What are we listening to this week? 

The Physio edge podcast with David pope. This week they interview Kurt Lisle about anterior knee pain. Here is our synopsis:

One of the things they empahasized right off the bat was that patellofemoral pain not only refers about the knee but also below or most importantly posterior to the knee. The fat pad had a tendency to refer more locally where is other structures can refer to other areas.

Aggravating factors for patello femoral dysfunctional pain tends to be flexion or activities involving flexion as well as compression of the knee and rest is in alleviating factor.

The fat pad pain tends to be to either side of the patellar tendon and sometimes directly under it. This can be aggravated by standing, particularly with the knee and hyperextension, which compresses the fat pad.

Patellar tendon pain tends to remain at the inferior pole of the patella on the tendon whereas patellofemoral pain has a tendency to refer more.

Physical examination pearls:

• Patellar tendonopathy alone generally does not have effusion present where as the patellofemoral or fat pad injury may.
  
• Is there pain in passive hyperextension? This generally can mean fat pad injury or potential he ligamentous injury.
  
• Visually you may palpate a thickened fat pad, particularly in females.
  
• Pain with passive motions generally points away from patellar tendon.
  
• Dialing in as to where and when they are having their pain is an important part of the functional evaluation.

Kurt likes to do a table top examination first to ensure functional integrity of the knee before jumping right to functional tasks. His concerns are (which are valid) is the knee up to the task you’re about to ask it to do? Good advice here.
He emphasizes the need to be systematic and consistent in your examination, no matter how you examine them. Develop a routine that you follow each and every time. He recommends passively looking at the knee in extension and 90° flexion.

There is a discussion on functional movement about the hip and pelvis, knee, and foot and ankle. Emphasis is made, for example at the knee, as to “is the knee moving medially and laterally or are the femur and tibia rotating mediately or laterally” in which is precipitating the pain?

“Catching” of the patella is often due to patellofemoral pathology such as a subchondral defect, slap tear of the chondral surface, or abnormalities of the trochlea of the femur.

Advanced imaging strategies are also discussed with a brief overview of some of the things to look for.

Finally treatment strategies were discussed. It is emphasized that identifying the specific activity or change activities that’s causing any pain he’s made as well as activity modification. We were happy to hear that footwear and its role in knee as well as hepatology was discussed as well as looking at occupational contributions to the pain.

There was emphasis on exercise specificity particularly with respect to if the problem was unilateral not giving “blanket” exercises for both knees but rather concentrating on the symptomatic side.

A discussion on the use of EMG and activation patterns was also entertained with some good clinical pearls here. More marked rather than subtle changes and activation side to side seem to be more clinically significant. In other words, with respect training, can they achieve similar levels of activation on each side with a similar activity (for example isometric knee extension with the leg bent 60°).

The judicious use of tape from a functional testing standpoint was interesting. Emphasis was made that tape is not a cure and will merely a tool.

All in all and informative, concise podcast with some great clinical pearls and a nice review of the knee and patellofemoral pain.

link to PODcast: http://physioedge.com.au/pe-029-acute-knee-injuries-with-kurt-lisle/

Congenital clubfoot anyone?

This gentleman, a longtime patient came in for new orthotics, as his old ones were 10 years old. From the pedographs above, you can see it is his LEFT foot. 

Note the following:

• shortened apparent foot length left compared to right (the foot is merely deformed and plantarflexed)
  
• The increased plantar pressures laterally, from the foot being supinated 
  
• increased arch height L > R
  
• clawing of digits 2-4 to provide stability
  

This case made me think about some common issues that you may be wondering about if you see these folks. 

There are several things you should think about:

• People with clubfoot generally have a high arched, rigid, cavus foot. 
  

• These folks generally are fixed in some degree of plantar flexion.
  

• Because of the plantar flexed posture of their foot, they generally have a loss of a ankle rocker
  

• If you utilize an orthotic with these patients, you need to make sure that there is significant ramp delta (heel higher than the 1st metatarsal)
  

• Clubfoot can often be unilateral.
  

• Clubfoot is usually not congenital
  

• Gait training and balance (proprioceptive) work can be especially helpful in these cases. 

