I have treated a lot of foot pain over 22 years as a physical therapist. Because I make custom foot orthotics, I am exposed to foot ailments much more than other PT’s. Geoff and I treat a lot of these problems in the clinic every day. One of my patients even went so far as to nickname us the “foot whisperers” and another patient coined OrthoWell as the “doctors of knotology”. Can you feel the love? I have spent a lot of time researching the BEST strategies to treat foot pain. This has culminated in the release of my Ebook entitled “Physical Therapist Discovers the Truth about Plantar Fasciitis“ as well as my self-help DVD on the treatment of Foot Pain & Plantar Fasciitis. Both of these are now available and are on my HOMEPAGE.
The Ebook includes a complete review of the literature on the treatment of plantar fasciitis as well as a description of the the most effective treatment strategies. This book is not a re-tellling of on-line information about plantar fasciitis. It is the missing link! You can read more by clicking HERE.
The DVD is a collection of videos that will “take you by the hand” and teach you specific methods and exercises to resolve your foot pain. It is designed for those people suffering from foot pain who cannot come to see us or who have not responded to other practitioners. It is a great way for our SUCCESS STORY patients to help friends and family members who have foot pain but cannot come to see us directly. You can read more HERE. Watch the intro video below. Talk to you soon!!
What do you think of when you visualize someone who is really stressed out? It sure seems like some people are wound tightly these days. I have had my own issues with stress. I’m sure you have too. I find myself talking more and more with my patients about the effects of stress and how beneficial diaphragmatic breathing and proper nutrition can be. We will discuss nutrition in an upcoming post. You also need to be aware of other possible manifestations of stress like increased muscle tone, rapid heart rate, palpitations, increased blood pressure, GI distress, mood swings, loss of appetite, and sleep disturbances to name just a few. These symptoms make living a happy, relaxed and “normal” life much more difficult.
So what about the relationship between stress and breathing? Breathing occurs at a very primal level. If you don’t breathe, you don’t live! Your body will do whatever it takes to draw air into the lungs. Instead of using the diaphragm, it may recruit other accessory muscles in your neck or low back. This pattern reinforces poor posture and causes impaired flexibility which can promote shallow, ineffective breathing. It prevents the ability to exhale fully and to perform a proper, full diaphragmatic breath. Lets review what that means.
First of all, when performing a diaphragmatic breath, your belly should expand outward. This is due to the downward movement of your diaphragm as you inhale. Secondly, your lower ribcage should expand. Thirdly, your upper ribcage will expand during a maximal inhalation. Your ribcage should expand as a unit. It should NOT elevate. Movement of your ribcage upward, shoulder shrugging, or contraction of your neck muscles are all signs of faulty breathing patterns. Remember that slouched sitting and forward head posture encourages shallow breathing and prevents full, complete expansion of your ribcage. We discussed breathing pattern disorders in relation to CORE activation during my last post and video demonstration. Here it is in case you missed it:
So what does the research say about the link between pain and breathing disorders? A very interesting phenomenon is the prevalence of pain syndromes that are NOT caused by a specific organic illness. Katon & Walker (1998) noted that patients with the most common physical symptoms (i.e. abdominal pain, chest pain, headache, back pain), are responsible for half of all primary care visits in the USA, and yet only 10%–15% of these are found to be caused by organic illness! All these symptoms are well recognized as capable of being the result of breathing pattern disorders.
Perri and Holford (2004) evaluated 111 patients attending a chiropractic pain clinic and found 56.4% demonstrated faulty breathing on relaxed inhalation, increasing to 75% when taking a deep breath. 87% reported a history of various musculoskeletal pain problems. Based on this population, they observe that: “Chances are 3 in 4 that new patients seen today will have faulty breathing patterns.”
So what does the research say about the effects of breathing exercises on stress? Remember, stress reactions are controlled by our autonomic nervous system i.e. sympathetic and parasympathetic. Fight or flight? In Pal and colleagues, breathing exercises were shown to enhance the parasympathetic (inhibitory or calming) effects and decrease the sympathetic (excitatory) effects of muscles and nerves. They improve respiratory and cardiovascular function and improve both physical and mental health. Convinced yet?
