Lower extremity injuries make up 66% of all sports injuries. One of the most common knee injuries is rupture of the anterior cruciate ligament or ACL. Recent data indicates that the rate of ACL injuries is rising rapidly.
Spring has sprung, but it sure didnt feel like it last week. So how do you feel when it is sunny and warm versus cold and damp? There may be a physiological reason why you feel down or painful on cold and damp days. Check out the posts below to see why.
I want to share with you what my staff and I have learned to maximize your health and wellness and to keep you up-to-date on the happenings at OrthoWell. So read on and let’s keep you on track.
HOW TO FEEL HAPPY & VIBRANT
No, I havent found the fountain of youth or am advocating that everyone apply for a medical marijuana card. lol. But…there are a few things that could make your body work more efficiently on good weather days as well as bad ones. Knowledge is power so I want to share a few things with you.
So WHY do you feel stiffer or more painful on rainy days??
A recent systematic review of the relationship between joint pain and weather found no consensus on the issue. However, several researchers have found evidence that a decrease in the barometric pressure associated with a storm front can increase the pressure inside your joints thereby potentially increasing your stiffness or pain.
A study published in the Archive of Internal Medicine in 2009 showed that Vitamin D levels have “plummeted” among ALL U.S. ages, races, and ethnic groups over the past two decades. Because there are such small amounts of Vitamin D in food, the only 2 ways to get adequate amounts is thru direct sun exposure or via supplements.Over the past 10 years, several researchers have found an association between extremely low vitamin D levels and chronic, general pain that doesn’t respond to treatment. Check it out HERE. So start taking your Vitamin D! Click here for a great source of Vitamin D.
EXERCISE-The Happy Drug
Did you ever notice how some people are addicted to exercise? There are good reasons for that (some bad if you push through pain…..) Exercise releases endorphins which are your body’s natural painkillers and “feel good” hormones. Read more HERE.
Turmeric-The Spice of Life
You may know turmeric as that yellow spice that is used in indian curry dishes. The active ingredient in turmeric that has been extensively researched and provides more health benefits than there is room on this page is curcumin. One of the main reasons people take curcumin is for its potent natural anti-inflammatory properties. It is important to take curcumin with a pepper based supplement to maximize the effects such as Pure’s Curcumin with Bioperine. You can read more about turmeric HERE.
So what should you take for supplements??
If you want even more information, then you could read my post on which vitamins and supplements are best for you. CLICK HERE.
GET RID OF SURGICAL SCARS
GET A FREE FACIAL FOR TRYING
Dear OrthoWell patients,
My name is Andrea Linn and I am currently a patient at OrthoWell PT. I just had an ACL reconstruction.
Prevent Your Pain from EVER coming back
Click the link to read about
this new option at OrthoWell
Our wellness maintenance program is for those of you who want consistency of care after being discharged from physical therapy in order to prevent any reccurence of pain. We have three different plans the we offer that you can read about by clicking the link above.
SUCCESS STARTS HERE!
The winter of 2015 had me shoveling so much snow on our alpaca farm. Spring into summer convinced me my sore shoulder wasn’t just going away. I quit “using” my arm as it hurt to even raise it. I procrastinated so long that I thought for sure I would have to have surgery. I was in such pain that I finally saw a surgeon. He strongly suggested I try PT and said he’d heard good things about OrthoWell. Talk about life changing! After 5-6 weeks of working with Chris and his team, I have to say that I’m calling this just short of a miracle! Everything was explained to me and shown to me in a clear and concise manner. I am looking forward to having my life back this summer, if that sounds dramatic, well, it is!
– Olivia Sanderson
WALL OF FAME
Here is the update on our Wall of Fame in Beverly. We are proud of our patients and the success that they have had. If you have previously provided us with a testimonial, we would love to take your picture with your therapist and hang it with your testimonial for display it in our clinic! Seeing is believing!
All the Best,
I have struggled over the years as to the importance of including toe flexor strengthening as part of a program for plantar fasciitis. Many researches agree that the potential causes of plantar fasciitis are just too numerous and multi-factorial. The evidence in the literature has not been conclusive and I have let many of my patient’s comments that “this is silly” when picking up marbles dictate my decision-making. I have slowly but surely, and I believe wrongly, eliminated this important exercise from my treatment approach. I have recently read several articles that have rekindled my enthusiasm for toe flexor strengthening. So why the change in heart??