Which sports burn the most calories?→

Photo: Gallo Images/iStockphoto  

Look at this photo. Do you see it ? How much posterior rotation (left rotation) is being driven through that left shoulder/torso rotation. That is nuts! We have a hard time believing that is not a compensation. We would be assessing for stability and mobility issues elsewhere. Heck, the elbow practically crosses the spine posteriorly ! Sheesh ! When you cannot put the movement where it should be, or control it (stabilize) where it should be controlled, sometimes you try to get it or put it elsewhere. We would love to see this lady run, we bet there is a host of clean gait problems down below. We would bet some cross over gait is present as well, after all, that left arm swing is largely predicated off of the right leg swing. Arm swing is far less independent than people think, we have written about that here on our blog numerous times. Just search “arm swing” over on our Tumblr blog.

Remember this, and if you need to go back to read about phasic and anti-phasic gaits head over and search our blog, but the amount of shoulder “girdle” (essentially thoracic rotation) is typically met by the same amount of pelvis rotation. These should be symmetrical. And, when they are not, we can drive it through various means, even as in this case, through more arm swing unilaterally. We wish we could see some axial photos from above to see how much pelvis rotation is noted  here.

Just some brief thoughts from Dr. Allen

Photo link attributed to owner: http://africanspotlight.com/wp-content/uploads/2016/03/CdBVhTzUkAELVp6.jpg

Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

Podcast 103: Effects of Cold on Physiology/Athletes

Using Cold adaptation to your advantage, Walking Rehab “Carries”, Walking and Proprioception.

Show Sponsors:
newbalancechicago.com
Softscience.com

Other Gait Guys stuff

A. Podcast links:

direct download URL: http://traffic.libsyn.com/thegaitguys/pod_103f.mp3

permalink URL: http://thegaitguys.libsyn.com/podcast-103-effects-of-cold-on-physiologyathletes

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show Notes:
Cold
Switching on a cold-shock protein may restore lost connections between brain cells & memory function in aging brain.  
http://www.bbc.com/news/health-30812438

-“Connections between brain cells - called synapses - are lost early on in several neurodegenerative conditions, and this exciting study has shown for the first time that switching on a cold-shock protein called RBM3 can prevent these losses.
http://www.pnas.org/content/111/20/7379.abstract

New study in mice in the inaugural issue of Brain Plasticity reports that new brain cell formation is enhanced by running.
http://neurosciencenews.com/neurogenesis-exercise-memory-3165/

Walking changes our mental state, and our mental state changes our walking.  60 sec audio clip.
http://www.scientificamerican.com/podcast/episode/bouncy-gait-improves-mood/

http://www.sciencedaily.com/releases/2015/…/151119122246.htm

Walking. You don’t have to have the pedal to the metal.
"Those who walked an average of seven blocks per day or more had a 36%, 54% and 47% lower risk of CHD, stroke and total CVD, respectively, compared to those who walked up to five blocks per week.”

http://www.sciencedaily.com/releases/2015/…/151119122246.htm
New proprio study:
http://www.nature.com/neuro/journal/v18/n12/abs/nn.4162.html
Piezo2 is the principal mechanotransduction channel for proprioception
Seung-Hyun Woo et al,
Nature Neuroscience 18, 1756–1762 (2015) doi:10.1038/nn.4162Received 14 July 2015 Accepted 13 October 2015 Published online 09 November 2015

Magnesium intake higher than 250 mg/day associated with a 24% increase in leg power & 2.7% increase in muscle mass.
http://onlinelibrary.wiley.com/doi/10.1002/jbmr.2692/full

Dietary Magnesium Is Positively Associated With Skeletal Muscle Power and Indices of Muscle Mass and May Attenuate the Association Between Circulating C-Reactive Protein and Muscle Mass in Women

Ailsa A Welch et al.
http://www.readcube.com/articles/10.1002%2Fjbmr.2692?r3_referer=wol&tracking_action=preview_click&show_checkout=1&purchase_referrer=t.co&purchase_site_license=LICENSE_DENIED

Gray Cook
https://duker2p.wordpress.com/2015/11/16/illuminating-insights-gray-cook-part-1/

Carries, lots of carries
https://www.facebook.com/otpbooks/videos/1004044686323688/