So how do you begin breathing exercises?The first step is understanding that the relaxation response has to be relearned. You need to learn how to identify and turn off the stress response. As stated by Kabat-Zinn, “you need to learn how to replace negative thoughts and physical tension with regular practice of ‘calm stillness of mind and body’ “. Buddha is in the house! The next step is to schedule regular daily practice. You need to invest 10-15 minutes at least one time every day. According to Leon Chaitow, we need to “restore an energy-efficient, low chest, nose-breathing pattern with a relaxed pause at the end of exhalation”. He calls it “low slow nose breathing”. Initially, lay comfortably supported by pillows in a quiet room. Progress to sitting once a positive outcome is achieved in lying. You need to reinforce proper posture at home, work, and car and realize that breathing and relaxation techniques only help eliminate the symptoms, not the causes of stress. Be honest about making realistic lifestyle changes. The video below demonstrates a method that uses both breathing and physical relaxation techniques.
Remember that breathing drives everything that happens, both good and bad, throughout our entire bodies. So breathe right to live right!!
It may sound like a strange question but “do you breathe properly?” Breathing pattern disorders (BPD) are surprisingly common in the general population. They remain commonly under-recognized by health care professionals and can contribute to pain, fatigue, and dysfunctions in the lumbopelvic region i.e. your CORE!
Core activation remains a hot topic in physical therapy. The problem is that there is not a universally accepted strategy to achieve optimal stability. A decade ago, we started using the “abdominal hallowing” technique which I have talked about before. The abdominal hallowing was an attempt to isolate a key core muscle called the transversus abdominis in which you would “pull your navel in and hallow out your abdoman”. The original work done by Hodges and colleagues on the transversus abdominis also demonstrated simultaneous activation of the diaphragm muscle. The diaphragm, however, took a back seat and has often been ignored during core training. So how do we correct your BPD and “wake up” your diaphragm?
Your diaphragm is attached to your lower ribcage, thoracic wall, and lumbar vertebrae. When you breathe, the diaphragm contracts and pushes DOWN into the abdominal cavity. This movement causes a pressure change which draws air into the lungs. As a result of the contraction, intra-abdominal pressure increases and lumbar spine stiffness, hence stability, also increases. The diaphragm acts in coordination with the abdominal muscles, spinal muscles, and pelvic floor to create lumbar stability in all directions. This is what some refer to as “360 degree of stiffness.” The contraction of the diaphragm creates core stability from the inside-out. When you perform an abdominal hallowing or abdominal bracing you create stability from the outside-in. Professor Kolar and colleages performed two MRI studies of the diaphragm and showed that the diaphragm can perform dual functions of inspiration and stabilization simultaneously! The activation of the diaphragm was shown to vary greatly among individuals. This variability may be the reason why one person can resolve low back pain and another cannot.
Lets take a look at HOW you can activate your diaphragm while breathing and HOW you can enhance the benefit of your core stability exercises. Check out the video below.
First of all, I would like to apologize to everyone who is reading this article. I apologize for the fact that you have pain, whether chronic or acute, that may be as a result of unfortunate circumstances or the result of an inadequate health care system. Pain is very misunderstood even in the medical community. Chronic pain sufferers can be stigmatized because of this lack of understanding. Currently, one in four Americans have chronic pain. That’s 75 million people! I want to reassure you that there is an answer. There is a physiological reason WHY you have pain. I want to convince you that the pain you feel may not be coming from where you think and feel it is. You WILL get better. Let me explain your pain!
Anatomically, we are essentially all the same. Each of us has approximately 206 bones, 640 muscles, and 400 nerves in our bodies. Our spine consists of 24 vertebra which are attached via ligaments and muscles to our head at the top and to our sacrum and pelvis at the bottom. Each vertebra is separated from the next via our discs. At each vertebral level, there is a spinal nerve that exits a small hole called a foramen. This nerve is the connection between your spinal cord and the rest of your body. Each spinal nerve sends branches to specific locations in your body. They connect the muscles adjacent to your spine to the small nerves at the ends of your fingers and toes. Think about your spine as the tree and the nerves as all of the branches.
