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

Why does your knee keep on hurtin’?

As the adage goes “ The more treatments we have for something, the more we don’t understand the cause”, it seems that anterior (front) knee pain or patellofemoral (kneecap) dysfunction would fall into that category. We understand that a torn meniscus or torn anterior cruciate ligament requires surgery. So how about that nagging, chronic pain in the front of your knee. The kind of pain that returns on a whim and makes you think twice about returning to your break-dancing hey day at your nephew’s wedding. The kind of “twinge” that shrinks your confidence on the 18th hole of your company’s summer, for-boasting-rights golf outing. The reason—not as obvious. So here’s one for you, for boasting rights, of course. In Dye et al (AJSM 1998), the lead researcher decides that he would be the guinea pig in a “mapping” of pain responses during arthroscopic probing, WITHOUT anesthesia, of his anterior knee and patellofemoral joint. Ouch!! The authors rated the level of conscious awareness from no sensation to severe pain. They also subdivided the results based on the ability to accurately localize the sensation. So what did they find? They found that palpation to the anterior synovial linings and capsule (front aspect of the inside of the knee joint), retinaculum (ligament on either side of the knee cap), and fat pad (underneath the patellar tendon) produced moderate to severe pain. The most interesting thing about this study, besides the masochistic aspect, is that NO sensation was detected on the patellar articular cartilage (the underside of the kneecap) even in high level “chondromalacia” or arthritis of the undersurface of the kneecap. The implication of this study is that anterior knee pain is NOT caused by the patellofemoral or kneecap joint.

To take it a step further, Faulkerson et al (Clin Orthop 1985) reported a direct relationship between the severity of pain in the anterior knee and the severity of neural damage within the lateral retinaculum (ligament on the outside of the kneecap). They found that patients presenting with moderate to severe pain were found to have the highest degree of change in the neural tissues of the lateral retinaculum. Very interesting! I’m sure you would agree.

What this means for your therapy is that we can utilize manual therapy and taping strategies to address the neural and soft tissue changes in the lateral retinaculum.  KinesioTaping techniques can produce a “proprioceptive override” effect in which the stimulation of the tape on the skin can override and cancel out the pain receptors. This, of course, is an adaptive process that occurs through consistent intervention and compliance with a home exercise program. Let us show YOU how to get back control of your knee pain.

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

Foam Rolling Technique

As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.

The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.

1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.

2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.

3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.

4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.

5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.

6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.

7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.

Keep on rollin’

 

 

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

Low Back Pain – Part 3 – BEST Evidence-Based Core Exercises!

So what are the BEST evidence-based Core exercises?  

Evidence from random controlled trials of people suffering from low back pain show that core stabilization exercises result in significant improvements in pain and function(5,7) . However, the most effective combination of which muscles to target and which stabilization methods to utilize are still debated(1-11).  One technique that has been suggested is abdominal hallowing or “drawing-in” your navel to activate the transversus abdominis (TrA) muscle.  This technique has been shown to increase the cross-sectional area of the TrA(10), however, many exercise scientists are now advocating a method called “abdominal bracing”(demonstrated in my last post) in which ALL the abdominal muscles are recruited instead of just one(11). It should be the goal of core exercises to activate as many torso muscles as possible in order to ensure spinal stability and to prepare our bodies for the dynamic and often complex movements that occur during our daily activities.  So what does the research say about which exercises activate which muscles the best?

Numerous studies have used EMG to determine the greatest electrical activity of torso muscles during various core stabilization exercises.  In Escamilla et al(3), they used surface or skin electrodes to compare exercises such as traditional crunches, sit-ups, reverse crunches, and hanging knee-ups using straps to exercises using an Ab Roller/ Power Wheel and a device called the Ab Revolutionizer. What they found was that the activation of the upper and lower rectus abdominis(the “washboard” muscle) as well as both the internal and external obliques was the greatest with Power Wheel roll-outs and hanging knee-ups with straps.  Because research indicates that the internal obliques are activated in the same manner(within 15%)  as the tranversus abdominis(3), we can assume that these results apply to the TrA as well. The activation was least with a traditional sit-up!   In Okubo et al(8), they used both surface electrodes and intramuscular fine-wire to compare curl-ups, side planks, front planks, bridges, and bird dogs.  What they found was that the TrA was activated the greatest during front planks with opposite arm and leg raise and that multifidus activation was greatest with bridging.  Although core stabilization exercises should be performed in multiple planes of motion, these two studies highlight the enhanced activation that occurs during “face down” exercises such as front planks and roll outs.

The functional progression of exercises as well as training in all planes of motion are important aspects of OrthoWell’s core stabilization program. Our program will uncover your weaknesses and maximize your strength by progressing through successive levels of difficulty in all directions of movement ie anterior, posterior, lateral, and rotatory. Optimal development of the “local” system ie your functional neutral position and bracing technique(my last post) should occur before attempting to train the “global” or big muscle system.  Unfortunately, most people over-train the global system and need to be re-educated. So be patient as we take you by the “core” and steer you in the BEST, evidence-based direction.

The following videos are examples of some of our functional progressions for each plane of motion(sorry for the  occasional “sideways” view).  I demonstrate a particular exercise and then follow with an exercise of progressive difficulty. Functional progression is very individualized and requires skilled observation to determine competency.  Many thanks to two of my peers, Mike Reinold,PT and Eric Cressey for being very helpful in this regard.

Anterior Core Stabilization Exercises

Anterior/Posterior Core Stabilization Exercises

Posterior Core Stabilization Exercises

Lateral Core Stabilization Exercises

Rotatory Core Stabilization Exercises

1.  Allison GT, Mo4444rris 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.

10. Critchley, D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother. Res.Int. 7:65–75. 2002.

11. Kavic, N., S. Grenier,  S.M. McGill. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 29:1254–1265. 2004a.

 

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, 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 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 0 Comments All, Other, Pain Management, Patients

Heel Pain – The scientific facts!!

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.