ART gets you better – QUICKER!!

Active Release Technique or ART is a patented and proven manual therapy technique that can speed recovery from injury or surgery. ART can alleviate symptoms that have been unresponsive to other treatments. Certified practitioners for the NBA, NFL, PGA Tour, and Ironman events utilize Active Release Technique. It is a hands-on system that allows the practitioner to diagnose and treat soft tissue injuries and peripheral nerve entrapments. ART uses the fundamentals of anatomy and biomechanics to determine and to treat dysfunction in the system. The “touch” is developed through a comprehensive certification process. At OrthoWell/WalkWell, we are certified in Active Release Technique.

So how does it work? As repetitive injury or cumulative stress occurs to soft tissue, the normal longitudinal arrangement of fibers can become disrupted via the haphazard and erratic formation of scar tissue. Stretching a muscle with scar tissue only stretches the area above and below the “knot”. Hence, more stress occurs at the point of dysfunction. ART entails the application of specific pressure via one’s thumbs or hands on an area of fibrosis or adhesion as the patient actively or passively moves through a specific, guided range of motion. The “knot” will release through the applied tension.

SO WHAT DO OUR PATIENTS THINK ABOUT ACTIVE RELEASE?

After 13 months of suffering through debilitating left hamstring pain, I had given up hope. Two courses of PT and multiple trips to my primary and orthopedic specialist brought little relief. WalkWell changed all that! Throughout the entire process of evaluation and treatment, I believed from the start that I would one day be painfree. Today, I have never felt better!”
Chad Konecky, Program Manager for ESPN

GRASTON versus Scar Tissue!! Any bets??

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 may use Graston’s instrument assisted soft tissue mobilization (IASTM)  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 or re-growth 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!

Graston Technique:

Are you SURE it’s plantar fasciitis?

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 population becomes heavier, more de-conditioned, and more susceptible to concurrent orthopedic dysfunction, the chance of referred symptoms arising from the low back and/or a pinch along the sciatic nerve is greater. If your symptoms 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. You may be instructed to return to PT when you 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.  The “double-crush” means that you are more susceptible to nerve entrapment in one area if you already have an entrapment in an adjacent area.  A pinched nerve in your low back due to a herniated disc may make you more vulnerable to a “pinch” along the sciatic nerve as it courses through the lower part of your leg.   Active Release Techniques, as performed at OrthoWell/WalkWell, are very effective in resolving these entrapments.

The importance of closed-chain exercise.

Closed chain exercises for the lower extremities (exercise with you feet contacting the floor) should be an integral part of your rehabilitation program.  They are important in terms of regaining dynamic stability and improving neuromuscular control.  Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities.  An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups.  A patient recovering from an ankle sprain should perform balance board activities.  In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain.  Open chain exercises such as straight leg raises should be performed in every plane of motion.  Closed chain exercises should incorporate multi-planar strengthening as well.  The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge.  Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get you better- FASTER!  The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell.  After only 10 visits, I have made more progress than in the 15 years combined.  The individual attention and rehab is without peer.  And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA

OUCH!!…My shoulder hurts!!

Shoulder pain is the third most common musculoskeletal disorder, following low back and neck pain (Donatelli). Because of the mechanical demands placed on the shoulder, it is susceptible to numerous soft-tissue injuries. One of these injuries is called shoulder impingement syndrome. It is the result of compression of the soft tissues i.e. most typically, the rotator cuff tendon, within the sub-acromial space. Impingement results from the cumulative stresses of repetitive shoulder motion such as pitching or sustained overhead activity such as painting. This repetitive stress can lead to tendonitis, rotator cuff tears, bone spurs, or bursitis.

Impingement syndrome can be classified in two ways – external vs. internal and primary vs. secondary. An external impingement affects the superior surface of the humeral soft tissues in the sub-acromial or coraco-acromial region. Applicable clinical tests include the Neer and Hawkin’s/Kennedy tests. An internal impingement may affect the undersurface of the rotator cuff, the posterior labrum, and is, more specifically, a post/sup impingement. Clinical exam may produce post/sup shoulder pain with passive ER which can be alleviated with a passive posterior humeral glide. A primary impingement is caused by the structural anatomy of the sub-acromial region. X-Rays can determine an abnormal variation in the shape of the acromion process. A type 3 “hooked” acromion may require surgical intervention to correct. On the other hand, a secondary impingement is the result of dysfunctional biomechanics of the shoulder joint. It may be due to weakness of the rotator cuff muscles, poor posture, gleno-humeral joint stiffness, thoracic hypomobility, and/or in-coordination/weakness of the scapular stabilizing muscles. And that is what WE treat at OrthoWell?

“I play tennis and developed pain in my shoulder so strong that I could not even sleep, let alone play! After the very first treatment (ART combined with joint mobilization) 80% of my pain was gone! I am practically pain free now after 4 visits. Thank-you Chris! Great job!” – DK

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.

Shoulder Exercises: The Evidence

Everything we do at OrthoWell is evidence-based! Maximizing results in minimal time depends on the expertise of the clinician. As our knowledge of biomechanics and muscle function improves, more of an emphasis is placed on scientifically based rehabilitation protocols. This is particularly true regarding the shoulder and scapulothoracic complex. In the February 2009 volume of JOSPT, Mike Reinold, the Boston Red Sox team physical therapist, presented a thorough analysis of the shoulder and scapular stabilization exercise literature. One of the most effective exercises for each muscle will be presented.


Supraspinatus
*Full Can Exercise
*Enhances scapular position>
*Decreased deltoid compared to empty can
*Minimizes superior humeral translation

Infraspinatus/Teres Minor
*Side-lying ER
*Minimal capsular strain
*25% increased EMG using towel roll
*Highest EMG for infraspinatus

Subscapularis
*IR at 90 deg abd
*Position of shoulder stability
*Enhanced scapular postion
*Less pectoralis activity than 0 deg abd

Serratus Anterior
*Push-up with plus
*Easy position to resist protraction
*High EMG activity
*Also activates subscapularis

Lower Trapezius
*Prone full can at 135 deg abd
*Full can = horiz abd with ER(thumbs up)
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Middle Trapezius
*Prone Full Can at 90 deg abd
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Rhomboids
*Prone Row
*Below 90 deg abduction
*High EMG activity
*Good ratio of upper, mid, low traps

Combo Exercise
*Bilateral T-band ER
*25% increased EMG ER’s with towel roll
*Good ratio upper:lower traps per McCabe
*Emphasize scapula retraction and post tilting

In addition, it is clinically imperative to ensure proper technique during all therapeutic exercises especially as your patient is progressed to plyometrics, closed chain UE exercises, and sport- specific exercise training. Proper exercise TECHNIQUE and proper exercise CHOICE is required to effectively treat the muscular imbalances seen in most shoulder pathologies.