Your nerves respond to any and all types of stimulation such as touch, temperature, pressure, pain and relay a message thru the spinal nerve to your spinal cord and then up to your brain. Impulses and/or commands from your brain are then transmitted back down the spinal cord to the spinal nerve and out to the targeted area. This communication system is active ALL the time. Our brain determines whether we are consciously aware of it or not. For example, if you are running from a lion attack and step on a tack do you think your brain will tell you “Ouch! Stop. You stepped on a tack?” Hopefully not or else “Dinner is Served!” So what happens if something goes wrong with this system? What happens if this system becomes over-sensitive?
As mentioned above, we have 400 nerves in our bodies. That amounts to 45 MILES of nerves! So how does a nerve “talk” to the brain? At rest, a nerve is always “listening”. Every nerve has a certain threshold that, once surpassed, will generate an electrical signal (called an action potential) that will be sent thru the spinal nerve to the spinal cord and up to the brain. If the threshold isn’t reached, then the nerve just continues to “listen”. For example, how long does it take for you to shift your weight while sitting in the movie theater? The threshold of your “buttock nerves” has been surpassed when your brain tells you to shift your weight. This threshold is different for everyone. In the diagram below, you can see that that the resting state of the nerve is at a certain level while it is “listening”. After the action potential occurs, the nerve returns to its previous resting state. However, in certain circumstances, the nerve does NOT return to the previous resting state and the nerve remains in a heightened state. It is essentially MORE sensitive, or hypersensitive, and will fire an impulse much more easily.
After an injury, 1 in 4 people experience this heightened nerve state. Why? The answer has a lot to do with the individual’s response to stress. For example, people that get injured in a stressful environment such as a car accident, playing competitive sports, or a stressful job are 7-8x more likely to develop a chronic pain syndrome. In addition, emotional responses to the injury such as worry, fear, and anxiety perpetuates this stress cycle. To use the lion example above, this fear is like an ongoing emotional lion attack to the nerves of a chronic pain sufferer. The Kendall study found that the biggest predictor of developing chronic pain is FEAR! Fear that your pain will not go away. Fear that your life will never return to normal. All of these responses have one thing in common physiologically, they release both inflammatory chemicals and several stress hormones including one that I am sure you have heard of called ADRENALINE.
Throughout the length of our nerves, there are channels or pores that open or close in response to physical or chemical stimulation. They are called ion channels. The amount and type of ion channels are based on our genetic coding as well as what our brain THINKS we need to survive. Ion channels live for only 48 hours so the amount and type is always changing. When the channel is closed the nerve is “listening”. When it is open the nerve is “reacting”. During cold weather we produce more temperature sensitive channels. During times of stress or fear we produce more adrenaline sensitive channels. The more that we focus on the pain, the more that our brains perceive a threat and continue to send inflammatory chemicals and adrenaline into the area. This response is like a constant “knock on the door” of the ion channels. Regular ion channels stay open for milliseconds. Certain adrenaline channels can stay open for up to 5 minutes! As a result, the nervous system up-regulates and becomes much more sensitive. Can you see the physiological link now between your emotions and your nerves? The initial trauma or injury caused your pain, but it is your BRAIN that perpetuates the pain.
Logically, your next question would be “Is that what’s wrong with me” and “How do we know this?” The explanations are based on what we know about nerve science. We know that you have a pain syndrome based on your physical examination and what you have told us about your pain.
Your next question may be “Why did this happen to ME?” As I mentioned earlier, 1 in 4 people after a traumatic event develop chronic pain. The greatest predictor of chronic pain is uncontrolled acute pain from the injury. Medications, icing, rest, bracing are important strategies in the beginning. Our brain determines our pain tolerance and everyone is different in this regard. Having high levels of stress chemicals in our system not only perpetuates the pain cycle, it also leads to chronic fatigue, depression, mood swings, and sleep disorders to name a few.
So then, “What can we do to treat it?” Our objective is to determine what we can physically as well as mentally do to control your pain. The more that you understand your pain, the more control you have over your brain. Studies have been done that demonstrate a significant reduction in perceived pain just by understanding the physiological process. So re-read this article several times until you REALLY get it. Doing this means you are already moving in the right direction! Choosing the right medications is an important part of the healing process as well. Non-steroidal anti-inflammatories (NSAID’s) such as ibuprofen and Aleve may help. Medications such as Cymbalta, Lyrica, and Neurontin(Gabapentin) function by plugging the openings in your ion channels. Narcotics such as morphine can actually make nerve pain worse! As a side note, your brain can produce pain relieving chemicals that are 50x more powerful than any drug that your doctor can prescribe.
