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By admin 0 Comments All, Clinicians, Pain Management, Pain Management, Patients, Spine, Spine

Low Back Pain -Part 2- Getting Down To The “CORE”

Getting down to the CORE!!

What is your Core?

It is defined as the center or “core” of your body.  It is the “powerhouse” around which all limb movement is performed. It consists of 29 pairs of muscles as well as boney, ligamentous, and discs structures that support the lumbo-pelvic-hip complex in order to stabilize the spine, pelvis, and kinetic chain during functional movements.  In short, it’s pretty important!

 What is the function of the Core?

The core functions to provide both stability and mobility.  It can generate forces in order to complete a sit-up as well as provide spinal stability as you reach your arms overhead.  The muscles that are most important in providing core stability can be divided into two groups:  the primary stabilizers and the secondary stabilizers.  The primary stabilizers are the transversus abdominis in the deep abdominal region and the multifidus muscles which are deep in your back and attach directly to each vertebrae in the spine.  The secondary stabilizers are the obliques in the front, the quadratus lumborum & lumbar paraspinals in the back, the pelvic floor muscles at the bottom, and the diaphragm at the top.

So what does the research say about the Core muscles?

Current research has promoted the transversus abdominis (TrA) and the multifidus as the primary stabilizers of the spine.(1,4,6,8,9)  The TrA is the deepest of the abdominal muscles and, when contracted, it increases tension of the thoraco-lumbar fascia, it increases intra-abdominal pressure, and increases spinal stiffness in order to resist the forces that act upon the spine(4,7) The multifidi span from 1 to 3 vertebral levels and attach one vertebrae directly to another.  As a result, they provide the largest contribution to inter-segmental stability.(4,9) The TrA and multifidus have been found to activate prior to limb movement in order to prepare and stabilize the spine(1,4,9) and it has been shown that the EMG activity of the TrA may be delayed in patients suffering with chronic low back pain (LBP).(7)  The TrA is activated regardless of the direction of trunk or limb movement(4) and this is the reason why performing spinal stabilization exercises in multiple planes of motion can be so effective. A significant reduction in the cross-sectional area ie atrophy of the multifidi as well as poor motor control of the TrA has been associated with patients with acute or chronic LBP.(6.9) Patients with LBP who did not receive exercises specific for the multifidi continued to have atrophy of the multifidi even after 6 weeks of being painfree as compared to the increases in multifidi cross-sectional area in those that performed the exercises.(6,9)  In other words, just because your pain is gone does not mean that your muscles are functionally recovered.  One of our primary objectives in physical therapy is to prevent FUTURE episodes of LBP!  So how do we do it?

How do we test the Core?

Unfortunately, there is not a research-proven, valid testing regimen for core stability.  However, Shirley Sahrmann has proposed a test called the Sahrmann Core Stability Test which is the most common test of function.  It involves the use of a pressure cuff placed under the lumbar spine to measure one’s ability to maintain pelvic neutral while performing five exercises of progressive difficulty.  The chart is included below.

 

How do we perform spinal stabilization exercises?

In physical therapy, we utilize the concept of a neutral spine while performing spinal stabilization exercises.  Every joint has what we call a  “resting” or “open-packed position”. It is the position of a joint when the joint spacing is maximized and the resistance from boney or ligamentous structures is the least. These are the fundamentals of Orthopedic Manual Therapy.  In the following video, we will review the concept of the Functional Neutral Position as well describe how to activate the transverses abdominus and multifidi muscles in mutiple positions.

 

 

NEXT POST:

So what are the BEST evidence-based, core stabilization exercises? 

 

1.  Allison GT, Morris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.

2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.

3. Escamilla RF, Babb E, Dewitt R. Electromyographic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Physical Therapy. 2006; 86: 656-671.

4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.

5. Hall L, Tsao H, MacDonald D. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2007; 19:763-773.

6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.

