All Archives - Page 5 of 7 - Orthowell Physical Therapy

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 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!!

By admin All, Clinicians, Knee, Pain Management, Pain Management, Patients, Special Techniques, Special Techniques

Kinesio Taping – How does it work?

Kinesio Tex tape is the world’s #1 elastic Kinesio tape. It is used by 78,000 practitioners in the United States and 150,000 worldwide. It is being used by professional athletes and Olympians such as Kerri Walsh of the gold medal winning US women’s beach volleyball team. Here at OrthoWell/WalkWell, we are KT1 and KT2 certified in the Kinesiotaping Method. How does Dr. Kenzo Kase , the inventor of Kinesio Taping, explain the concept of Kinesio Taping?

“ The concept of Kinesio Taping is the replication of the therapist’s hands on the patient’s skin using Kinesio tape. The Kinesio tape mimics the qualities of the patient’s skin and success of the Kinesio Taping method depends on two factors. One , proper evaluation of the patient’s condition by the therapist. Two, proper application of the Kinesio Taping technique.”

So how does Kinesio Taping work?

AFFECTS ON MOVEMENT

Proprioception is our ability to sense our body’s static position in space. Kinesthesia is our ability to sense how our bodies move through 3-dimensional space. This “sense” occurs through several different types of sensory organs under our skin and around our joints that provide our brains with information about pressure, vibration, touch, temperature, and tension. The effectiveness of the Kinesio tape lies in its ability to alter the sensory feedback that enters your nerves in the area that the tape is applied. The contact of the tape on the skin appears to increase the ability of the joint and/or tissue to detect movement and to respond to outside forces. As a result, this has a positive effect on the communication between your brain and the affected tissue which, in turn, could enhance athletic or movement performance.

AFFECTS ON PAIN

The sensory feedback from the tape has been hypothesized to reduce pain by stimulating large nerve fibers under the skin. The input from these nerves fibers travels more rapidly to the brain than the input from pain receptors. This is the concept of the Gate Control Theory of pain in that the sensory input overrides the pain input, thus, reducing the sensation of pain.

AFFECTS ON SWELLING

An important concept of applying Kinesio tape is “less is more”. Athletic taping is used with tapes of high tensile strength in order to stabilize and/or reposition a joint. Once applied, the tape resists being stretched. Kinesio tape is applied with low levels of tension. In most applications, the tape is applied with the affected tissue in a stretched position so that the tape has a convoluted appearance when the tissue is at resting length. As a result, the tape has a “lifting” effect on the skin which improves circulation and lymphatic drainage below the level of the skin. This effect can create channels of low pressure in a congested area as well as assist in opening the epithelial flaps that are present on lymph vessels resulting in a significant reduction in swelling.

“>Check out our You Tube video link in the slider on the bottom of this page to see a Kinesio Taping technique for reducing knee swelling.

Check out our post on the research behind KinesioTape.

By admin 0 Comments All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Patients, Running, Running, Special Techniques, Special Techniques

What kind of foot orthotic do you need??

Have you been asked this question? Let me help you with the foot condition that you probably diagnose most often – plantar fasciitis!!

The purpose of foot orthotics with a diagnosis of plantar fasciitis is to decrease the strain on the plantar fascia. Kogler, in his articles in Clinical Biomechanics, has provided evidence highlighting the effect of several variables on plantar fascia strain. Let me give you a summary:

Heel lifts do NOT decrease the strain on the plantar fascia

A wedge placed under the outside of the forefoot decreased the strain.

A wedge placed under the inside of the forefoot increased the strain.

Foot orthotics that raise the apex of the arch and prevent excessive loading of the first ray (the inside part of foot) are the most effective in reducing plantar fascia strain.

The foot orthotic should be custom molded, fit snugly up against the navicular bone, and flare away from the outside aspect of the foot. The orthotic can include a post under the outside 4 metatarsal heads. We call this post a reverse Morton’s extension. It will allow the first ray to be in a downward position relative to the other metatarsals. As a result, we decrease the strain on the plantar fascia.

At WalkWell, biomechanical analysis is our specialty. We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy. We hope to hear from you soon!!

By admin All, Pain Management, Patients, Special Techniques

Is it REALLY tendinitis? Or tendinosis?

All physical therapy is NOT created equal. As a physical therapist with almost 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston Technique and Active Release Technique for more information.

As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At WalkWell, we do just that!