And what have we been saying? parallel processing seems to be OK (balancing and reading), but dual or multitasking has its hazards…

• decreased speed of movement. not surprising because of the dual tasking
• increased ankle dorsiflexion (not necessarily a bad thing. This is probably to create a wider and more stable base through pronation
• reduced cadence
• decreased stride length

we were surprised there was not a increased “base of gait”, as balance requirements increase, gait usually decomposes (see here for a cool post and video we did on this a while ago)

“Numerous studies have analyzed the impact of dual tasks—specifically, tasks that cause cognitive distraction—on gait. With regard to texting as a dual task, many studies have consistently found that it does have an effect on gait, and that’s mostly to slow a person down.

For instance, Italian researchers in the Journal of NeuroEngineering and Rehabilitation assessed 18 healthy young adults who did not have problems with vision, or neurological or musculoskeletal disorders that could affect their gait.3 Barefoot participants walked a straight path of 15 meters (about 50 feet) for three minutes under two conditions: walking alone and walking while texting.

They found that texting while walking differed from walking alone in terms of muscle activation, kinematics, and spatiotemporal variables. Texting was associated with delayed activation of the gastrocnemius lateralis muscle and slightly increased ankle dorsiflexion followed by slightly reduced plantar flexion. It was also associated with a slower gait speed, reduced cadence and stride length, increased flat-foot contact, and decreased push-off. The researchers also found increased co-contraction of the ankle antagonist muscles during what they called the “critical” gait phase—from load response to midstance, corresponding to the transfer of body weight from one leg to the other.”

its a short one. Take the time to check it out…

link to article: http://lermagazine.com/cover_story/texting-while-walking-gait-adaptations-and-injury-implications

Using a boot to heal a bone, tendon, post-op ?  Think deeper please.

Please please, please ! If you are going to put your client in a CAM rocker boot/shoe for a fracture, or post-op can you please try to level out the leg length discrepancy caused by the thickness of the boot’s sole ? Please ? Pretty please with sugar on top?

Some boot brands have a huge midsole thickness. This leads to a functionally longer leg length. If they are barefoot much of the day, there will be a huge leg length discrepancy. If in shoes all day, you can offset this with a sole lift in the healthy foot’s shoe or you can add something like this to the outsole. Use common sense. IF someone is in a CAM boot for 6 weeks and thus a longer leg, this is going to promote a knee flexed posture on the boot side (ie. shortens the leg) and/or hyperextension of the healthy leg’s knee, supination of the foot, more forefoot habitus (sustained calf loads) and even frontal plane lurch pelvis gait mechanics (this is why many folks will get opposite hip pain). These embedded gait flaws must be addressed and remedied after they are out of the boot to reset normal gait. We have seen enough problems come to our offices that are suspect as a result of prolonged boot use and failure to reteach normal gait patterns, meaning, to reduce the learned gait behaviors of being in a boot for prolonged periods. Gait retraining is just as important as the rehab post-boot removal.  Of course, this is rarely done.  Using logic is never a bad thing.   

Dr. Shawn Allen, one of the gait guys

Here is a neat device we found to help.http://www.braceshop.com/procare-evenup-shoe-balancer-walker-system.htm?gdftrk=gdfV28018_a_7c2568_a_7c10961_a_7c32290&gclid=Cj0KEQiA37CnBRChp7e-pM2Mzp0BEiQAlSxQCCeL74AvCkYXbQX_jV1jEP27mfocB87f8pSfbo2PZMIaAsOV8P8HAQ

Medial longitudinal Arch age stablization.

It seems to depend on what source you read as to when the MLA (medial longitudinal arch) stabilizes, but here is a number, between 7-9 years old. 

Conclusions: The MLA of children remained stable from 7 to 9 years old. Gender and the type of footwear worn during childhood may influence MLA development.

Reference:

Medial Longitudinal Arch Development of Children Aged 7 to 9 Years: A Longitudinal Investigation.Jasper W.K. Tong, Pui W. Kong Journal of American Physical Therapy Assoc.   DOI: 10.2522/ptj.20150192 Published February 18, 2016

http://ptjournal.apta.org/content/early/2016/02/17/ptj.20150192

Medial knee pain in a skier.   Considering an orthotic?  You had better know what you are doing! 