7. Hodges P, Kaigle A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In Vivo porcine studies. SPINE. 2003; 28: 2594-2601.

8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.

9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.

 

By admin 0 Comments All, Clinicians, Other, Patients, Running, Running

I DID IT !!!!!!

My inaugural return to a competitive 5K!!  The RUSH has returned!!  After a year of strength training and a progressive increase in running intensity, distance, and frequency I thought I would make my big return this fall.  The Maudslay 5K Turkey Trot was it!! A bright , sunny, cool Thanksgiving morning. A great day for a run through the park.  What I forgot about, were the hills. Oops!!  No worries though, I paced myself, remembered my breathing strategies, and pushed onward, and upward.  As I approached the finish line I realized that my competitive juices had returned in full force.  Albeit, this time, without the sharp knee pain that sidelined my efforts last year.  My time:  24:38 with a 7:57 pace.  I placed 163rd out of almost 1200 runners. WOW!!  What a Surprise!  What a Relief!  I’M BACK!!

Click HERE for the link to race results.

THIRTY-THIRD ANNUAL MAUDSLAY TURKEY TROT

FIVE KILOMETER ROAD RACE

JOPPA FLATS RUNNING CLUB

MAUDSLAY STATE PARK NEWBURYPORT MA NOV. 24TH 2011

Place Name                Age S City            St Time    Pace

1 LOUIE SAVIANO        20 M                      16:26  5:19

2 John Stansel         18 M Newburyport     MA   16:34  5:21

3 Aidan Kimball        18 M Atkinson        NH   16:42  5:23

4 Colin Ingram         29 M Hampton         NH   17:23  5:37

5 CHRIS KEALEY         44 M NEWBURYPORT     MA   17:38  5:42

6 JOHN AYERS           45 M                      17:48  5:45

7 CAM LOUGHLIN         17 M ROWLEY          MA   18:00  5:49

8 QUINN PARKER         18 M HAMPTON         NH   18:03  5:50

9 BRYCE PARKER         16 M HAMPTON         NH   18:06  5:51

10 Corey Masson         35 M Newmarket       NH   18:27  5:57

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

160 bridget ryan evange  20 F newburyport     MA   24:33  7:55

161 sara oliveri         47 F lynnfield       MA   24:36  7:57

162 Gwen Ellis           12 F Boxford         MA   24:37  7:57

163 Christopher Dukarski 44 M West Newbury    MA   24:38  7:57

I felt so good after the 5K that I thought I would challenge my dogs to a race.

This past year has been filled with ups and downs regarding my “orthopedic status”.  This getting older thing is the pits!  I certainly took my time and respected what my body was telling me during the course of my training this past year.  Sure, I could have returned to a competitive 5K sooner, but WHY?  What was I trying to prove?  I cannot emphasize enough to my runners the importance of 2 things.  Number 1:  Listen to your body.  It is wise in the ways that you have abused it over the years. Number 2:  Train to run, dont just run to train.  It has been proven that strength training can enhance running and athletic performance.  Here are several references to convince you of the evidence.

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%.  For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes.  Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?).  And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test.  With the exception of VO2max, none of these measures improved in the control group that just did endurance training.  How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively.  Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

By admin 0 Comments All, Clinicians, Pain Management, Pain Management, Patients, Spine, Spine, Uncategorized

Low Back Pain -Part 1- Common Sense or Evolution?

So why is it that 80% of people at some point will experience low back pain? Is it that we were never meant to evolve from knuckle dragging or is there a better reason? The answer to this question has more to do with common sense than with evolution. What do you think would happen to your car if you didn’t put oil in the engine? Common sense. Right? So why is it difficult for some people to understand the importance that proper posture, body mechanics and exercise play in spinal disorders such as neck and low back pain, herniated discs, and sciatica? Let me explain.
First, let’s think of the discs in between your vertebrae as water balloons. When you squeeze one side of the balloon, the fluid will move in exactly the opposite direction. Right? However, physics tells us that when a pressure is exerted on a closed system, the pressure is equal in all directions . This would be true for a “healthy” system. So, yes, when the disc is healthy and strong, the pressure exerted on the disc is the same in every direction. However, what if one of the “walls” of the system is weaker due to chronic overuse and microtrauma?  Think about the daily sloucher at the computer.

