Kinetic Health - Calgary

Medial Ankle Pain - Dancer’s Tendonitis

2012-02-01T23:14:00.004-07:00

An injury to the Flexor Hallucis Longus (FHL) tendon causes medial ankle pain or pain on the bottom of the foot. FHL injury is a condition that is often overlooked or misdiagnosed. This injury affects dancers, runners, soccer players, and any other athlete who performs repeated, propulsive forces, or jumping. Injury of theFlexor Halicus Longus muscle is sometimes called “Dancer’s tendonitis” but it is not limited to just dancers. Image Alvin Ailey American Dance Theater dancer Constance Stamatiou.

The Flexor Hallucis Longus (FHL) muscle allows you to point your big toe (plantar-flexing your big toe) and stabilizes the Subtaler Joint. The Subtaler Joint is located between two bones in your ankle - the Talusand the Calcaneus. The Subtaler Joint allows movement of the heel toward the medial plane (inversion) as well as movement of the heel towards the lateral plane (eversion).

Anatomy/Biomechanics of Medial Ankle Pain

The Flexor Hallucis Longus muscle is located deep under your calf muscles (the most lateral muscle of the deep compartment). The FHL originates on the lateral lower leg (distal 2/3 of Fibula). It then travels at an oblique angle (crosses the posterior surface of Tibia) down towards the medial ankle (posterior surface of Talus) and travels under a section of the heel bone (Sustentaculum Tali of Calcaneus). The FHL then passes under the sole of the foot (between the two heads of the FHB) and inserts into the base of the big toe (base of the Distal Phalanx of Hallax).

As mentioned the FHL Tendon curves around a structure called the Sustentaculum Tali. TheSustentaculum Tali is a bony section on the inside of the heel bone (Calcaneus). This is often a site of friction and irritation for the FHL tendon. The FHL tendon also travels between the twoSesamoid bones just behind the big toe (Metatarso-Phalangeal Joint). The sheath that surrounds the FHL tendon is often irritated.

Causes and Presentation of Medial Ankle Pain

The repetitive motion of pushing-off with your foot (plantar flexion) during dance, running, soccer, and jumping can cause injury to the FHL.

Injury to the FHL tendon and muscle can present in a variety of ways - sometimes involving inflammation and sometimes not. Injury to the tendon without inflammation is refer to as a “Tendinopathy”. Tendinopathy refers to a degenerative lesion in the tendon without affecting the tendon sheath that surrounds the tendon.

When FHL inflammation (tendonitis) is present in the foot, it usually occurs in one of the following three locations.

1. Inside of the ankle (fibro-osseous tunnel along the Posteromedial Ankle).

2. At the “Knot of Henry” – a section just behind the big toe (first metatarsal) where the FDL muscle crosses the FHL tendon.

3. Just behind the big toe by the Sesamoids bone.

o A Sesamoid bone holds its tendon away from the center of the joint and acts to increase mechanical force.

When the FHL tendon becomes nodular, a condition called Hallux Saltans can develop. Hallux Saltans is similar to trigger finger in the hand, except it occurs in the big toe. Triggering of the toe occurs when the nodular thickening of the tendon snaps through the fibro-osseous tunnel. This causes a jerking motion, much like a trigger finger.

If not addressed Hallux Saltans can contribute to the progression of an additional condition called Hallux Rigidus. Hallux Rigidus means "stiff great toe". Hallux Rigidus is the second most common disorder of the first MTP joint. The most common injury is a bunion - otherwise known as Hallux Valgus.

Special Considerations For The Dancer

Injury to the FHL in dancers is often caused by the repetitive motion of changing position from a plié position to a relevé position. This action produces a force that is 10 times the dancer’s body weight.

Ideally, for greater stability and increased propulsion, the foot should be in a supinated position at the heel during push-off. For a dancer, any action that causes a reduction in plantar flexionmotion can create an FHL injury. Biomechanically, a lack of plantar flexion leads to a prolonged pronation position of the foot when pushing off in the Propulsion Phase.

In dancers, the FHL tendon is often compressed while performing a relevé position and is over-stretched while performing a plié postion. In such a case, the dancer will feel posterior medial ankle pain when performing the plié. (Photo - Dance Theatre of Harlem).

Diagnosis and Imaging - FHL Injury

X-rays for this condition are not very specific. X-Rays are good for ruling out fractures (Calcaneus, Distal Medial Malleolus, or Os Trigonum) that may cause an impingement of the FHL tendon. It is important to note that X-Rays will not provide a definitive diagnosis of FHL injuries.

A good history is much more definitive, especially when accompanied by a full physical examination and an MRI. MRI imaging is an excellent resource for showing damage to tissue fibers, inflammation, and swelling (edema).

If the MRI is not available or is too expensive, a CT scan (Computed Tomography) can prove to be a useful alternative.

Treatment

In most cases, FHL syndrome (involving partial tears, tendinosis, or inflammatory conditions) responds well to conservative care. However, a complete tear of the FHL tendon may require corrective surgery since serious cases of FHL injury could end an athlete’s career.

Conservative care includes:

· Ice or heat depending on stage and type of injury (inflammation or not). See our Icing andHeating blog.