So how do we turn on our brains? As I mentioned earlier, education is the key. The more you know, the more you control. Secondly, choose your foods wisely. Tryptophan is an amino acid that cannot be produced by our bodies. It is a powerful precursor to the “happy” hormone our bodies produce called serotonin. High levels of serotonin can also aid in plugging holes in ion channels. Serotonin is also a precursor to melatonin which plays an important role in mood and sleep disorders. Foods with high levels of tryptophan are turkey, bananas, soy products, tofu, almonds, sesame seeds and walnuts. Lastly, the right type of physical activity is key to controlling your pain and normalizing your nervous system. “Move it or lose it!” certainly applies in this case. There is Gold Level evidence in the literature that aerobic activity performed daily for 10 minutes at 50% max effort can reduce chronic pain. Aerobic exercise cleanses our system of inflammatory chemicals and stress hormones. The most important things that our nerves need to heal are proper movement, adequate space to move, and lots of blood! Our nerves constitute 2-3% of our body weight and use 25% of our blood. The circulation to a nerve will be cut off if the nerve is stretched more than 7-8%. It is very important to determine what kind of movement and/or irritability is occurring in the nervous system. We call this nerve movement “neural dynamics”. Stretching a nerve is NOT something that you want to do. A qualified physical therapist will perform a thorough assessment of your neural dynamics and establish an appropriate plan of care to restore proper and painfree nerve mobility. Manual techniques such as soft tissue and joint mobilizations, Primal Reflex Release Techniques and spinal manual traction can also be beneficial. Hands-on techniques can help to retrain your brain and to desensitize the system. Proper diaphragmatic breathing is also key. If you don’t get enough oxygen, how will you feed your healing nerves?
Once again, I apologize to everyone who has read this article. I know that having pain every day must be very difficult and challenging. I want you to know that there is HOPE. Reading my article is only the beginning. Please let me know if we can help you further.
Yes. We treat a lot of plantar fasciitis. There is a lot of foot pain out there. While performing a literature review of heel pain in 2005 (follow this link to READ MORE), I made reference to several articles about the prevalence of heel pain. One United States study estimated that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. This disorder appears in the sedentary and geriatric population, it makes up one quarter of all foot injuries in runners, and is the reason for 8% of all injuries to people participating in sports. As many of you know, all that we do regarding foot orthotic fabrication and physical therapy is with good, evidence-based reason. I fabricate custom foot orthotics based on sound biomechanical principles and evidence-based research. Patients are always asking me “so how will foot orthotics help my plantar fasciitis?” Here is the answer! I have included both a clinical description as well as a more basic description in the video. This will allow you to refer your doctor and/or PT as well as a relative who may ask WHY or HOW we made your foot orthotics. I have included references for several articles that have had a profound influence on my treatment and fabrication philosophy regarding plantar fasciitis. I would like to share my insights with you.
It has been my experience that positive results can be achieved much more quickly for cases of plantar fasciitis using the combination of softer materials to cushion the foot in combination with stiffer, denser materials to redistribute pressures on the foot. My direct molding techniques produce a total contact orthotic which reduces weight bearing pressure on both the heel and forefoot. These findings for total contact orthoses have been confirmed by both Mueller et al10,11 and Ki et al12. As you can see from my samples on the video, I utilize softer materials as a top layer with the addition of a heel pad on the bottom. I reinforce the arch in order to redistribute pressures up against the talonavicular joint (or midfoot). I utilize a forefoot valgus post (higher on the outside of the forefoot) with a slight reverse Morton extension (ledge under toes 2-5) in order to plantar flex the first ray (big toe lower than the other four toes) and unload both the fascia and 1st MTP joint (big toe joint) As I tell my patients, the foot orthotic is only as good as the shoe you put around it. Our best results with the over-pronating foot are achieved via the combination of motion control shoes and custom orthoses.