 

The more we are slumped, or flexed forward, the more stress that occurs to the back part of the disc. Remember, if we pinch the front, the fluid moves toward the back. In this regard, evolution is cruel, because the back part of the disc is the thinnest and the most susceptible to trauma. Bingo! The origins of a bulging disc. Why is it that some people with low back pain have an MRI and it doesn’t show a bulging disc? Oh, and by the way, radiologists use the terms “bulging”, “herniated”, and “protruded” interchangeably. Some even go as far as saying “there is bulging, but no herniation”. Huh? The proper medical terms would be protrusion, extrusion, and sequestration. I hope you’re not totally confused now! So what if the radiologist report says “only mild bulging” of the disc? Does this mean that the disc is definitely not the origin of the pain? Absolutely not! Although there is no clear relationship between the extent of disc protrusion and the degree of clinical symptoms, the periphery or annulus fibrosis of the disc is highly innervated. In fact, Bogduk in 1981 reported that “nerve fibres were found up to a depth equivalent to one third of the total thickness of the anulus fibrosus”. Edgar in 2008 confirmed this deep penetration of sensory nerves into the disc. Therefore, any trauma or even “mild bulging” to the peripheral layers of the disc could elicit pain. Kuslich confirmed that probing and electrical stimulation to the annular fibers could produce local LBP, but not leg pain. However, Ohnmeiss discovered that partial or full thickness anular tears, with or without disc bulging/herniation, can reproduce sciatica symptoms in about 60% of properly screened patients with chronic lower back pain . So then, what is sciatica? It is referred pain down your leg from a pinched or irritated nerve or from a traumatized disc or facet joint. The facet joints are the “winglike” structures in the picture below and, as you can see, the spinal nerves exit the spinal canal right next to the disc. Hersch showed that injection of an “irritant” such as saline into the facet joints of the spine can cause LBP. In addition, McCallwas able to reproduce sciatic symptoms with facet joint injections. It has also been well documented that a protruded disc can cause a “pinched nerve” and associated sciatic symptoms. Ouch!

So what does all this evidence mean for you? It means that the source of your low back pain is not always definitive. It can be multifaceted. In most cases, a thorough physical therapy evaluation will determine your neural sensitivities and functional impairments. Common sense tells us that avoiding postural stresses will place the body in an optimal position to heal. Appropriate manual therapy such as joint & soft tissue mobilization and manual traction as well as evidence-based spinal stabilization exercises should alleviate and prevent reoccurrence of symptoms. These will be the topics of the next two blog posts. So stay tuned!

By admin 0 Comments All, Article Reviews, Clinicians, Elbow/Wrist/Hand, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Pain Management, Patients, Running, Running, Shoulders, Shoulders, Special Techniques, Special Techniques, Spine, Spine

KinesioTape-The Evidence

I have received several comments from bloggers that “there is no evidence” regarding the effectiveness of Kinesiology Taping or KinesioTaping Techniques. I would like to share with you some very detailed clinical study outcomes that are present, and copied here, from the SpiderTech website. This post is definitely more clinical in nature, but it can certainly help any interested patient or practitioner in understanding the evidence behind the WHY and HOW of KinesioTaping.