· Reduction in activity. Usually, some modification in all activities is necessary.

· Supports (crutches or walker boot) can be beneficial.

· Taping – Kinesio Taping. At Kinetic Health we use SpiderTech Kineso-taping.

· Soft-tissue and joint mobilization (Active Release, Graston Techniques, Massage, and Fascial Manipulation).

· Inflammatory strategy implementation (medication for no longer than seven days). See ourblog about Reducing Inflammation.

· Exercises for increased strength, flexibility and balance. Go to www.releaseyourbody.comfor exercises you can use to treat this condition.

· Biomechanical corrections (footwear or Orthotics) .

· A gradual return to activities.

This information is derived from our Release Your Kinetic Chain Exercise Series. If you would like to more information or to purchase our books please go towww.releaseyourbody.com . If you would like information about our clinic in Calgary Alberta please go towww.kinetichealth.ca.

Shin Splints - Symptoms, Causes, Diagnosis, Treatment

2012-01-31T13:40:00.010-07:00

One of the most common running injuries we treat in our clinic is shin splints or Medial Tibial Stress Syndrome (MTSS). Shin splints cause one in five athletes to stop running. In addition to running, engaging in soccer, rugby, basketball, volleyball, or any sport that involves running or jumping can cause shin splints.

Symptoms

Most people would describe the initial pain of shin splints as a dull ache along the inside of the the lower leg (tibia). Shin splint pain is often felt at the beginning of a run and then diminishes as the run continues, only to return near the end of the run. In this initial stage the pain from shin splints will often dissipate completely with rest. If the shin splints progress, the pain will often be present with both activity and rest. Once shin splints reach the stage of constant pain, a medical professional should be seen to determine if additional injuries are present (stress fractures or compression syndrome).

The exact location of shin splints is often hard to find, because it is usually more of a diffused pain in the soft tissue (fascia, tendon, muscle) rather than on the bone (tibia) itself.

Causes of Shin Splints

The most common cause of shin splints is repetitive motion. This is not surprising considering the force of impact of each runner’s stride. A runner’s shins are subject to two to three times the runner’s body weight on foot impact. This high level of force can easily overwhelm the shin muscles (dorsi flexors) if they are not strong.

Shin muscles are called dorsi flexors because of the motion they perform with contraction. On contraction the dorsi flexors pull the foot up towards your shins, this is what is referred to as dorsi flexion.

During running, the dorsi flexor muscles also control plantar flexion, through the process of eccentric contraction. Eccentric contraction occurs when a muscle elongates while under tension. Controlling plantar flexion of the foot is not an exclusively linear motion. As the foot strikes the ground it is subjected to both rotational forces (pronation and supination) and side to side motions.

Any type of muscle imbalance, or abnormal motion pattern in the ankle, knee or hip could cause increased stress on the dorsi flexors as they try to control motion. In other words, the dorsi flexorsmay be the site of the shin splints, but the root cause could be far from the location of symptoms. For example, we know that excessive pronation (flat feet) will increase the load placed on thedorsi flexors as they try to control plantar flexion. We also know that weak or imbalanced external hip rotators (gluteus muscles) will increase pronation of the foot. Though it may not be a direct connection, weak external hip rotators could be part of the development and continuation of shin splints.

When it comes to shin splints, it is important to address the problems in all potential problem areas as well as the symptomatic structures in order to identify the root cause of the problem.

Differential Diagnosis

It is very important in diagnosing shin splints to make sure that you are actually dealing with shin splints and not a stress fracture or a case of compartment syndrome.

Stress Fractures

See our recent blog on Stress Fractures to review this condition.

Compartment Syndrome

Another condition that must be ruled out is compartment syndrome (CS). The muscles of our legs are divided into rigid compartments. These compartments are bound by strong fibrous tissue (deep fascia), and bones.

The anterior compartment contains some very important structures. It contains the dorsi flexors, the muscles directly linked to shin splints.

Anterior compartment Contains:

· Dorsiflexion muscles of the ankle and foot

o Tibialis anterior

o Extensor digitorum longus

o Extensor hallucis longus

o Peroneus tertius

· Anterior tibial artery

· Deep peroneal nerve

CS occurs when the pressure inside these compartments increases to the point where it interferes with the blood supply to your muscles and nerves. This can occur when the muscle inside the compartment becomes too large, increasing the pressure. CS can also occur from trauma, bleeding, swelling, overuse or even excessive medication.

In a case of anterior compartment syndrome, a runner may experience sharp pain and swelling over the shins. They may also notice weakness of the dorsi flexors, especially against resistance. In addition there is often a decrease in the extremities pulse and a decrease in sensation. There are two types of compartment syndromes: chronic and acute.

Chronic Compartment Syndrome is not a medical emergency and can often be treated with manual therapies (ART, Graston, Massage). Chronic CS is also referred to as exertional CS. The pain of exertional CS in runners usually comes on with the first 15 minutes of running, then subsides within an hour after the run. The pressure of these compartments can be measured by a medical practitioner. A resting pressure of greater than or equal to 15 mm Hg is an indication that compartment syndrome is present.