Can you guess why this gal has pain in both knees? Especially when skinning up a hill and skiing down? 

 Take a close look at the photos above and notice the orientation of her knee with her foot. Now look at you tuberosity and drop a line straight downward.  This line should pass through or slightly lateral to the second metatarsal shaft. Can you see how it falls to the outside of this? Perhaps even between the third and fourth metatarsal?

This gal has bilateral internal tibial torsion.  When she wears a standard foot bed (creates a level surface for the right for the foot) or an orthotic without appropriate posting, it pushes her knee outside of the saggital plane. This creates abnormal patellofemoral tracking  and appears to be a major contributor to her pain. 

 You will notice that we placed a valgus post under the orthotic(  a post that is canted from lateral to medial) which pushes her knee to the midline as the first ray descends.  You can see her alignment is better with her boots on and the changes. 

 The bottom line? Know your torsions and versions.  Posting a patient like this incorrectly could result in a meniscal disaster!

Lower limb muscle strategies in low back pain patients.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. It is possible that your client may be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired. This problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges.

So you have sporadic low back pain and knee pain. Could they be linked ?

It has been a long believed rule that it is “all about the core”.  We have learned in recent years that this should be a very loosely accepted rule. 

In an old blog post (link) we stated some deeper truths:

Dr. McGill discusses the basic tenet that the hips and shoulders are used for power production and that the spine and core are used for creating stiffness and stability for the ultimate power transmission through the limb.  He makes it clear that if power is generated from the spine, it will suffer.  As gait experts, you should never forget this principle, if the spine and lumbopelvic interval is not strong/stiff and stable enough, the limbs can over power them and thus your gait, your running, your sport, could be causing you pain as the forces are poorly managed as they attempt to traverse the spine. 

Here we find a study referenced below that suggests that when the lumbopelvic interval is fatigued, that the lower limb muscles may step up activity.  This is a neat concept, not earth shaking by any means, but it nice to have studies that help solidify knowledge of compensation strategies.

“Individuals with low back pain (LBP) have been shown to demonstrate decreased quadriceps activation following lumbar paraspinal fatigue. The response of other lower extremity muscles is unknown. The purpose of this study was to determine changes in motoneuron pool excitability of the vastus medialis, fibularis longus, and soleus following lumbar paraspinal fatigue in individuals with and without a history of LBP.” 

What this study attempted to do was perform a controlled laboratory study designed to compare motoneuron pool excitability before and after a lumbar paraspinal fatiguing exercise. Twenty individuals (10 with history of low back pain) performed isometric lumbar paraspinal exercise until a 25% shift in paraspinal muscle surface electromyography median frequency occurred. 

What they discovered was that the soleus motoneuron pool excitability increased following lumbar paraspinal fatigue independent of group allocation and occurred in the absence of changes in vastus medialis or fibularis longus muscles. 

The authors propose that “increased soleus motoneuron pool excitability may be a postural response to preserve lower extremity function”.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. They very well could be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired.The problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges. 

Dr. Shawn Allen, one of the gait guys.

Reference:

J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain.Bunn EA¹, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

http://www.ncbi.nlm.nih.gov/pubmed/21388827

What have we listened to lately? Patello Femoral Pain!

The David pope Physioedge PODcast with  Dr Micheal Rathleff talking about adolescent patellofemoral knee pain, which has a prevalence of 6 to 7%. 

Here is our summary: 

Two thirds of the population do sports five times per week and often do the sports with pain. This group (adolescents) has usually been doing one sport their entire life and has had pain on and off. The other third of the population are adolescents who do not play sports at all. This group often are going from primary secondary school and encounter a lot of stairs or increased amounts of activity which is believed to contribute to the condition. So the majority are increased intensity or frequency of load whereas the other one is increased load only.

For the first group, playing in identifying with the sport is part of their social network and they would rather play with pain than be excluded.

One of the questions was “is there a different treatment protocol for each group”? 

The short answer is no. Many times and adolescent in the “overuse” group is given additional exercises. Often this just contributes to increasing load. Education appears to be key in the rehab process. Males with the shortest duration of pain and lowest intensity seem to be the best responders to this program. Females with longest duration and highest intensity of pain seem to respond the least.