The Clinically Proven Effectiveness of Kinesiology Taping

Taping is widely used in the field of rehabilitation as both a means of treatment and prevention of sports-related injuries. The essential function of most tape is to provide support during movement. Some believe that tape serves to enhance proprioception and, therefore, to reduce the occurrence of injuries. The most commonly used tape applications are done with non-stretch tape. The rationale is to provide protection and support to a joint or a muscle. Utilizing existing stretch tape, investigators have shown clinical improvement in patients with grade III acromioclavicular separations, anterior shoulder impingement, and hemiplegic shoulders. In recent years, kinesiology tape has become increasingly popular as a therapeutic treatment option in North America and Europe. Kinesiology tape was developed in the 1970’s and was engineered to mimic the qualities of human skin. It has roughly the same thickness as the epidermis and can be stretched between 130% and 140% of its resting length longitudinally. The application techniques were developed through the use of applied kinesiology taping, which
logically gave the therapy and material its name. The tape reportedly has several benefits, depending on the amount of stretch applied to the tape during application: (1) to provide a positional stimulus through the skin, (2) to align fascial tissues, (3) to create more space by lifting fascia and soft tissue above the area of pain/inflammation, (4) to provide sensory stimulation to assist or limit motion, and (5) to assist in the removal of edema by directing exudates toward a lymph duct. The clinical information on kinesiology tape suggests improved function, pain, stability, and proprioception in pediatrics and patients with acute patellar dislocation, stroke, ankle and shoulder pain, and trunk dysfunction. The respective information comes from case series and pilot studies, the most important of which are summarized in the following:

In a prospective, randomized, double-blinded, clinical trial using a repeated-measures design Thelen et al. investigated the clinical efficacy of kinesiology tape for shoulder pain. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: A therapeutic kinesiology tape group or a sham kinesiology tape group. The therapeutic kinesiology tape group showed immediate improvement in pain-free should abduction after tape application. It was concluded that kinesiology tape may be of some assistance to clinicians in improving pain-free active range of motion immediately after tape application for patients with shoulder pain.

In 2009, Fraizer et al. examined in a case series the clinical outcomes for patients with shoulder disorders who were treated with a comprehensive physical therapy program that included kinesiology taping techniques. Five patients
were treated with this taping method among other interventions. All patients demonstrated clinically important improvements in function. The authors concluded that kinesiology taping should be considered as an optional clinical
adjunct in the treatment of shoulder pain as part of a comprehensive physical therapy regimen.

Also in 2007, Yoshida et al. studied the effect of kinesiology tape on lower trunk range of motions. Thirty healthy subjects with no history of lower trunk or back issues participated in the study. Based on their findings, the authors determined that the application of kinesiology tape applied over the lower trunk may increase active lower trunk flexion range of motion.

In 2007, Lie et al. studied the application of kinesiology tape in patients with lateral epicondylitis. The experimental results indicated that wearing kinesiology tape causes the motions of muscle on the ultrasonic images to be enhanced which the authors believe to indicate that the performance of muscle motion was improved.

The effect of taping using kinesiology tape in an acute pediatric rehabilitation setting was investigated in a 2006 pilot study by Yasukawa et al. The purpose of this pilot study was to describe the use of the kinesiology tape for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. Fifteen children (4 to 16 years of age), who were receiving rehabilitation services participated in this study. The improvement from pre- to post-taping was statistically significant. These results suggest that kinesiology tape may be associated with improvements in upper-extremity motor control and function in the acute pediatric rehabilitation setting. The authors concluded that the use of kinesiology tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child’s inpatient stay.

In 2009, Tsai et al. evaluated the effects of a bandage replacement by kinesiology tape in decongestive lymphatic therapy (DLT) for breast-cancer-related lymphoedema. Forty-one patients with unilateral breast-cancer-related lymphoedema for at least 3 months were included in this study. The study results suggested that kinesiology tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphoedema patient with poor short-stretch bandage compliance after 1-month intervention.

As published in the journal Top Stroke Rehab., Jaraczewska et al. indicated that kinesiology tape could improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that had previously been described in the literature is the athletic taping technique. The authors concluded that kinesiology taping in conjunction with other therapeutic interventions could facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in developing an effective treatment program for the upper extremity in hemiplegia.