By admin All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Other, Pain Management, Pain Management, Patients

Literature Review – Heel Pain

Plantar heel pain is a very common and painful condition. One United States study estimates that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. (1 in Radford, 07) This disorder appears in the sedentary and geriatric population (2-4 in Radford), it makes up one quarter of all foot injuries in runners (5 in Radford), and is the reason for 8% of all injuries to people participating in sports. (6-8 in Radford, 07) The exact nature of the disorder as well as the most appropriate treatment, however, remains unclear. (Martin 98, Radford 07, Wolgin 94, Crawford 02, Gill 97, Gill 96, Davis 94, Lynch 98) A study of 364 painful heels could find no causal relationship. (Lapidus in Wolgin 94) Few random, controlled studies document the efficacy of conservative care, (Barrett 11/06, Atkins in Barrett article, Radford 07, Crawford 02, Davis 94) ,yet success rates for conservative treatment of plantar heel pain vary from 46% to 100% in the literature. (Wolgin 94, Martin 98, Lynch 98,) It becomes clear from a review of the literature that the etiology of plantar heel pain is multi-factorial i.e. “multiple etiology heel pain syndrome”. There is not one specific cause, nor is there a panacea for conservative treatment. In 1972, Snook and Chrisman (36 in Wolgin) wrote “ it is reasonably certain that a condition which has so many different theories of etiology and treatment does not have valid proof of any one cause”. Are we any better off today?

The management of plantar heel pain begins with the correct differential diagnosis. (Gill 97, Shapiro 97, Meyer 02) Plantar fasciitis is the most common diagnosis for plantar heel pain. (1-Aldredge in Barrett 06) Clinical findings include medial heel pain which is often worse in the morning, worse after periods of rest, worse after prolonged weight bearing activity, and pain to palpation at the medial/plantar heel. (Perelman 95, 10-Scherer in Richie, Gill 97) Most researchers agree that the pain is caused by microtrauma to the origin of the plantar fascia at the medial tubercle of the calcaneus. (Perelman 95, Richie 05, 7-Grasel in Richie 05, 10-Scherer in Richie, 7-Schon in Gill 97). Subsequently, this microtrauma causes marked thickening and fibrosis at the origin of the plantar fascia. (Grasel in Richie, Schepsis, Martin 98) Many practitioners believe that the pain of plantar fasciitis is caused by inflammation. (Barrett, Khan’s work, Almekinder) However, researchers have shown through histological examination that there is an absence of inflammatory cells in chronic overuse tendinopathies. (Khan’s, Almekinder, Huijregts 99, Puddu 76) Animal studies conclusively demonstrate that, within 2-3 wks of insult to tendon tissue, inflammatory cells are not present. (Khan BMJ 02) Histologic findings from plantar fasciotomies have been presented to support the thesis that plantar fasciitis is a degenerative fasciosis without inflammation, not a fasciitis. (Lemont, Schepsis 91). In addition to the absence of inflammatory cells, tendinosis is characterized by a degeneration of tenocytes and collagen fibers with a subsequent increase in non-collagenous matrix. (Khan) The collagen tissue of tendons, for example, have only 13% of the oxygen uptake of muscle and require >100 days to synthesize collagen. (Khan, 94-95 in Khan) Thus, tissue repair in tendinosis may take 3 to 6 months. (Khan) With this increasing body of evidence suggesting fasciosis, not fasciitis, the practitioner needs to shift his/her treatment perspective.

As payers demand practitioners to maximize outcomes and minimize costs, the need for evidence-based interventions becomes clear. As stated above, however, there are few studies that have tested the efficacy of treatment protocols. (Khan, plus above) The first treatment goal for plantar fasciosis should be to protect the healing tissue. (Khan, Chandler 93, Cornwall 99, McPoil 95, Ross 02, Crosby 01)) How can damaged tissue heal if environmental stresses are not controlled? (McPoil 95) The second goal should be to restore the normal mechanical behavior of the tissue and to positively influence the structural reorientation of damaged collagen fibers. (Graston) Physical therapists have proposed that the treatment of plantar heel pain should be impairment based. (Young 04) A detailed examination would identify these impairments and an appropriate plan of care would utilize manual therapy, exercise, and modalitites. (Young 04) There is no standard physical therapy protocol for plantar fasciosis, however, upon review of the literature by this author, a framework of evidence is available to establish an appropriate protocol.