Not surprisingly, compliance with treatment protocol can be difficult with a teenager. In a recent RCT that they performed, 55% of folks that did their exercises three times per week were recovered in one year whereas those that did less were at 20%.  These statistics are often put on the chart, laminatedand shown to the patients. This seems to improve compliance.

Another chart is made with these bullet points: 

• Low hip strength
• low quadricep strength
• different movement pattern. 

The anatomy is then shown and explained to the patient and an attempt is made to tie it all together.

Differentiation is made between: patellofemoral pain, Osgood-Schlatter’s disease, and patellar tendinopathy. The differentiating factors are with patellofemoral pain, the pain is diffuse; with Osgood-Schlatter’s it’s located over the tibial tuberosity and with patellar tendinopathy it is more at the inferior patellar pole.

Differentiation is always made between Sinding-Larsen-Johannsen disease and the others by the fact that this is mostly pain at the inferior patellar pole and relatively rare and adolescent population.

Differentiation between patellofemoral pain and Osgood-Schlatter’s disease usually involves the latter having locking in addition to pain. These conditions are usually confirmed with ultrasound or MRI.

There don’t appear to be specific reliable tests to rule in patellofemoral pain so the process becomes one of ruling out.

Palpation in the diagnostic process of course please large role. Also specific localization by the patient can be helpful. Dimension and “app” that the patient can draw on to show the examiner where the knee pain is. We really like this idea. 

Exclusionary tests include the patellar fat pad compression test, but it is emphasize that this is more generalized rather than specific to the Tele femoral pain and a brief discussion as to its anatomy ensues. 

Treatment includes 3 main steps

1. patient education as to activity limitations. 
2. Patient refrains from activities a check of the pain for approximately four weeks and then his gradually reintroduce as long as they can keep their VAS scores below three. 
3. Exercise can begin at the four-week timeframe, again depending upon the patient’s symptoms. A gentle progression with pain as a guide is advised with a return to activity previous activity as early as 5 to 6 weeks. Frequency of training is increased first and then duration of training.

Exercise initially is confined to the more proximal joints such as the core and hips.  They begin with open chain, theraband exercises (which we do not necessarily agree with). They also do RM testing 10 to 12 reps.some standardization is done with regards to therapy and length and amount of travel.

Compliance is discussed as adolescence often have an extensive social network. Exercise in 15 minute intervals is encouraged. Prognostically it shows that patients that can control their loads earlier tend to do better longitudinally.

Foot orthoses are discussed but it is pointed out that there is not a lot of data and research on their efficacy in an adolescent population for the telephone real pain. He goes on to talk about how a foot orthoses “takes your brain out of the equation” and can provide some degree of increased compliance albeit, passive. The orthotics are left in until they are “worn out” (they use a great expression:”until the natural mortality of the orthotic runs its course” which we loved ! and then see how the patient does.

Hip strengthening is discussed. It appears that adolescents develop weaknesses after patellofemoral joint pain,  not as a result of it. 

Other treatment modalities included “fat pad unloading tape”. A “v”  pattern is done with crossing at the tibial tuberosity. The Chris Barstann method is given in a YouTube link is provided. Plane “white tape” can be utilized for adolescents who hyper extend their knees, with the tape running behind the knee a few hours at a time.David talks about an anchor above and below the knee with an X pattern crossing at the middle of the popliteal fossa and having the knee in slight flexion.

So after the progression of one activity modification, two taping three therapy and exercises they then move onto hip strengthening with close chain exercises such as squatting and lunches.backpacks with different amount of weight totaling there 10 or 12 RM are then employed. Care is exercised to keep them in a pain-free range. When they can accomplish this then they move onto one legged work

Stretching was deemphasized because of the increased compression at the patellofemoral joint.

Guidance as to speed, frequency and ranges of motion of exercise are carefully given to each patient. Eight seconds of time under tension for each repetition using a thorough band (three second concentric, two second isometric hold, three second eccentric) adding up to 80 seconds for each 10 repetitions. This allows good proprioceptive control because of the long contraction and increased exercise dose. They often use a “smart phone” to video the exercise for the patient (with the doing this for years and it’s a great way to assist in compliance; a person may lose a sheet of paper or their keys but they will not lose their phone).