In regards to prefabricated orthotics such as ALine, it is one-shape-fits-all and only utilizes rearfoot posting “to help align the leg from foot to hip” per the website. The concept of rearfoot posting for biomechanical control is a much debated topic in the literature. Forefoot modifications are not an option. It is also a very rigid material against a painful heel. It has been my experience that prefabs such as ALine or Powerstep are a good option for the younger, athletic patient.
Don’t forget, our custom foot orthotics range in price from $120 to $165. I direct mold, fabricate, educate and issue in one hour! All adjustments included. Our WalkWell guarantee since 1997!!
Research findings continued……
Research done by Kogler1,2,3 et al has been instrumental in determining the appropriate type of rearfoot and/or forefoot posting for foot orthotics for plantar fasciitis. Kogler showed that rearfoot posting had little effect on plantar fascia strain, forefoot varus posting increased the stress, and forefoot valgus posting actually decreased the strain. Kogler concluded that foot orthotics which raised the talonavicular joint and prevented dorsiflexion of the first ray were most effective in reducing the strain on the central band of the plantar fascia. I recently made orthotics for a patient who said her doctor issued bilateral heel lifts “to take the stress off of the fascia”. Kogler actually showed no change in plantar fascia strain using heel lifts. However, heel lifts have been shown by Trepman et al4 in 2000 to decrease the compressive forces in the tarsal tunnel. Benno Nigg5, a researcher in Canada, has also published over 200 articles on biomechanics. He has stated that based on his results, custom foot orthotics, on average, control only 2-3 degrees of motion. This would be his kinematic results, however, he has done a lot of enlightening research on the kinetic effects of foot orthotics. A little bedtime reading for you!
Paul Scherer6,7,DPM has published several articles on the effects of custom orthotics on the 1st MTP joint. The concept of maintaining the first ray in a plantar flexed position unloads both the 1st MTP joint as well as the plantar fascia. Howard Dananberg8,DPM has also written several articles on this topic. Doug Richie9,DPM has been a great resource for the evidence behind the treatment of plantar fasciitis as well as posterior tibialis dysfunction. You may have heard of the Richie brace. Dr Richie states that the “most effective foot orthotic for plantar fasciitis is one that hugs against the navicular and flares away from (or plantar flexes) the first ray.”
1.Kogler, G. F.; Solomonidis, S. E.; and Paul, J. P.: Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin. Biomech., 11: 243-252, 1996.
2.Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of wedges on loading the plantar aponeurosis, An in vitro study. J Bone and Joint Surg Am. 81:1403-1413, 1999
3.Kogler GF, Veer FB, Verhulst SJ, Solomonidis SE, Paul JP.
The effect of heel elevation on strain within the plantar aponeurosis: in vitro study.
Foot Ankle Int. 2001 May;22(5):433-9.
4.Trepman E, Kadel NJ: Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle Int 20(11):721, 2000
5.Nigg, B. Biomechanics of Sport Shoes. 2011
6.Scherer PR, Sanders J, Eldredge, DE, et al. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc 2006;96(6):474-481.
7.Scherer,P. Recent Advances in Orthotic Therapy. 2011
8.Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc. 1986; 76(11):648-52
9.Richie,D. Offloading the plantar fascia: What you should know. Podiatry Today, Vol 18. Issue 11, Nov 2005.
10.Mueller MJ, Hastings M, Commean PK, et al. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech 2003;36(7):1009-1017.
11.Mueller MJ, Lott DJ, Hastings MK, et al. Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. Phys Ther 2006;86(6):833-842.
12.Ki SW, Leung AK, Li AN. Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods. Prosthet Orthot Int 2008;32(3):356-362.
The sacroiliac or SI joint is the articulation between the bone at the base of the spine called the sacrum and the bones on both sides of the pelvis called the ilium. Refer to the picture below.