Acute Compartment Syndrome could be a serious limb-threatening condition. Any delay in treatment may lead to infection, complications and even limb amputation. In most cases an acute compartment syndrome occurs after a traumatic event, and is most commonly seen with traumatic fractures.

If you suspect a stress fracture or compartment syndrome you need the help of a medicial practitioner.

Running and Dorsi Flexor Strength

When a runner has weak dorsi flexors they will have a tendency to slap the ground with every foot strike. A runner slaps the ground because they are unable to control foot motion as they hit the ground (eccentric contraction). Next time you are out running, listen to the runners around you. You will be surprised to hear just how many of those runners are slapping the ground with their feet. These runners are susceptible to shin splints (MTSS).

Another point to consider is that slow runners have a tendency to slap the ground more. In other words, they have weak dorsi flexors. This is a very interesting observation seeing that faster/elite runners are hitting the ground with more force, yet the fast runner is a quieter runner. This is because most elite runners have strong dorsi flexor muscles which are able to control the foot as it comes down. Essentially they have good shock absorbers that are able to dissipate the impact of each stride.

Some of quietest elite runners you will see (actually not hear) are the east Africans. Many of these runners have extremely strong dorsi flexor muscles from running barefoot throughout their lives. Having strong dorsi flexors may be one of the factors as to why east Africans have dominated major marathons around the world for decades. When I ran the Paris Marathon in 2009, the winner was Tadesse Tola from Ethiopia in a time of 2 hours, 6 minutes and 40 seconds. Seeing runners maintaining such incredible speeds while quietly taking each stride is incredible.

A runner at this level recycles about half their energy through elastic recoil. This process is very similar to a spring mechanism, loading and releasing the spring with each stride. Part of this amazing spring mechanism is the dorsi flexor muscles.

Treatment of Shin Splints (MTSS)

The classic treatment of shins splints involves: rest, icing, elevation, compression and some easy stretches. This is good advice especially in the acute stage of the injury. However, exclusively following this advice will not prevent the return of the problem.

In order to resolve MTSS, the removal of any myofasial restrictions that may have formed in the soft tissue is required. This will be done in combination with a program of functional strengthening exercises for both the dorsi flexors and other areas that are affecting gait stability.

Manual Therapy

Any type of restriction that forms in the dorsi flexors, or other related areas should be removed for a full resolution of shin splints. Some of these restrictions can be removed through the process of self-myofascial release (foam rollers, and stretching). If the restrictions are severe, a manual therapy practitioner (ART, Graston, Fascial Manipulation, Massage) will be needed to break the restrictions.

Any time a restriction is removed from one muscle the antagonistic and synergist muscles must also be assessed for restrictions. This is a key point that many manual therapists fail to recognize. For a full resolution, myofascial adhesions must be removed from the entire kinetic chain.

The following list of dorsi flexor muscles are common sites of adhesion removal, but a much larger kinetic chain must also be assessed and treated if necessary.

Dorsi Flexors (Primary)

Tibialis Anterior Muscle (TA)

The TA dorsiflexes and inverts the foot. In running, the TA is twice as active as many of the other muscles in the lower extremity. Consequently it is easily fatigued if weak. Once fatigue sets in, abnormal pronation is likely to increase.

Extensor Hallucis Longus Muscle (EHL)

The EHL dorsiflexes and assists with foot inversion.

Extensor Digitorum Longus Muscle (EDL)

The EDL dorsiflexes the foot.

Peroneus Tertius

The Peroneus Tertius is weak dorsiflexion of the ankle joint and is used to evert the foot at the ankle joint.

Exercise

As with all musculoskeletal conditions, exercise is essential for a full resolution. Just because passive therapy has eliminated the symptoms does not mean the condition will not return. The following exercises are example of exercises that we prescribe to our patients with shin splints.

Strengthening Exercise – Example

Shin Raises – This is a great exercise for strengthening the dorsi flexors. It is best not to overdue this exercise at first, give your dorsi flexors time to adapt to the exercise. Slowly increase to the recommended number of repetitions and sets.

Stand with your back to the wall, have your feet about 12-18 inches away from the wall.
Lean back against a wall with your shoulders and gluteus touching the wall.
Keep your heels on the ground, dorsi flex both ankles at the same time to maximum dorsiflexion. Then slowly lower your feet to almost touching the ground and repeat immediately.
Do 10 to 15 repetitions then walk around for a short time. Do a total of 2 to 5 sets, depending on the strength of your dorsiflexors.
Repeat this exercise every other day. Once you have done this exercise for several weeks, combine this exercise with version two.

Version Two: This exercise is similar to version one except in two important aspects. First, the repetitions are performed at a much faster rate. Second the range of motion in which the exercise is performed is reduced.

Stretching Exercises - Example

Dynamic Shin Stretch – This dynamic stretches should be performed after a short warm-up.They are great for developing shin strength and overall motion control.

Heel Walking

With your feet straight ahead walk on your heels (maximum dorsi flexion) with short steps for about 15 – 25 meters, depending on your strength. Your legs should be straight, but your knees should not be hyper extended.
Next do exactly the same procedure, but this time with your feet turned outward.
Finally perform the same procedure with your feet turned inward.
Note: This exercise can also be performed on your toes.