All in all, an informative PODcast for those who have a deeper interest in treating PFP in the adolescent population.

The Gait Guys

link to PODcast:  http://physioedge.com.au/physio-edge-039-patellofemoral-pain-adolescents-dr-michael-rathleff/

Heat Exertion and Gait Decline

Changes in gait characteristics are found when exertional heat stress is experienced during prolonged load carriage.  As heat stress increased, step width decreased while percent crossover steps increased. Reduced stance time variability, step width variability, and percent crossover step were observed.  These are frontal plane gait parameters for the most part. 

Think about these things during your long summer run or as you go deeper into those last miles of your long run.  Simple muscular fatigue in the frontal plane hip-pelvis stabilizers are going to render the same results.  This is quite possibly why many problems and injuries crop up in the latter miles of your run. 

Reference:

Gait Posture.

2016 Jan;43:17-23. doi: 10.1016/j.gaitpost.2015.10.010. Epub 2015 Oct 23.Using gait parameters to detect fatigue and responses to ice slurry during prolonged load carriage. Tay CS, Lee JK, Teo YS, Q Z Foo PTan PM, Kong PW

We had a great PODcast in the studio last Friday, talking about tendon vascularity and compression vs tension therapies for tendinopathies.

Here is a great FULL TEXT article on tendon vascularity that can serve as a catalyst for designing your treatment programs

“Conclusions
Neovascularization is critical to tissue repair and wound healing. Therefore, strategies to enhance vascularization to promote regeneration are considered promising treatment modalities, i.e., the use of platelet rich plasma (PRP) to restore functional bone (Zhang et al., 2013) or skin (Kakudo et al., 2011). However, in acute or chronic tendon injuries hypervascularity often does not pave the way to functional recovery of the tissue. Therefore, to overcome the limited intrinsic regeneration capacity of tendon and to achieve scarless healing will most likely require a balanced manipulation of the angiogenic response in tendon tissue. For a variety of treatment methods, such as the use of PRP, the availability of clinical data is limited, due to heterogeneity in application (Khan and Bedi, 2015). In order to develop rational strategies to achieve a well-balanced angiogenic response following tendon injury, we need a thorough understanding of the molecular and cellular networks driving tendon vascularization and regeneration—a challenge for years to come.”

image from: http://www.slideshare.net/ShoulderPain/rotator-cuff-repair-23326992

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650849/

Ankle spains and hip abductors

We see it ALL THE TIME. But sometimes it is nice to point out the obvious, just in case you are not looking for it.
“Conclusions: Our subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar-flexion range of motion on the involved sides. Clinicians should consider exercises to increase hip abduction strength when developing rehabilitation programs for patients with ankle sprains.”-Friel et al
Dr. Allen: if the hip abductors are weak, the leg will posture more adducted (ie, cross over type pattern) and this places the foot more directly below the body midline plumb, this will posture the foot in inversion and thus at greater risk for future inversion sprains.  This sets up the vicious cycle of hip abductor weakness, frontal plane drift of pelvis, inversion of the foot and more ankle sprain risks/events.  The cycle must be broken. The hip must be addressed. That lateral chain must be restored all the way up from the foot.  All stuff you likely already know, but good to find another study to validate.

Dr. Allen

J Athl Train. 2006; 41(1): 74–78.PMCID: PMC1421486Ipsilateral Hip Abductor Weakness After Inversion Ankle SprainKaren Friel,Nancy McLean,Christine Myers, and Maria Caceres
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421486/

Why don’t some folks pay attention to anatomy?

Movement isn’t important…until you can’t…

Grey Cook

Manipulation of a joint appears to change the instantaneous axis of rotation of that joint (1). It would stand to reason that this change would effect muscle activation patterns (2). Can this be applied to the lower extremity? Apparently so, at least according to this paper (3). 

“…The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.”

So, what does this mean?

The peroneus longus contracts from just after midstance to pre swing to assist in descending the 1st ray and assist in supination. The soleus contracts from loading response (medial portion, eccentrically, to slow calcaneal eversion) until just after midstance (to assist in calcanel inversion and supination). 