Over 22 years of physical therapy, I have treated many patients with low back and buttock pain who were diagnosed with an SI joint dysfunction. The difficulty with diagnosing an SI joint dysfunction is that the SI joint has no specific distribution pattern of pain. Pain directly over the SI joint does not necessarily mean that the joint itself is involved. SI joint pain can very often be referred pain from other structures such as the disc, nerve root, or facet joints of the lumbar spine. Many physical therapists or physicians attempt to diagnose an SI joint dysfunction through palpation of bony landmarks as well as assessment of SI joint mobility. There is only a very small amount of motion in the SI joint i.e. 2-3 mm or 2-3° of gliding or rotation thereby making an accurate diagnosis very difficult. In addition, evidence based research refutes the reliability and validity of accurately assessing bony landmarks and SI joint mobility. McGrath et al has published an article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized. Freburger and Riddleperformed a literature review looking at our ability to perform SI joint motion testing. They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests. Inter-rater reliability is essentially the ability for multiple practitioners to come to the same diagnostic conclusion. If you have multiple individuals perform the same test, the results should be the same. Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability. At present, the only acceptable method of confirming or excluding a diagnosis of a symptomatic SI joint is a fluoroscope guided intra-articular anesthetic block ie an injection directly into the SI joint. (Laslett et al) So how can I, as your physical therapist, assist in the diagnosis of an SI joint dysfunction? The answer: SI joint provocation tests!
Two recent studies by Laslett et aland Van der Wurff et al have demonstrated that there isn’t just one key or ideal SI joint provocation test. However, by performing several tests together, you can increase your sensitivity and specificity of detecting an SI joint dysfunction. Both studies reported that the accuracy of detecting SI joint dysfunction is increased if least 3 of the 5 tests are positive. Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint. Van der Wurff et al reported that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain. Interestingly, another study by Kokmeyer et alagreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire series performed together.
Combining the two studies, there are 5 provocation tests to perform when attempting to diagnose SI joint pain:
Thigh thrust/Femoral Shear test
SI Distraction Test
SI Compression Test
FABER / Patrick’s test
The following video will demonstrate these tests. I would like to thank Mike Reinold, PT for his blog information that was used to complete this explanation of SI Joint dysfunction. Check out the video below!!
CORRECTION: I would like to clarify the SI distraction test as described in Laslett. I believe that he considers the direct posterior shear of the innominates as a distractive force of the ilium away from the sacrum. I initially interpreted this test as a compression of the SI joint via a distraction of the ASIS’s. I guess it depends on HOW you apply the force to the ASIS’s. Also, the sidelying “compression” test needs to be performed in a straight, linear fashion as well in order to compress the SI joint. It is important to place a towel roll under the lumbar spine in women in order to prevent sidebending stress t the lumbar spine. In OMT, we use the sidelying position to “distract” the SI joint using more of a rotational force on the lateral edge of the ilium in order to “open up” and distract the SI to get a feel for joint play. As you can see, these tests are not definitive for exactly HOW they stress the joint but they are specific for a stressing maneuver TO the SI joint.
I would like to highlight one of the unique treatment techniques that we offer at OrthoWell. As many of you know, we spend a lot of quality time during our biomechanical evaluation trying to “figure things out”. This is the reason that several of our referring physicians call us “THINKERS”. We pride ourselves in determining your functional diagnosis. This diagnosis is what we use to develop your plan of care and to educate you in how to alleviate your pain or dysfunction. Many of our patients have seen several physicians or therapists before hearing about us. For this reason, we offer specialized evaluation and treatment services that our patients may not have heard of and that may be appropriate to alleviate symptoms that have been unresponsive to prior interventions. One of these is Nerve Mobilization or NeuroMobilization. So what is it?
What is NeuroMobilization?
NeuroMobilization or Nerve Mobilization is a technique that we utilize to treat nerves that may be adhered, irritated, or compressed. Many patients that have been unresponsive to other physical therapy and present with a chronic history of referred symptoms like pain, numbness, or tingling into the arms or legs may respond to NeuroMobilization. Every patient that presents with referred symptoms or pain that has been unresponsive to localized treatment receives a complete neural tension evaluation. Neural tension testing is a way for your therapist to determine the extent of nerve involvement. By mobilizing a nerve, we can determine, in combination with manual traction and sensitizing maneuvers, whether your pain is originating from the spine or the periphery.