Iontophoresis and corticosteroid injections have been used to treat the proposed presence of inflammation at the origin of the plantar fascia. Iontophoresis is a process that uses bipolar electric fields to propel molecules of a drug such as dexamethasone across intact skin and into underlying tissue. (Anderson 03) The depth of drug penetration averages 8-12 mm with deeper penetration occurring through a slower process of passive diffusion. (Anderson 03, Li 95, Costello 95) Two articles have documented an improvement of plantar heel pain using iontophoresis with dexamethasone, yet long term relief was questionable. (Gudeman 97, Page 99) Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Corticosteroid injections for relief of plantar heel pain have had mixed results. (Martin 98, Wolgin 94, Crawford 02, Acevedo 98, Davis, Gill) However, ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig in response) Improper injection technique may be the reason for unfavorable results. (Wolgin 94)

Tissue protection can occur through rest, activity modification, taping techniques, and foot orthoses. Low-dye taping and various plantar strapping techniques have been shown to be effective in relieving plantar heel pain as well as altering foot kinematics and plantar pressures. (Lange 04, Hyland 06, Keenan 01, Holmes 02, Vicenzino 00) Although limited evidence exists (Gross 02, Kogler 99, Kogler 96, Scherer&Waters 07, Mundermann 03,Razeghi 00, Pfefer, Lynch), no conclusive evidence has been found to demonstrate the effectiveness of foot orthoses on plantar heel pain. ( Young 04, Lynch, Gill, Davis, Gross 02, Brown 95, Landorf in Pod Tod)

Manual therapy procedures used by medical practitioners can include soft tissue mobilization, massage, manual traction, joint mobilization, and joint manipulation. (DiFabio 92) Clinical interventions involving joint mobilizations and manipulations have been developed or refined by many authors. (Difabio 92, In DiFabio Maitland Periph/Spine, Grieve, Kaltenborn Periph/Spine, Cyriax, McKenzie) Although there is clear evidence to justify the use of manual therapy on spinal disorders, there is an absence of controlled trials in peripheral joints. (DiFabio 92) We can only speculate that a relationship exists between the identified joint impairment and the patient’s plantar heel pain. (Young) There is, however, a body of work that attempts to demonstrate the effect of mobilizations and/or manipulations of the talus and fibula on ankle dorsiflexion range of motion, yet with varied results. (Dananberg 00, Pellow 01, Denegar 02, Soavi 00, Nield 93, Dimou 04, Green 01)

Dorsiflexion range of motion restrictions have been identified as a significant impairment associated with plantar heel pain. (Young 04) One study reported a 5 degree or more dorsiflexion restriction in 78% of his patient population with unilateral plantar fasciitis. (Amis 88) Numerous studies have shown that heel cord stretching is one of the most effective treatments for resolving plantar heel pain. (Richie, Wolgin, Gill, Davis, Pfeffer) Plantar fascia-specific stretches have been shown to be even more effective than calf stretches in alleviating plantar heel pain (DiGiovanni 03,06) Due to the viscoelastic properties of muscle-tendon units, the duration of the stretch, active warm-up, and the concept of reciprocal inhibition can influence the outcome of stretching. ( Shrier 00, Taylor 90) Dorsiflexor and plantarflexor muscle weakness via isokinetic testing has also been identified as impairments in chronic plantar fasciitis. (Chandler 93, Kibler 91)

Collagen production is probably the key cellular phenomenon that determines recovery from tendinosis. (Khan 00) Animal experiments have revealed that loading the tissue improves collagen alignment and stimulates cross-linkage formation, both of which improve tensile strength. (Khan 00, Villarta #34 in Khan 00) Interventions such as friction massage (DeLuccio, Loghmani 05, Davidson, Gehlsen 98, Chamberlain 82), ultrasound (Enwemeka 89, Ramirez 97, Young 89, Crawford/Snaith 96,Gum 97,Speed 01, DeDeyne 95,Dyson 68, Noble 06,Cunha 01,Draper 95,Doan 99Jackson 90,Ng 03,Harvey 75), and eccentric exercise (Stanish 85,Cannell 00,Ohberg 02,Alfredson 98, Khan 99,00,00 have been shown to stimulate collagen production and, thus, help to reverse the tendinosis cycle.