The tibiofibular articulation is a dynamic structure during gait, and the fibula appears to move downward during the stance phase of gait (rather than upward, as previously thought from cadaver studies)(4), with the distal articulation having a rotational moment (5). 

Consider checking the integrity of these joints, and asuring their proper ranges of motion, particularly in patients with chronic ankle instability (6). A little joint motion can go a long way : ) 

1. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint LaxityCraig R. Denegar, Jay Hertel, Jose FonsecaJournal of Orthopaedic & Sports Physical Therapy 2002 32:4, 166-173 

2. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee painSuter, Esther et al.Journal of Manipulative & Physiological Therapeutics , Volume 22 , Issue 3 , 149 - 153

3. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability.Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. J Electromyogr Kinesiol. 2011 Aug;21(4):652-8. doi: 10.1016/j.jelekin.2011.03.011. Epub 2011 May 4.

4.  Dynamic function of the human fibula. Weinert, C. R., McMaster, J. H. and Ferguson, R. J. (1973), Am. J. Anat., 138: 145–149. doi: 10.1002/aja.1001380202

5. Kinematics of the distal tibiofibular syndesmosisAnnechien Beumer , Edward R Valstar , Eric H Garling , Ruud Niesing , Jonas Ranstam , Richard Löfvenberg , Bart A Swierstra  Acta Orthopaedica Scandinavica  Vol. 74, Iss. 3, 2003

6. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle InstabilityJames R. Beazell, Terry L. Grindstaff, Lindsay D. Sauer, Eric M. Magrum, Christopher D. Ingersoll, Jay HertelJournal of Orthopaedic & Sports Physical Therapy 2012 42:2, 125-134 

What are we listening to lately?

We have been getting into David Pope and the “Physioedge” podcast.

This particular title piqued our interest talking all about plantar fasial pain. It is an interview with Michael Rathleff from Denmark. Michael works in the areas of patellofemoral research, plantar fascia research, and exercise.  

Approximately 10% of the population from 840 to 60 suffers from some sort of plantar fasciopathy. These people usually have jobs where they are upright and standing on her feet for extended periods of time.

Plantar fascial pain seems to respond better to loading-based therapies rather than stretching-based therapies,  due to the similarities between tendons and fascia . He emphasizes not to overlook educating the patient about their condition and taking the time to explain what’s going on. He then goes on to talk about activity modification in the treatment plan.

He classifies two major types of people who develop planter for shop: runners and people that are overweight ( repetitive loading versus constant loading).

Pain patterning is often threefold: 

1. pain during the workday

2. pain when they get home

3. pain after they get up after taking a rest for any length of time. 

So, how much can you reduce the loading and, how much does that reduce their symptoms?  With runners it’s a little easier as you can just tell them to reduce their mileage.

Some “rules of engagement” are given: runners need to be able to walk a 10K briskly, without pain before during or after or at three time frames when they had pain before. After this baby can begin a running program eight weeks of five k’s of continued running. Ching that yes this can take some time is important and offering the patient alternative means of exercise (cycling, swimming etc.) is important.

Running should begin with one minute running, two minute walking and repeating the cycle and a pain-free patch fashion. Pain should never exceed a 3/10 on the analog scale.

The distinction is made between plantar fasciopathy and plantar fasciitis with the former being more of a degenerative condition and the latter an inflammatory one. Palpation and thickening of the central portion of the planter fascia is emphasized in fasciopathy.

A link to some downloads with handouts, instruction, etc. is also provided within the podcast. 

Rehabilitative exercises focus on increasing loads. A simple calf raise with the toes of dorsiflexion using a town introduced. The patient begins with three sets of 12 RM done every other day for a few weeks with increased to an eight RM as they get stronger. Repetitions are three seconds up, hold for two seconds, three seconds down, hold for two seconds.

The pros and cons of this exercise are discussed: in short if you need high tensile loads across the plantar fashion then this exercise is key. This would be more for chronic conditions rather than acute ones which would probably require rest rather than loading. Up to six months the high load strengthening exercises seem to be superior to stretching and simple he’ll inserts, but after six months there appeared little difference between the two. Speculation was that most people probably discontinue the exercises because they were feeling better.