There are numerous strengthening and dynamic stretching exercises that we recommend to our patients for the prevention and treatment of shin splints. The exact exercises that we recommend will vary depending on which areas of the patient’s kinetic chain are weak or restricted. In prescribing exercises, it is very common to prescribe both core and hip exercises as well as the exercises that directly affect the muscles of the shins.

Stress Fracture - What You Need To Know

2012-01-29T14:01:00.007-07:00

Stress fractures are one of the most common, and potentially serious, overuse injuries. A stress fracture is an incomplete fracture that can occur anywhere in the body, and are typically caused by repetitive forceful actions. In contrast, most other types of fractures are caused by a single, direct, traumatic impact.

Stress fractures usually occur in weight-bearing bones, and are commonly seen in the metatarsals of the foot, bones of the ankle, shins (tibia), knees, and hips (the neck of the femur is one the worst stress fractures). Stress fractures are often caused by repetitive activities such as running, dancing, soccer, or any sport that involves high levels of repetitive actions. Stress fractures can eventually lead toa complete fracture.

How the injury occurs

Your body is continually remodeling your skeletal system based on the stresses that are placed upon it. This remodeling process gives your body the ability to handle increased loads without further injury. The problem arises in that your body can only adapt to these stresses at a certain rate, and there is a finite limit to the amount of stress to which it can adapt. Injuries to the bone (microscopic fractures) occur when increased stress is placed upon your body too quickly, or when too much load is applied.

In more technical terms, stressfractures occur in the early stage of bone remodeling whenosteoclasticreabsorbtion of bone, outstrips the osteoblastic development ofnew bone. This results in a weakened bone that is susceptible toinjury. Osteoblasts and Osteoclasts control the amount of bone in your body:

· Osteoblast - Osteoblasts are cells which are responsible for bone formation. These cells produce osteoids, that are composed primarily of Type I collagen.

· Osteoclast – Osteoclasts remove bone (reabsorb bone) by removing its mineralized matrix and breaking up organic bone.

Two Common Types of Stress Fractures

· Low-Risk Stress Fractures– An athlete can often heal these injuries by reducing activity, focusing on cross-training, nutritional supplementation, and a programs of conservative care accompanied by appropriate rehabilitation exercises.

· High-Risk Fractures – These fractures often occur on the tension side of a bone. Typically, these type of stress fractures do not respond well to any weight bearing activities or stresses, and require a non-weight bearing cast or complete immobilization to heal. In advanced cases surgery may be required to complete the healing process. Typical high risk areas include: Medial malleolus, navicular bone, fifth metatarsal, and the femoral neck.

You will need to consult a qualified medical practitioner to determine if a stress fracture is high-risk or not.

Risk Factors for Stress Fractures

Many factors can result in stress fractures including:

Faulty or worn-out equipment such as:

Using worn-out running shoes, worn-out point shoes for dance, or other defective supports.
Using the wrong type of support in your shoes such as a supinator using a shoe that correctsexcessive pronation. It is important to seek someone with expertise in your sport to fit you with the proper shoes.

Training errors such as:

Sudden increases in frequency or duration of training.
Training while in a state of exhaustion.
Poor training techniques.

Amenorrhea or the absence of menstrual bleeding results in loss of bone mass at a similar rate to that experienced by post-menopausal women (up to 5% per year). This makes them very susceptible to stress fractures.
Restrictive diets that results in an inadequate supply of essential nutrients or calories, and can have a negative effect on bone density.
Muscular weakness or muscle imbalances.

Diagnosis

History – Patients who develop stress fractures often have a historyof pain that is brought on by physical activity, and reduced pain with rest. There is usually an accompanying history ofrecent increases in physical activity.
Palpation – Touching the affected area (around the stress fracture) often elicits localized tenderness directly over the bone. Swellingover the area and redness is also commonly observed. Often there will be tenderness to percussion over the area.
Pain – Unfortunately, the pain pattern of a stress fracture may not provide a direct indication about the actual presence of a stress fracture. The pain from a stress fracture is usually well localized, but in some cases, can be spread out over a larger area.

Note: In the case of a femoral neck stress fracture (seen in runners/dancers or high impact athletes) the patient will feel groin pain that becomes worse with any activity (including walking) and that gets better with rest. This can become a very serious stress fracture if it transforms into a complete fracture. In such cases, the head of the femur can die due to lack of blood supply caused by the fracture.

Tuning Fork – The vibrations of a tuning fork have been used as an indication of a stress fracture. Some practitioners dispute this test, but it may give the practitioner an indication that further diagnostic tests need to be performed.
X-rays – Diagnostic X-rays are often not very good at finding a recent stress fracture. A stress fracture may not show up on the X-ray for 2-3 weeks. Despite this, an X-ray is one of the first diagnostic procedures that should be performed. If possible an MRI, or bone scanshould also be performed, these procedures are much more definitive than an X-Ray.

Treatment Considerations: Keep the following points in mind when treating stress fractures.