The clinical efficacy of kinesiology taping in reducing edema of the lower limbs in patients treated with the Ilizarov method was investigated by Bialoszewski et al. The study involved 24 patients of both sexes subjected to lower limb lengthening using the Ilizarov method who had developed edema of the thigh or leg of the lengthened extremity. The mean age of the patients was 21 years. The patients were randomized into two groups of twelve, which were then subjected to 10 days of standard physiotherapy. The study group was additionally treated with kinesiology taping (lymphatic application), while the control group received standard lymphatic drainage. The application of kinesiology taping in the study group produced a decrease in the circumference of the thigh and leg statistically more significant than that following lymphatic drainage. It was concluded that kinesiology taping significantly reduced lower limb edema in patients treated by the Ilizarov method and that the application of kinesiology taping produced a significantly faster re-education of the edema compared to standard lymphatic massage.

Hsu et al investigated the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement. Seventeen baseball players with shoulder impingement were recruited from three amateur baseball teams. All subjects were taped with both the kinesiology tape and a placebo tape over the lower trapezius muscle. The kinesiology tape resulted in positive changes in scapular motion and muscle performance. The results supported its use as a treatment aid in managing shoulder impingement problems.

By admin 0 Comments All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Pain Management, Patients, Running, Special Techniques, Special Techniques

Reebok pays 25M – Kick in the Butt!

As an addendum to the my last post “Whats Up with the Shape-Ups?”, guess what happened to Reebok? They have to pay 25 million due to false “toning” claims. Talk about a kick in the butt!! Read on.

PORTLAND, Ore. — Reebok will need to tone down advertising for its shoes that claim to reshape your backside.

The athletic shoe and clothing company will pay $25 million in customer refunds to settle charges by the Federal Trade Commission that it falsely advertised that its “toning” shoes could measurably strengthen the muscles in the legs, thighs and buttocks. As part of the settlement, Reebok also is barred from making some of these claims without scientific evidence.

“Settling does not mean we agree with the FTC’s allegations,” Dan Sarro, a Reebok spokesman, said in a statement Wednesday. “We do not. We have received overwhelmingly enthusiastic feedback from thousands of EasyTone customers.”

It’s the latest controversy surrounding so-called toning shoes, which are designed with a rounded or otherwise unstable sole. Shoemakers say the shoes force wearers to use more muscle to maintain balance and consumers clamored for them, turning toning shoes into a $1.1 billion market in just a few years. Companies such as Reebok, New Balance and Skechers have faced lawsuits over their advertising claims. But the FTC settlement, announced Wednesday, is the first time the government has stepped in.

Reebok International Ltd. makes a range of toning products, including its RunTone running shoes, EasyTone walking shoes and flip flops and some clothing. The company, which is owned by Adidas AG, said that its toning shoes were one of its most popular product launches ever when they debuted in 2009. The company marketed them heavily with ads featuring women in short shorts and with shapely bottoms; one ad even said the shoes would “make your boobs jealous”.

The FTC took issue with Reebok’s ads that claimed its EasyTone footwear had been proven to lead to 28 percent more strength and tone in the buttock muscles and 11 percent more strength and tone in hamstring and calf muscles than regular walking shoes. The FTC said it could not disclose if it was pursuing similar actions against other shoe makers.

“We think this is a real victory for consumers,” said Dana Barragate, an FTC attorney involved in the case. “We hope it sends a message to businesses that if they are going to make claims they must be justified.”

Shoe makers, including Reebok, have funded studies and say they have anecdotal evidence that proves they are effective. Several experts have questioned their validity and the American Council on Exercise, a nonprofit fitness organization, conducted a study that found toning shoes failed to live up to the claims of shoe makers. However, the council said the shoes could be beneficial to one’s health if they motivate people to get moving.

Christopher Svezia, with the Susquehanna Financial Group, said many shoemakers have changed their advertising approach as criticism has mounted. “The emphasis has moved to fitness instead of making these kinds of claims and promises,” he said. “The question is who is next and how much is it going to cost them.”