People that were more active or engaged in sports, at least in this RCT, seem to do better than folks that had the fascia apathy due to having a high BMI.

One study they cite looks at intrinsic musculature of the feet and legs as a contributing component to chronic plantar fasciopathy. It’s emphasized that an individualized program be designed for each patient.

All in all a nice evidence-based lecture/interview with some great clinical pearls. Consider adding a progressive loading program to your planter fasciopathy patients and perhaps consider adding intrinsic muscle exercises well.

http://physioedge.com.au/pe-038-plantar-fasciopathy-loading-programs-michael-rathleff/

Fatigue and exercise.

Do your clients do their home program exercise before activity ? We warn our clients about fatigue/endurance all the time. We will build capacity and durability on skills before we hit strength parameters all the time. We like to ensure that we get a durable pattern engrained before we challenge it with more strength challenges.
*However, do not let your clients do their home program to fatigue before activity. It is ok to prime the movement patterns with corrective exercise, but just a few reps before activity. This study suggests why:
“We conclude that 20min is not enough to see full recovery of gait after exhaustive quadriceps muscle fatigue.”-Barbieri FA et al.\

addendum:  Keep in mind, that during exercise, say a 7 mile run, if you fatigue some critical joint stabilizers at the 5 mile mark, ……. you will begin to run a comensatory sub-motor program.  You hope !   Just don;t do that too often !  How do  you know ?  You don’t, until you get pain from that pattern failing quite possibly !

Gait Posture. 2016 Jan;43:270-4. doi: 10.1016/j.gaitpost.2015.10.015. Epub 2015 Oct 25.Recovery of gait after quadriceps muscle fatigue.Barbieri FA¹, Beretta SS², Pereira VA³, Simieli L², Orcioli-Silva D², Dos Santos PC², van Dieën JH⁴, Gobbi LT².

http://www.ncbi.nlm.nih.gov/pubmed/26531768

Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

- another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. Shawn Allen, one of the gait guys

Muscle Contraction and Antibacterial Soap.

Using antibacteria soaps and gels? New study suggests you think twice. We knew of its alleged endocrine disrupting properties, but this one shocked us.“triclosan disrupted communication between two proteins crucial for proper muscle functioning, causing failure in both the heart and skeletal muscle cells.”
“triclosan penetrates the skin and enters the bloodstream more easily than previously thought. A new paper, (Triclosan impairs excitation–contraction coupling and Ca2+ dynamics in striated muscle) published today in the Proceedings of the National Academy of Sciences, indicates that triclosan impairs muscle function in both animals and humans. The study found that the chemical hinders human muscle contractions at the cellular level and inhibits normal muscle functioning in both fish and mice.

Reference:
http://www.smithsonianmag.com/science-nature/triclosan-a-chemical-used-in-antibacterial-soaps-is-found-to-impair-muscle-function-22127536/?no-ist

Study: http://www.pnas.org/content/109/35/14158.abstract

Triclosan impairs excitation–contraction coupling and Ca2+ dynamics in striated muscle

Asymmetries in limbs

Repetitive loading of limb asymmetries may have a cost down the road in terms of bone mass and bone structure. This can impact loading responses and musculoskeletal function.

Study purpose: “Asymmetrical loading patterns are commonplace in football sports. Our aims were to examine the influence of training age and limb function on lower-body musculoskeletal morphology.” -Hart et al.

“Conclusion: Asymmetries were evident in athletes as a product of limb function over time. Chronic exposure to routine high-impact, gravitational loads afforded to the support limb preferentially improved bone mass and structure (cross-sectional area and cortex thickness) as potent contributors to bone strength relative to the high-magnitude, muscular loads predominantly afforded to the kicking limb.” -Hart et al.

From:

Musculoskeletal Asymmetry in Football Athletes: A Product of Limb Function over Time.

Hart, Nicolas H.; Nimphius, Sophia; Weber, Jason; Spiteri, Tania; Rantalainen, Timo; Dobbin, Michael; Newton, Robert U.

Medicine & Science in Sports & Exercise:Post Acceptance: February 11, 2016