What Not To Do for Stress Fractures

Certain treatments and behaviors will exacerbate, or inhibit the healing of your stress fractures, including:

DO NOT USE NASID’s – These medications inhibit bone healing and mask pain symptoms. Unfortunately many athletes, especially professional dancers, use large doses of NSAID’s.
Ignoring a stress fracture - A stress fracture that is ignored could turn into a complete fracture, which then requires surgery, resulting in a long healing time. Bottom line, you will never get over a stress fracture by just ignoring it, it will only get worse until even minor motion becomes extremely painful.

What To Do to Treat Stress Fractures

The following has been found to be effective in dealing effectively with stress fractures.

Prevention – The best way to treat this injury is to avoid it in the first place.

o Training – No matter which sport or activity you are involved in (running, dance, etc.) be sure to increase your distance, frequency, or intensity gradually over a period of time.

§ Focus on the quality of your training, not just quantity. Adequate rest goes a long way in preventing a stress fracture. Rest is an essential training component for avoiding injury and stress fracture.

§ Do not train when you are exhausted, higher levels of injuries occur when in states of exhaustion.

§ Make Your Bones Strong (preferably before the injury occurs).

A key point here is that you can only make deposits of calcium (and other minerals) into your bone bank up until age 25. After age 25, you need to take daily calcium to prevent unnecessary withdrawals from your bones. Note of interest: Calcium deficiency is a prerequisite for a stress fracture. 98% of Adolecent dancers are calcium deficient (Harkness Centre for Dance Injuries 2010).

o First consider the composition of your bones:

§ 30% organic (collagen, proteins, osteoblasts, osteoclasts, osteocytes).

§ 70% minerals (calcium phosphate, magnesium, sodium, potassium, fluoride, chloride). This bone matrix of mineral is called hydroxyapatite. You need all of these minerals. It pays to focus on good dietary habits including the right amount of supplementation.

o Maintain your calcium levels:

§ Children under 9 years of age require 800 mg. per day. If you are between 9 - 50 years old, you need 1300 mg of calcium per day. Those over age 50 require at least 1000 mg. of calcium per day.

§ 70% of your bones are made up of minerals (hydroxyapatite). The best way to ingest calcium is through a complete Bone Matrix supplements. We often recommend that our patients take MCHA to meet their nutritional requirements.

§ After the Stress Fracture has Occurred - The time frame for recovering from most lower-extremity stress fractures is between 8 to 17 weeks. This time frame will be much longer if the area is not given adequate time to heal. The good news is that most stress fractures respond well to conservative therapy and do not require surgery (if the stress fracture is not ignored).

o Initially, weight bearing exercises must be eliminated with any lower-extremity stress fracture. This is essential to allow the bone to heal and complete the normal remodeling process.

o An air cast (pneumatic walker/walker boot) or crutches is often recommended during the initial stages of injury. The air cast will often be used for 4 to 6 weeks depending on the speed of healing.

o Cross-training is essential to speed the recovery. Swimming, cycling, and routines that do not involve weight bearing are often recommended. The patient should also continue with upper extremity exercises.

o A slow rate of return to activity should be implemented since introducing weight-bearing exercises too soon will increase the duration of the injury. As a general rule, once the area is completely pain-free, light walking can be resumed.

o Pulsed electromagnetic field or low-intensity pulsed ultrasound therapy could speed the healing.

o Rehabilitation programs need to focus on several key factors (flexibility, strength, endurance, balance, propiroception, and alignment). This also includes addressing any weaknesses in hip or proximal stabilizers.

o Custom made orthotics may also be useful in helping to reduce biomechanical stresses on the affected area (Available through Kinetic Health).

Bunions - Understanding And Treatment

2012-01-29T11:22:00.008-07:00

Bunions (Hallus Abducto Valgus) are a common foot problem that affects the joint at the base of the big toe (first metatarsophalangeal joint). In Latin “bunion” means enlargement, while “hallux abducto valgus (HAV)” refers to a bending inwards of the big toe as seen on the image.

As you see, the big toe bends in towards the other toes while the bone behind it (1^stmetatarsal) pushes outward. This creates a considerable amount of stress on the joint (first metatarsophalangeal joint). Due to this bending inwards, a sharp angle at the big toe joint is created, resulting in the formation of a bunion. Initially, this enlargement is composed of swollen tissue which becomes irritated by any external pressure (for example tight shoes). Eventually this swollen tissue thickens to form a very large lump or bunion.

There is an obvious relationship between bunions and shoes, since bunions do not occur in cultures that go barefoot. High heels, pointed shoes, ballet shoes, excessively tight shoes, and even cowboy boots often lead to the development of bunions.

Anatomy and Biomechanics

From a biomechanical perspective, bunion formation creates a cycle of dysfunction. As the bone behind the big toe (1^st metatarsal bone) moves outwards, the inner arch of the foot becomes unstable and starts to collapse. This instability, or lack of support in the arch, increases stress on the angle at the point where the bunion is forming. This stress accelerates the formation of the bunion, which in turn further destabilizes the arch of the foot. To truly deal with this problem, you must address both the foot instability and joint angle.