We can then perform NeuroMobilization techniques utilizing controlled neural tension maneuvers to mobilize the nerve up and down. David Butler,PT, has been at the forefront of these techniques for over 20 years. Although we still do not completely understand the exact mechanism, he proposes that NeuroMobilization (what David Butler calls Neurodynamics) can accelerate nerve healing and quiet down what he calls an “altered impulse generating system (AIGs)”. These AIGs may respond to the oscillations of NeuroMobilization by enhancing circulatory exchange or ion transfer in and around the nerve. You can read more about the techniques and science in David Butler’s book The Sensitive Nervous System.
Here is a video that highlights a sciatic nerve tension test and Neuromobilization.
I cannot count the number of times over the past 22 years that patients have told me “I USED to have an arch, but not anymore”. Is it true that you can actually lose your arch as you get older? The answer: YES. So what happens? Many doctors attribute a loss of your medial arch height to a condition labled posterior tibialis tendon dysfunction or PTTD. Your posterior tibialis muscle lies deep under your calf and it’s tendon inserts into your midfoot. It is responsible for turning your ankle inwards and “reinforcing your arch height.”
PTTD typically presents as a progressive increase in tendonitis pain which can lead to partial or complete rupture. The loss of PTT integrity has been hypothesized to produce a gradual change in the alignment of your foot. However, recent evidence shows that a partially torn or ruptured PTT is NOT the definitive reason for an adult acquired flatfoot. Let me show you. A study by Yeap et al followed 17 patients who underwent a surgical transfer of the PTT to a different part of the midfoot in order to control a drop foot. At a 5 year follow-up, none of the patients had a clinical flatfoot deformity. In other words, “losing” the PTT tendon by attaching it to a different part of the foot did NOT cause a flat foot. In light of this one study, there is sufficient evidence to rebuke the PTT as the sole reason for an adult acquired flatfoot.
Another study by Deland et al attempted to produce an adult acquired flatfoot in cadaver models by cutting the PTT. This produced only a minimal drop in height. It wasn’t until they severed the ligaments and plantar fascia on the underside of the arch that a complete arch collapse was achieved. Researchers Chu and Myerson confirmed the results of this study as well. So the evidence is here. A major contributing factor to the loss of arch height as we age is the loss of ligamentous integrity in the foot.
Did you know that women are 3 times more likely to be diagnosed with PTTD? It is most frequently found in women in their 50’s. Although a definitive hormonal link has not been established, PTTD appears to peak during the perimenopausal period. An interestingstudy performed at USCin 2011 found that women with PTTD compared with a control group had significantly decreased endurance and strength of hip muscles. Strengthening your hips may help to strengthen your arch. More evidence that everything is connected!
Can you raise your arch by strengthening the muscles in your feet? Did you know that there are 18 muscles in the arch of your foot? What does the research tell us? In my previous article on running technique, I mentioned an article by Robbins who showed radiographic changes in arch height after runners ditched their shoes and started walking and/or running barefoot. This should be a very slow process, but many coaches and therapists advise walking barefoot on grass or sand as a starting point. Two other studies by Fiolkowski et aland Headlee et alalso show that when muscles in the arch weaken, the arch falls.
So what, specifically, can you do about your fallen arches?
Number 1 : Custom Foot Orthotics. You need to control the pain and unload the injured structures first. We are attempting to control some of the mechanical imbalances by fabricating foot orthotics that “hug” your midfoot. We utilize both rearfoot and forefoot posting (angling of the orthotic) in combination with motion control shoes to control your excessive motion. For more severe cases, some research shows better control of the twisting or internal rotation of the leg using braces such as ankle-foot orthoses. The Richie Brace is one example.
Number 2: Exercise!! Yes, it is very important. The articles above prove it. In order to “raise” your arch height with exercise, you need to be very consistent and compliant with your program. I have mentioned HOW to exercise in a previous post. I want to emphasize that, if you have flat feet, your arches will fall every time you stand or take a step if you don’t train yourself to prevent it. This means using the appropriate intrinsic muscles in your arch in combination with active joint repositioning. If you can master this, you will be in a constant state of muscle retraining and joint stabilizing while bearing weight on your feet.
You could then add barefoot walking on grass or sand as an adjunct to your program. My next post will highlight the research on the muscle training effects of minimalist shoes such as the Nike Free. Stay Tuned! Now, check out my videos on foot intrinsic training and an effective hip strengthening exercise called Clams.
