giving it a new name?!

    No. Forefoot varus is described in the literature as incomplete derotation of the talus. You can't redefine forefoot varus as something completely different (talar AND calcaneal varus) the assign a new name to an incomplete derotation of the talus (PMS).

    5.
    You ARE dealing with a forefoot varum foot type Well, actually you're probably dealing with forefoot supinatus but we'll let that slide. The fact that between the 90's and the 00s you unilaterally decided that forefoot varum was something different to what had been previously described does not make it so. That would be like me deciding that pronation was only pronation when accompanied by internal rotation of the leg and assigning a new name to dorsiflexion, eversion and abduction WITHOUT said rotation.
     
  36. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Dear Robert,

    I disagree with you. And to be very frank, anyone who argues that forefoot varum (as described by Root et cal) does exist, is just not very conversant on the embryological development of the lower limb bud/ foot. There is just nothing to discuss on this subject. I suggest you review the embryological development of the foot before continuing this discussion.

    Professor Rothbart
     
  37. Brian Rothbart made up a foot deformity that already had been previously described for decades by authors before him just so that he could put his name on that deformity. Nothing more, nothing less.

    Brian Rothbart has determined that the only way he will make a name for himself is by naming foot deformities, techniques and even weeks after himself, since no one in his right mind would believe a fraction of what he says, considering his past actions, or name a foot deformity, technique or a week after him.

    I admire you, Robert, for having this argument with him publicly since I wouldn't even give him the time of day.
     
  38. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A systematic review: the effects of podiatrical deviations on nonspecific chronic low back pain.
    O'Leary CB, Cahill CR, Robinson AW, Barnes MJ, Hong J.
    J Back Musculoskelet Rehabil. 2013 Jan 1;26(2):117-23.
     
  39. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Relationship between lumbar changes and modifications in the plantar arch in women with low back pain.
    Borges Cdos S, Fernandes LF, Bertoncello D.
    Acta Ortop Bras. 2013 May;21(3):135-8.
     
  40. alextsang

    alextsang Member

    Hi guys very interesting discussion, many things to think over.

    I am a chiropractor and here are my thoughts

    Howard has highlighted that the flexion of the lumbar spine due to the increased contraction of the iliopsoas can cause low back pain. This makes sense since many low back pain sufferers have 'flexion intolerant backs' and repeated flexion at the L4/5 and L5/S1 areas can cause many issues. It can also be argued that there could a rotational/torsional component occurring here further weakening the structures supporting the low back (fascia, muscles, ligaments, joint capsules, facet joints etc.)

    Thanks to the work of Professor Stuart Mcgill we know that the Lumbar spine and Lumbosacral junction should be as stable as possible. There should be no excessive movement in this area. Normally this is facilitated by motor control by the thoracolumbar fascia, transverse abdominus, and the deep paraspinal muscles in the spine. e.g. multifidii

    Often this motor control is impaired due to previous injury (e.g. trauma) incorrect postures (e.g. slumped sitting in chairs) or incorrect movements (e.g. repeated lumbar spine flexion).

    If poor motor control has been established, patients will need to perform exercise rehab in order to fully recover from LBP.


    It is common for individuals with altered gait patterns to complain of low back pain. I see this all the time. Classic scenario is when a patient limps into the office with a lower limb complaint. Many will then complain of Lumbar Spine discomfort after a few days/weeks.

    The question then becomes whether gait pattern or specifically, does functional/structural hallux limits contribute to repetitive stress and strain of the spine.

    It is also well known and accepted within chiropractic is that lack of mobility in the hips especially hip extension can contribute to Lx pain. Vladmir Janda quotes at least 15 degrees is required. If the hips or hypomobile then the lumbar spine must compensate for this and becomes hypermobile. As discussed above the lumbar spine needs to be stable at all time to prevent injury.

    In gait, if there is a lack of extension at the hips then the lumbar spine will have to compensate and extend from midstance to toe off. This repetitive extension causes irritation of the facets and leads to 'extension intolerant' lumbar spines. Similar to lower cross syndrome.

    I have many patients complain that their lumbar spine is very tired after walking, sometimes after only 30 minutes. It can often be the result of repeated extension and rotation of Lx spine.

    My question then to Howard is, how will correcting the functional hallux limitis increase extension range of motion at the hip?

    Thanks
     
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