In addition to the stresses caused by poor shoes, simply walking with your feet in a turned out position can also lead to bunion formation from the stress it puts on two particular muscles. This “turned out” position leads to an imbalance between two muscles - the adductor hallicus and the abductor hallicus.

The adductor hallicus is an interesting muscle which is shaped like the number seven. The adductor hallicus transverses from several of the lateral toes into your big toe. When the adductor hallicus contracts, it pulls the big toe towards the 2nd toe.

· For those of you who have been asking for a more technical anatomical description…well here you go! The adductor hallicus has two heads - the oblique and lateral head. The oblique head originates in the 2^nd, 3^rd, and 4^th metatarsals. The tranverse head originates from the 3^rd, 4^th, and 5^th toes (metatarsophalangeal ligaments). Both heads insert into the big toe (lateral sesamoid bone at the MP joint, and into theproximal phalanx of the big toe).

When the adductor hallicus muscle becomes tight and restricted, it continually pulls the big toe towards the second toe (even without contracting). The adductor hallicus tends to become restricted in individuals who excessively pronate or walk with their feet turned outwards (a huge percentage of runners and dancers).

This pulling action of the adductor hallicus disrupts a key balance in muscle tension, which normally keeps the big toe in a neutral or straight position. This balance occurs between the adductor hallicus and the abductor hallicusmuscles.

The abductor hallucis normally resists the pulling action of the adductor hallicus. The abductor hallucis runs from your heel (calcaneus) to your big toe (proximal phalanx). Constant pulling from the adductor hallicus weakens and overstretches the abductor hallucis. Without the appropriate counter-balancing action of the abductor hallucis, the big toe moves inward, and bunion formation accelerates.

Symptoms

In the first stages of bunion formation, bunions are often not painful until there is a significant inward deviation of the big toe. Some of the symptoms commonly associated with bunions include localized pain near the joint (often only with palpation), redness, swelling and restricted motion.

Diagnosis

In addition to a complete physical examination and history, X-rays are often taken. X-rays enable the physician to measure joint angles in order to determine the severity of the condition. It also allows the physician to rule out fractures or other pathological processes.

Treatment

Treatment can be divided into non-surgical (conservative) and surgical treatments.

Surgical Treatment: Surgery is sometimes necessary when the pain from a bunion is extremely severe, or when a bunion has grown past certain limits. The success rate for bunion surgery is very high, especially when measured in terms of performing your ADL’s (activities of daily living) and pain reduction. Complications from surgery include: infections, nerve damage, scar tissue formation, over or under-correction, and blood clots. It is also import to note that the bunion can reoccur if the underlying factors that caused the initial bunion formation are not properly dealt with. The surgery it self may alter the pressure pattern on the bottom of the foot (alignment), causing certain biomechanical imbalances.

Please Note: Something to keep in mind for professional dancers; a bunion surgery will often be the end of that dancer’s career. This is because most dancers cannot return to their pre-operative state.

Conservative Treatment: The objective of conservative treatment is to prevent the progression of the bunion by correcting the biomechanical stress on the foot, realigning the joint as much as possible, and increasing the intrinsic strength of the foot.

Fortunately, in most cases surgery is not necessary, and conservative treatment can be very successful, especially when the following factors are addressed:

· Shoes: Sorry - but those high heels will have to go (except on the rarest of occasion) - especially when the bunion is extremely painful. The best shoes for bunions are flat shoes with a wide toe box. If you wear shoes that rub against your bunion it will only get larger. Some of the best choices are: wide athletic shoes, crocs, and sandals. The only problem with sandals is that you will not be able to wear orthotics within them to correct excessive pronation (if over-pronation is part of the problem). You can also try a shoe stretcher to increase the space in your current shoes.

· Soft Tissue Restrictions: It is essential to remove soft tissue restrictions in order to bring the big toe back into its neutral position. Without addressing these restrictions, the bunion will continue to expand. There are various techniques that can be used to break up these restrictions such as Active Release Techniques, Graston Techniques, Massage Therapy, or various types of fascial manipulation. The exact area of restriction will vary for each individual case. Using a golf ball on the bottom of your foot and performing self-massage can also be of great benefit.

· Foot Stability: Besides the obvious restrictions that may be found in the Adductor Hallucis, we also have to consider the other muscles that are involved in stabilizing the entire foot. Think of your foot the same way you would think of your car. Your car has four tires, each of which must be kept in alignment. If one of your tires is out-of-alignment, it affects the motion of the entire vehicle. The same thing occurs with the muscles of your feet. It only takes a restriction in one muscle to affect the stability of the entire foot

Using Exercise to Treat Bunions

Exercise is an essential component in the treatment of bunions, it should not be optional. Soft-tissue therapy without exercise can only achieve a certain level of results, and the probability of the bunion returning becomes very high. Just as the kinetic chain must be considered when determining treatment therapy (ART, Graston, Massage, etc.), the kinetic chain must also be evaluated to identify weak links which can be strengthened through exercises.For example, it has been well established that weak hip muscles are directly related to an increase in abnormal foot pronation, and abnormal pronation has been shown to accelerate the formation of bunions. In such cases, to prevent a reoccurrence of the bunion, you need to do exercises to strengthen and correct the weak hip muscle.