WOW!! We have been really busy here at OrthoWell. Thanks to you-our awesome patients!! I have been a little sidetracked from my blog posts recently as I am SURE all of you have noticed and have “sorely” missed. With the help of my incredible crew we attended (with our treatment tables and elbow grease) one 5K, one half marathon, and one health care exhibition during the month of May. In the meantime, I have been very focused on bringing new life and a new face to my website. How do you like the snazzy, new look of this newsletter? You can see on our homepage how easy we made it to quickly view our clinic’s specialties and the things that set us apart from other physical therapy clinics. You can see how much more personalized and descriptive we made the website by adding our OWN pictures. We all felt like movie stars during the photoshoot. I have never before seen Geoff smile so much!?! The OrthoWell miracles continue!! With this post, I would love to introduce, with eager anticipation, my NEW LOOK at www.orthowellpt.com Please take the time to LIKE US if you like what you see. I also included a few pictures: Megh’s first and victorious half marathon run and Geoff and I healing the wounded at the Gloucester Twin Lights Half Marathon.
So how important is resistance training? I have had the privilege of working with one of my peers, a fellow PT, and strength and conditioning specialist, Mike Stare from Spectrum Fitness in Beverly, both professionally as well as personally. Mike helped to redirect MY fitness program while I was recovering from my knee injuries 1.5 years ago. Mike is on top of his game from a fitness training standpoint. He has devoted a lot of time and resources in developing an evidence-based approach to fitness and weight loss in ALL age groups. You can see this for yourself at his website. It is important for clients in a fitness program as well as our patients in physical therapy at OrthoWell to understand HOW to strengthen muscles.
The physiological principle of “overload” is what makes the difference between strength gains and stagnation. Resistance training is hard work! I tell my patients “If it’s easy, then you’re doing something wrong!” Is it true that people will lose 5-10% of muscle strength in every decade of life after the age of 40? Studies have shown that people can retain 100% of their muscle mass and strength from age 40 through their 80s with exercise! (Wrobelski, A. et al. The Phys and Sports Med, Sept 2011) You can read more on the Anti-Aging movement at Mike’s BLOG as well.
However, during exercise, you need to challenge your muscles physiologically. You need to provide a “load” that goes “over” your muscles comfort zone. In order for a muscle (including the heart) to increase strength, it must be gradually stressed by working against a load greater than it is used to. So how do you do this? There are many books and magazines such as Muscle Fitness that advocate all kinds of strategies for maximizing strength and muscle mass. Strength gains can be accomplished by performing a one-repetition maximum as well as via the typical 10 rep set approach. My approach, with the fine-tuning of Mike, is to instruct my patients in 2-3 sets of 8-12 repetitions per exercise. The most important factors to consider are the utilization of proper technique in order to isolate the specific muscle as well as to use the idea of the “loss of technical form” as your maximum output point. By the time you reach the 8-12th rep you should be tiring and on the verge of a loss of technical form. You should not work to fatigue as this will compromise your technique and become a safety concern. Regarding the frequency of strengthening exercise, studies show that strength gains are maximized at a frequency of 2-3x per week. The American College of Sport Medicine (ACSM) recommends working out a MINIMUM of 2x per week at an intensity that is equal to 70-85 percent of your one rep maximum (maximum weight you can use for one rep) for 8-10 reps and 1-3 sets. A program that comprises repetitions over 12 is considered endurance training. For cardiovascular benefits, the ASCM recommends exercising for a frequency of 3-5 times per week, at an intensity equal to 60-85 percent of your maximum heart rate for a time of 20-60 minutes. Research has shown that you’ll get the same beneficial results by exercising at 50-60% of your maximum heart rate that you would get exercising at an intensity 80% of your maximum heart rate.
At OrthoWell, as part of your physical therapy, we get you started on a strengthening program that targets your problem area. Finding the right practitioner to design a complete, individualized fitness program can be a very rewarding thing and Spectrum Fitness is definitely one of our choices. As Mike points out, “If there is one thing to do to improve the quality of life as we age, strength training would be it.”
For our athletes and runners, don’t forget that strength training has been PROVEN to enhance athletic performance. Read the following to get the facts!
-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”