The industry has faced other issues. There have been some injuries reported by wearers who have found themselves with shin splints, twisted ankles and sore muscles from the new gear and motions. Shoe makers suggest new wearers ease into wearing them.

Toning shoes were once the fastest-growing segment in the footwear industry, but recently lost some ground. SportsOne Source Group said that the $1.1 billion market of 2010 is expected to fall about 40 percent to $650 million in 2011 after Skechers flooded the market with products, forcing prices down. However, SportsOne Source said the number of shoes sold is only expected to fall 5 percent, suggesting there is still fairly strong demand.

Rebecca Sayre of Seattle, who bought a pair of Skechers more than a year ago, said they made her legs stronger and posture better. But, she says: “They’ve lost their luster.”

(Copyright 2011 by The Associated Press. All Rights Reserved.)

Story posted 2011.09.28 at 08:41 PM EDT

By admin 0 Comments All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Patients, Running, Running

So what’s up with the Shape-Ups?

So what’s up with the claims made by these toning shoes??

I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.

So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.

And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.

And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.

And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.

But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.

By admin 0 Comments All, Article Reviews, Clinicians, Other, Pain Management, Pain Management, Patients, Running, Running, Special Techniques, Special Techniques

My Guest Post Extraordinaire!!

My post today is actually a guest post from a several time “visitor” to OrthoWell. He is an avid runner as well as an avid reader of the running literature. In response to my post on the evolution of running and running technique, he offers some insightful comment and a vivid analogy of being mindful of your weak links. Our biomechanical and evidence-based approach at OrthoWell enables our therapists to find your weak links faster and more effectively than the competition. Don’t be fooled by imitations! Without further adieux, I would like to introduce Matthew Demers!

“After reading your post on running technique, I have come to most, if not all, of the same conclusions you arrived at. I feel like I could have co-authored the piece. There is one more item that I would have included. It would read something like this:

We run with the body that our environment and habits have created. Just as wearing shoes creates a dependency on shoes, other aspects of our lifestyles generate limiting factors. Take sitting down all day as part of a desk job; the hip flexors take on a different form over time (http://www.yogajournal.com/practice/588). This biomechanical limiting factor impacts running as it changes the gait by restricting the backward swing of the leg through the stance and propulsion phases. The net result (and I can attest to this one) is a very chopped stride. No heels-to-the-ass running for this plodder. Similarly, other facets of the lifestyle I have embraced have created associated limiting factors – and by limiting factors, I mean those things that stand between me and the ideal running form. An educated runner looks for these and addresses them. Hope, as in “I hope I don’t hurt anything,” is a lousy strategy.

To address these limiting factors, I give you my NASCAR solution. Barring accidents, the pit crew of any successful racecar driver has to anticipate what is going to break – and fix it – before the driver finds it. This begs the question, how do they know what is going to break? Odds are it is the weak link in whatever chain it belongs to. Driving 500 miles at full throttle is a perfect technique for finding the weak links. Sometimes the driver can give the pit crew feedback about a failing weak link before actual failure, at which point the pit crew can fix it and the race continues; ignore it or fail to fix it and the race is over. In running we are both driver and pit crew; driver while on the road and pit crew the rest of the time. The maddeningly repetitive nature of running makes it the perfect activity for identifying weak links. Every single running injury is the failure of a weak link (which is more than likely linked to a limiting factor of some sort). Changing your running dynamics by introducing speed work (higher revs) or hill work (higher torque) speeds up the weak link-identification process. So the solution is simple, you need to be a smart driver and a fastidious pit crew. You need to acknowledge that regardless of how well trained you are, there are still weak links – there has to be by definition. Live within your limiting factors, while acting to reduce or correct them, and you will be a happier runner. Finally, make sure your driver is talking to your pit crew.”

Thanks Mat!!