The following are examples of some of the exercises that we prescribe for our patients. (This is not a complete exercise protocol for bunion treatment.) At our clinic, the exercise routines are customized to treat weak links in each patient’s kinetic chain. For more information about specific exercise routines, see www.releaseyourbody.com.

Exercise Examples:

· Strengthening the feet

o Exercise #1: Sit down, with your feet flat on floor, and keeping your heels planted on the ground throughout the exercise. Now raise just your toes off the ground (as far up as you can) while keeping your mid-foot on the ground. Maintain the “toes up” position for 15 seconds with maximum tension, then bring your toes down. Repeat 5 to 10 times.

o Exercise #2: Sit in a chair with your toes on the edge of a towel. Flex and curl your toes to grasp the towel and pull it under your toes. Repeat 5 to 10 times.

· Stretching and mobilizing your foot: Keeping your toes mobile and flexible will help to reduce pain.

o Exercise #1: Sit on a chair, and cross your foot over your knee. Grasp the heel of foot with one hand; grasp your big toe with the other hand. Rotate and stretch your big toe in all directions (do not overstress the joint). At end-range, hold the stretch for 10 to 15 seconds. Repeat this procedure several times in all directions.

o Exercise #2: Stand upright, and wrap an exercise band around both big toes.Move your feet apart until your toes are straightened (keeping the elastic band taut between your feet), then hold this straightened position for several minutes. Repeat several times.

Supportive Aids:

· Orthotics – As mentioned earlier, excessive pronation can be a contributing factor in the formation of bunions. Custom fit orthotics can help stabilize the arch of the foot and reduce or eliminate excessive pronation or supination.

· Taping, bunion pads, toe spacers, and night splints can help to properly position your toes and reduce pain.

In most cases surgery is not necessary for the treatment of bunions. Conservative treatment can be very successful in the treatment of bunions, but you must ensure that your selected practitioner has a good understanding of anatomy, biomechanics, and the various factors causing bunion formation.

Exercise Rehab For Ankle Sprains

2012-01-26T22:47:00.007-07:00

When prescribing ankle exercises, we must take into consideration the multiple structures that are involved in performing and coordinating ankle motion. To attain a full resolution from an inversion sprain, we must be sure to consider multiple muscles and complex fascial layers, all of which work together across numerous joints.

To do this, we must be sure to address three essential components: strength, flexibility, and proprioception.

Strengthening the Ankle

Strengthening exercises are essential! Manual therapy, by itself, will not fully prevent an injury from returning without the addition of strengthening exercises. This is because the type and quality of tissue remodeling that occurs after an injury is dependant on the type of forces that are applied to that tissue. When appropriate strengthening exercises are applied, the collagen remodels to withstand the stresses that are placed upon it. The possibility of re-injury is very high without appropriate strength training.

Strengthening exercises for an inversion sprain can be subdivided into several categories depending on the stage of the injury. The following subcategories describe stages from non-weight-bearing to full-weight-bearing. Note: These are examples of possible recommendations, but actual exercise recommendations will vary from case to case.

1. Active Range Of Motion (AROM) – Non-weight bearing exercises

a. Four basic foot motions – Perform the following four basic motions: plantar flexion, dorsi flexion, inversion, and eversion. Perform these foot motions slowly, holding the end range of each position for 5-10 seconds. Repeat the action several times.

b. Alphabet exercise – Use your foot to draw the letters of the alphabet in the air, allowing your ankles to rotate with each motion

2. Isometric strengthening of the ankle – Isometric exercises are performed in static positions (unlike dynamic exercises which are performed through a range of motion).

a. The Isometric Four – In this exercise, you need to resist each basic motion (plantar flexion, dorsi flexion, inversion, and eversion) of the ankle. For example:

· Start with your ankle in neutral position, with your foot braced against a wall or table.

· Then, without allowing your foot or ankle to move, try to perform each of the four basic actions. This causes all the muscles involved in the action to contract.

· Hold this contraction for 5-10 seconds and relax for about 10 seconds.

· Repeat this process for 4-8 repetitions, slowly increasing the number of repetitions.

· Repeat this routine for each of the four basic actions.

3. Resisted Strengthening of the Ankle – using Theraband or Tubing

a. Four-Way Resisted Tubing – In this series of exercises, we recommend using a theraband or tubing as you perform each of the four basic ankle motions. For example, with the inversion action:

· Attach a theraband around your ankle and attach the other end to a table or door.

· Against resistance, roll your foot inward (invert your ankle) and hold for 3 to 5 seconds.

· Repeat for 10 to 15 repetitions, increasing the number of sets from 1 set/day to 4 sets/day as you increase your ankle strength.

· Repeat this routine for each of the four basic ankle actions.

4. Partial Weight Bearing Ankle Exercise

a. Shifting Your Weight – In this exercise, lean against a counter or table, and try shifting some of your weight onto the injured leg. Start with just a few seconds of weight, and then increase this time, as the ankle permits. Repeat this exercise about 10 times. Be careful not to do too much, too soon.