The purpose of this outcome study is to determine the effect of a standardized treatment protocol on a group of subjects that present with the diagnosis of plantar fasciosis or fasciitis. The subjects are required to have at least 3 of the 4 criteria listed above for the diagnosis of plantar fasciitis and to have a >4 week history of plantar heel pain. The specific goals of this outcome study are the following: 1) to evaluate how the subject population responds to the treatment protocol in terms of pain reduction and functional outcome measures, 2) to determine improvements in ankle dorsiflexion range of motion utilizing the protocol, 3) to assess changes of thickness at the origin of the plantar fascia via diagnostic ultrasound after utilizing the protocol, 4) to investigate the duration of time between start of treatment and maximal improvement in symptoms, 5) to investigate the time relationship between onset of symptoms and start of treatment to clinical outcome, 6) to investigate and document any reoccurrences of symptoms while performing a maintenance home program over a 6 month period, and 7) to assess patient compliance with the home program.

By admin All, Pain Management, Patients

IT HURTS!! HEAT or ICE?

As your therapist, one of my most important roles in your recovery is teaching you the fundamentals of proper healing. Healing of injured tissue is a physiological process that can be inhibited by many factors. Pain management strategies, activity modification, and proper exercise are three such factors that need to be examined.

PAIN MANAGEMENT

All new injuries or aggravation of old injuries need to be addressed with the acronym P.R.I.C.E. – Protect, Rest, Ice, Compress, Elevate. We will talk about the protection aspect in the next section on activity modification. After an acute injury, there is resulting tissue trauma and inflammation. Inflammation is part of the healing process as the body attempts to bathe the injured tissue with protein rich fluid as well as cells that cleanse and repair the injured tissue. Inflammatory cells can be present up to 21 days after an injury, but are the most prevalent during the acute inflammatory stage i.e. first 7-10 days. Uncontrolled inflammation is what delays healing and it is what we attempt to control with R.I.C.E. Ice should be applied for 10-15 minutes only in order to prevent frostbite. You can use soft, gel cold packs, bags of frozen peas or ice, or submerge the injured part into an ice water bath. You can ice every hour if you wish, but at a minimum of 2-3 times per day, for at least the first 7-10 days. Remember that the inflammatory process (in the controlled environment) can last 21 days. The adage “ice for the first 48 hours only” does not make physiological sense. Icing is not only anti-inflammatory, but it is also a great pain reliever. You should also consult with your physician regarding an anti-inflammatory medicine. Examples would be medicines such as Aleve 2x/day or 600-800mg of ibuprofen i.e. Advil or Motrin 3x/day for at least 7-10 days. Compression and elevation of the injury helps to prevent uncontrolled inflammation as well. Athletic taping, neoprene or Acewrap sleeves for ankles or knees, and back braces are examples of compression as well stabilization of an injury. Heating tissue can be relaxing and pain relieving, but it also causes the blood vessels to dilate, hence, increasing the flow of fluids to the area. If you wish, heating for 15-20 minutes can be added after the first 7-10 days as long it does not increase the swelling.

ACTIVITY MODIFICATION

Protecting the injury will prevent uncontrolled inflammation, thus encouraging proper healing. Pain is a warning sign. It is your body’s attempt to remind you that something is wrong. Pushing “through the pain” is NEVER a good idea. When a lower extremity joint is injured and walking becomes painful or limited, we advise and instruct patients in using crutches or canes. This is a temporary modification of activity in order to prevent reoccurrences of pain as the body is healing. Our patients use an assistive device as long as is needed, but most typically for the first 7-10 days. Proper posture and body mechanics are also very important in removing the stresses to an injured back or spinal condition. Remember that causing pain during activity is like taking a hammer and “banging” on the injured tissue. Take frequent breaks and pace your activity as to not provoke your pain. It is important to wean slowly back into walking or running. We will help to guide you in that process.

PROPER EXERCISE

Proper exercise can be initiated after the acute inflammatory stage. Movement of joints and tissues during exercise causes a mechanical “pumping”. This “pumping” can help to “push in the good and push out the bad”, prevent post-traumatic stiffness, and encourage a quicker return to function. Proper technique in these early stages would entail pain free, high rep, and low weight exercises. We will guide you in that process. Creating a global circulatory effect via pain free cardiovascular exercise is also beneficial to healing as it helps to cleanse and nourish the injured area.

I hope that helps!!

Chris Dukarski, PT

By admin 0 Comments All, Clinicians, Foot/Ankle

IS IT PLANTAR FASCIITIS OR NERVE PAIN??