By admin 0 Comments Clinicians, Elbow/Wrist/Hand, Elbow/Wrist/Hand, Patients, Spine, Spine

Is your tennis elbow a pain in the neck?

What came first, the chicken or the egg?  The fundamental premise behind this question can be applied to orthopedic physical therapy as well.  What came first, your pinched nerve, your shoulder pain, your elbow pain, or your poor posture?  Let me explain.

We live in a society dominated by “slouching” syndrome.  We prefer to sit in a soft chair with forward flexed posture instead of a firm chair with erect and supported posture.  Draw a line from the middle of your ear to the center of your shoulder to the center of your hip joint and, bio-mechanically speaking, you are lookin’ pretty good

 

We need to maintain a normal inward curve at our necks and low back as well as a normal outward curve in our mid backs.

 

So what is the connection?  Sit or stand with really slouched shoulders and attempt to raise your arm overhead.  Now, sit straight and try it again.  You have much more freedom of motion in your shoulder while sitting straight.  Now, think about how many times you reach during the day with forward flexed posture.  Each and every reach in this forward position will cause a “pinch” or impingement of your rotator cuff tendon in your shoulder. According to Flatow et al in the American Journal of Sports Med, all of us, physiologically, have a certain amount of “normal” impingement in our shoulders.  Compound this “normal” impingement with the exaggerated impingement that occurs with poor posture and you have a recipe for the pain of rotator cuff tendonitis.  Refer to my post on Impingement Syndrome for more details.

 

Do you know of anyone who has chronic tennis elbow (pain on outside of elbow) or golfers elbow (pain on inside of elbow)?  You may want to mention to them the results that were published in an article in the journal Sports Health. The authors evaluated 102 patients with documented cervical radiculopathy ie pinched nerve in the neck and found that more than half of the patients also had medial epicondylitis ie golfers elbow.  The prevalence of tennis elbow and neck involvement has also been documented and Berglund et al article is one example. What this means is that your therapist and YOU need to be aware of this connection and the appropriate steps need to be taken to rule out your neck as the CAUSE of your elbow symptoms.

 

The chicken or the egg?  Maybe you need OUR help.

 

 

physical therapist adjusting for hip pain
By admin 0 Comments Knee

How “HIP” is your knee pain?

“The knee bone’s connected to the…hip bone” may be your therapist’s greatest clue to solving your knee pain.  How many patients have gone to physical therapy for knee pain and received an ultrasound & VMO exercises only to be disappointed in his or her outcome?   What exactly is the link between knee pain and hip weakness?  What does the research tell us?

Patello-femoral pain syndrome (PFPS) is the most common condition seen in an orthopedic practice.  It is the most prevalent injury in persons who are physically active.  Iliotibial band syndrome (ITBS) is the second most common overuse injury in runners.  Anterior cruciate ligament (ACL) injuries are one of the most common ligament injuries in people who engage in athletics.  What common factor contributes to ALL of these orthopedic conditions?  You guessed it!!  Weak hips!  Read on for the proof.

In a recent review of the literature, Reinman cited 51 articles that provide some degree of evidence correlating proximal factors to knee loading and knee injury.  The position of the knee relative to the hip during weight bearing activities is a predictor of dysfunction.  Excessive hip adduction and internal rotation can adversely affect the kinematics and kinetics of the entire lower extremity.  This combined motion produces a “dynamic” knee valgus.  A valgus moment places a tensile strain on the iliotibial band as well as the medial soft tissue restraints of the knee, particularly the ACL and medial collateral ligament. Claiborne et al and Hollman et al have reported that reduced hip strength is related to greater knee valgus angles.  In the presence of hip abductor weakness, the opposite hip may drop during single-leg support causing a Trendelenberg sign.  This is especially apparent during a slow, “controlled” descent down a step.  A great functional test!