I am always looking for ways to get our patients better…faster. I have written a book on plantar fasciitis called the Plantar Fasciitis Treatment Manual and it identifies ankle muscle weakness as a result of plantar fasciitis but not include the presence of toe flexor weakness. That is my oversight and I will correct that in the book. Yes, the literature does identify weakness of the ankle muscles and the toes flexor muscles with the plantar fasciits population, yet the research does NOT confirm any causative factor of this weakness on the development of plantar fasciitis.(1,3,4) It is the chicken or the egg conundrum. Unfortunately, there are theoretical assertions that the “flexor digitorum brevis muscle (the muscle directly underneath the plantar fascia) plays an important role in distributing pressure away from the plantar fascia” that are simply not supported by research. (2) Does this mean that we should not perform strengthening exercises? Let me provide some more evidence.
As we get older, we get weaker. We all lose muscle mass, we lose muscle fibers and, as a consequence, we see decreases in strength between the ages of 30 and 80 within a range of 20-40%.(5) Several articles have also shown that “older people” exhibit 24-40% less strength in the muscles of the foot and ankle(5,6,7,8). As a consequence of foot and ankle weakness, older adults are more susceptible to loss of balance, the development of foot and toe deformities and can be susceptible to overuse syndromes such as plantar fasciitis. (5,6,7,8) The biggest question that has not been answered when it comes to strengthening exercises for older adults is WHICH exercises are the most effective?
As a result, we have to rely on some common sense. If the muscles in our ankles and feet get weaker as we get older (proven!), then we should strengthen them to avoid plantar fasciitis. Right? Not necessarily. There is not a direct correlation between weakness and the development of plantar fasciitis but, then again, many people don’t believe that there is a direct correlation between human activity and climate change. My point is why should we wait to change our approach until it is conclusive – whether it be climate change or your plantar fasciitis?
(Courtesy of Freedigitalphotos.net)
CROSS FIT 101
First of all, you need to understand the difference between aerobic and anaerobic exercise. Aerobic exercise requires oxygen, is low powered and lasts for greater than 15-20 minutes. Anaerobic exercise, like Cross Fit, does not require oxygen, is high powered and each exercise lasts less than 2 minutes.
The Positives: Recent studies have shown that anaerobic exercise is a vastly superior protocol for fat burning than it’s less intense aerobic counterpart. There is evidence that shows that anaerobic exercise is evenly matched to aerobic exercise with regard to cardiovascular benefits. Check out the evidence in an article in the Journal of Strength and Conditioning. More evidence that comparable calorie burning effects can be achieved in half the time with anaerobic exercise.
The Negatives: Potential for INJURY! The article in the Journal of Strength and Conditioning also states that 16% of the participants dropped out due to “injury or overuse”. In addition, in 2011, the U.S. military, in conjunction with the American College of Sorts Medicine, advised soldiers to avoid CrossFit, citing “disproportionate musculo-skeletal injury risk.” You can read it HERE. In 2009, the US Military was encouraging training programs such as CrossFit. You can read it HERE. So what happened?
CrossFit goes out of its way to warn people that if they can’t maintain proper technique, they should back off. After all, the CrossFit mantra is “Mechanics, Consistency, Intensity”. Backing off , however, is a hard sell for many participants because workouts are viewed as a competition. The 2009 US Military study states that “Properly trained coaches are fundamentally important in both establishing an effective training program and developing proper movement mechanics in athletes.” It sounds like something, or someone, went wrong between 2009 and 2011.
So I guess the biggest question that you should ask (before joining a local Cross Fit gym) is WHO is running the classes and HOW they are trained. Make sure they at least have Level I or Level II Cross Fit training. A power lifting background is very helpful as power lifters are obsessive about proper form. Make sure you observe a class or two to witness how or if the instructor is scrutinizing and ensuring proper form. The proof is in the puddin’.
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.
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 Riddle performed 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 al and 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 al agreed 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
- Gaenslen’s 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.