What happens when your patient returns and his/her heel pain has not improved? Do you assume that physical therapy didn’t work? What you CAN conclude is that your patient may not have received the RIGHT physical therapy.

Heel pain is multi-factorial. What needs to be determined in physical therapy is whether the origin of the pain is local, referred, or both. As our patients become heavier, more de-conditioned, and more susceptible to concurrent orthopedic dysfunction, the chance of referred symptoms from discogenic involvement and/or peripheral nerve entrapment is greater. If our patients at OrthoWell/WalkWell are not significantly improving after 4 visits of localized soft tissue treatment, then referring sources of pain need to be considered. If nerve involvement is suspected, then it is easier to perform manual differentiation testing after the nerve has been sensitized. Our patients are instructed to return to PT when they are most symptomatic. Neural tension testing of the sciatic nerve may elicit heel pain or a “doorbell” sign may be elicited along the course of the sciatic or tibial nerve. See below.

Our patients may be susceptible to the “double-crush” phenomenon due to concurrent areas of nerve entrapment. Centrally mediated entrapment may arise from a history of disc herniation or multiple lumbar disc sprains. Common peripheral entrapment sites are the lateral plantar nerve at the medial heel, the tibial nerve under the flexor retinaculum in the tarsal tunnel or as it courses through the tendinous arch of the soleus, and the sciatic nerve at the distal split of the hamstrings, between the biceps femoris and adductor magnus, or under the piriformis muscle. Active Release Techniques, as performed at OrthoWell/WalkWell Rehab, are very effective in resolving these entrapments.

By admin 0 Comments All, Clinicians, Foot Orthotics

Plantar Fasciitis and Foot Orthotics.

Heel lifts do NOT decrease the strain on the plantar fascia

A wedge placed under the lateral aspect of the forefoot decreased the strain.

A wedge placed under the medial forefoot increased the strain.

Foot orthotics that raise the apex of the medial arch and prevent dorsiflexion (loading) of the first ray are the most effective in reducing plantar fascia strain.

The foot orthotic should be custom molded, fit snugly up against the navicular, and flare away from the lateral aspect of the foot. The orthotic can include a post under the lateral 4 metatarsal heads. We call this post a reverse Morton’s extension. It will allow the first ray i.e. the first metatarsal and medial cuneiform to be plantar flexed relative to the other metatarsals. As a result, we decrease the strain on the plantar fascia.

At WalkWell, biomechanical analysis is our specialty. We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy.

By admin 0 Comments All, Clinicians, Pain Management, Special Techniques

Graston Technique and Scar Tissue

The first step in treatment is to identify scar tissue. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. Picture below.

During palpation, fibrosis will feel gritty or knotted. At OrthoWell/WalkWell, we use instrument assisted soft tissue mobilization (IASTM) and manual scar release techniques to “break up” restrictions. This deep massage creates a reactive inflammation which “jump starts” healing. Keep in mind that inflammation can occur without healing, but healing cannot occur without inflammation. During the inflammatory stage, scar tissue can be reabsorbed by the body. During the fibroblastic phase of healing, the damaged tissue is replaced by new collagen. This new collagen is reformatted through proper exercise. This “process” can take 3-6 months in chronic cases. So what does the research tell us about IASTM?

Instruments of Assisted Soft Tissue Mobilization

Craig Davidson et al in “Morphologic and functional changes in rat Achilles tendon following collagenase and GASTM”, J Am College Sports Med, 1995;27 showed increased fibroblast proliferation in the IASTM group and stated that “the study suggests that IASTM may promote healing via increased fibroblast recruitment.”

Gale Gehlsen et al in “Fibroblasts responses to variation in soft tissue mobilization pressure”, Med Sci Sports Exer, 1999;31:531-535 showed morphological evidence indicating that “the application of heavy pressure during IASTM promoted more fibroblastic proliferation compared to light or moderate pressure.”

Mary Loghmani et al in a 2006 research project at Indiana University (pending publication) revealed that “ligaments treated with IASTM were found to be 31% stronger and 34% stiffer than untreated ligaments” using Graston Technique instruments.

As a result of almost 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of soft tissue lesions is the proper release of scar tissue. Rehabilitation is accomplished through the functional integration of deep massage, strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration.

Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!

David Graston’s SASTM technique:

Graston Technique demonstration:

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