Why is it that the incidence of ACL injuries and PFPS is greater in women?   Prins et al concluded that females with PFPS exhibit impaired strength of the hip extensors, abductors, and external rotators.  Chen and Powers report that females with PFPS exhibit excessive “dynamic” Q-angles, especially with descending stairs.  Pollard et al states that females demonstrate insufficient utilization of the hip extensors due to decreased knee and hip flexion during a jump squat for example.  This leads to increased quad activation in the presence of a valgus knee and localizes the impact load onto the patella to a much smaller surface area.

So what if you’re a runner?  Ferber et al looked at 283 studies that examined running-related injuries and concluded that the connections between weak hips and running were far more conclusive than the connection with flat feet (over-pronation).  Interestingly, Earl et al prescribed a hip strengthening program to healthy female runners for 8 weeks and, in addition to improved hip strength, they measured a 57% decrease in pronation while running.  Strengthen the hips and ditch the orthotics?  Maybe.

If it hasn’t become obvious yet, hip weakness has been proven as a predictor of knee dysfunction.  So in addition to your runs or to your crunches, you need a hefty dose of hip resistance training.  Call us and we can get you started!!

By admin 0 Comments All, Hip, Knee, Patients, Running

How “HIP” is your knee pain?

“The knee bone’s connected to the…hip bone” may be your therapist’s greatest clue to solving your knee pain.  How many patients have gone to physical therapy for knee pain and received an ultrasound & quad exercises only to be disappointed in his or her outcome?   What exactly is the link between knee pain and hip weakness?  What does the research tell us?

Patello-femoral pain syndrome (PFPS) (pain under the kneecap) is the most common condition seen in an orthopedic practice.  It is the most prevalent injury in persons who are physically active.  Iliotibial band syndrome (ITBS) is the second most common overuse injury in runners.  Anterior cruciate ligament (ACL) injuries are one of the most common ligament injuries in people who engage in athletics.  What common factor contributes to ALL of these orthopedic conditions?  You guessed it!!  Weak hips!  Read on for the proof.

In a recent review of the literature, Reinman cited 51 articles that provide some degree of evidence correlating hip weakness to knee loading and knee injury.  The position of the knee relative to the hip during weight bearing activities is a predictor of dysfunction.  Excessive hip adduction and internal rotation (turning in of the knee such as being bow-legged) can adversely affect the motion and forces that act upon the entire lower extremity.  This combined motion produces a “dynamic” knee valgus.  A valgus force places a tensile strain on the iliotibial band as well as the soft tissue restraints on the inside of the knee, particularly the ACL and medial collateral ligament. Claiborne et al and Hollman et al have reported that reduced hip strength is related to greater knee valgus angles.  In the presence of hip abductor weakness (muscle that raises your leg out to the side), the opposite hip may drop during single-leg support causing a Trendelenberg sign.  This is especially apparent during a slow, “controlled” descent down a step.  A great functional test!

Why is it that the incidence of ACL injuries and PFPS is greater in women?   Prins et al concluded that females with PFPS exhibit impaired strength of the hip extensors, abductors, and external rotators.  Chen and Powers report that females with PFPS exhibit excessive “dynamic” Q-angles, especially with descending stairs.  Pollard et al states that females demonstrate insufficient utilization of the hip extensors due to decreased knee and hip flexion during a jump squat for example.  This leads to increased quad activation in the presence of a valgus knee and localizes the impact load onto the patella to a much smaller surface area.  Hence, more pain!

So what if you’re a runner?  Ferber et al looked at 283 studies that examined running-related injuries and concluded that the connections between weak hips and running were far more conclusive than the connection with flat feet (over-pronation).  Interestingly, Earl et al prescribed a hip strengthening program to healthy female runners for 8 weeks and, in addition to improved hip strength, they measured a 57% decrease in pronation (flat foot) while running.  Strengthen the hips and ditch the orthotics?  Maybe.

If it hasn’t become obvious yet, hip weakness has been proven as a predictor of knee dysfunction.  So in addition to your runs or to your crunches, you need a hefty dose of hip resistance training.  Call us and we can get you started!!