5. Full Weight Bearing Ankle Exercises

Once the injured ankle is able to bear the full weight of your body, there are many exercises that will help to further strengthen the ankle. One of my favorites is the Eccentric Calf Raise.

Eccentric Calf Raises - One Legged
(Actually…these are calf drops, not raises)

In this exercise, the rising up portion is not that important. The key lies in the slow lowering of the body, as this builds strength without causing further injury to the body.

· Stand on the edge of step or curb, heels hanging over the edge of the step, and rise up on both legs in a classic calf raise.

· Now, using only one leg, slowly drop down to the starting position for a count of three

· Do 5 to 15 repetitions in each set. Start with two sets and gradually increase to 4 sets as your ankle strength increases.

· Allow your ankle to build up its strength slowly. Do not increase your repetitions and sets until you can complete each repetition with perfect form, and without pain.

Once you are able to properly perform full weight bearing exercises, you should consider beginning a routine that exercises your full body. These exercises should activate the knee, hip, and core.

Restoring Flexibility to the Ankle

It is extremely important to stretch after experiencing an ankle injury of any kind. During the recovery phase, your body forms and lays down collagen to repair the injured area from two days, and up to 6 weeks after, the injury occurs.

If you suffer from an inversion sprain, and perform thecorrect stretching exercises, then you can ensure that the majority of the collagen that is being laid down, is being laid in the same direction as the tissue which is being repaired.This makes the repaired tissue stronger and more capable of performing its function in the future. However, if you do not stretch the injured area, the new collagen will be laid down in more random patterns, leading to the development of weaker tissue (scar tissue) that is easily re-injured

Here are some of the areas for which we recommend stretching exercises when our patients are recovering from an ankle injury:

• Calf muscle (gastrocnnemius and soleus) - Stretch the calf muscle as it often becomes very tight after an ankle sprain, as these structures try to protect the injured joint.

• Peroneal muscles – Stretch the peroneals (along the sides of your calf) as these muscles are often injured along with the ligaments in the ankles.

• Iliotibial Band – Yes, these tissues are in your upper leg, but there are direct fascial connections from the peroneal muscles into the IT band. A injury to the peroneal muscle may cause compensation injuries up into the IT Band. So be sure to perform stretches to release the IT Band.

• Gluteal muscles – Since the IT band is formed from the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae, problems in the IT band willaffect hip function. So it is important to release the muscles of the gluteals with stretches and foam rollers.

Proprioceptive Training

Whenever an inversion sprain occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to chronic ankle problems.

Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:

• One-legged Stand

This is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercise within a pain free range-of-motion.

• Wobble board training

Slowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.

· Upside Down Bosu Ball

The Bosu Ball is a great device for dynamically stretching and strengthening the ankle. Try this Side-to-Side Peroneal Stretch.

§ Turn the Bosu Ball upside down, balance on the flat surface, with your feet about shoulder-width apart.

§ Shift your weight to the right side so that the right edge of the Bosu Ball almost touches the ground. Then immediately shift your weight to the left side so the left edge of the Bosu ball almost touches the ground. Continue to shift from side-to-side. As you do this exercise, you should feel a stretch in the muscles along the lower outside of your leg (peroneals).

§ After a few minutes of performing this action your lower extremity muscles should start to feel fatigued.

§ Once you become comfortable with balancing the side-to-side actions, you can start integrating arm actions into this exercise. As you shift your lower extremity to the right side, swing both your arms to the left. When you shift your weight to the left side, swing your arms to the right. This simulates a downhill skiing (cross crawl) type of action that integrates all the muscles of your body.

Sport Specific

If you are involved in a particular sport, take the time to create a balance/proprioceptive exercise that matches your specific sport. For example:

· If you are a soccer player who is rehabilitating a sprained ankle, you may want to try one-legged stand on the injured ankle, while kicking a soccer ball with the other foot. To increase the level of difficulty, try standing on a balance pad with the injured leg, and then kick the ball with the other.

· If you are a dancer suffering from an inversion sprain, try moving through your basic dance positions while on a wobble board or balance pad.

· If you are a basketball player, try standing on a wobble board with the injured leg and practice throwing hoops.

Be creative with your individual sport. Use wobble boards, balance pads, half-foam rollers, or bosu balls to rehabilitate the damage to your nervous system that is caused by an inversion sprain.

Bottom line - inversion sprains are a common, yet complex, injury. This injury can involve multiple structures across numerous joints, and may even extend a considerable distance up the body. To correctly rehabilitate the injury, you must use an approach that takes into consideration musculoskeletal connections, the nervous system, and appropriate tissue remodeling.

Ankle Sprains - Ligaments And More

2012-01-25T13:35:00.019-07:00

An ankle sprain refers to the tearing of the ligaments of the ankle and account for approximately 40% of all athletic injuries. 85% of ankle sprains occur on the outside (lateral side) of the ankle and are known as an inversion sprain. This is the type of injury that most runners experience when they sprain their ankles. Medial ankle sprains (along the inside of the ankle) occur less frequently and are usually caused by fractures or other traumatic events.

So, why is an inversion sprain so common? You can put it down to our lopsided anatomy! The bone on the lower outside of the ankle (the lateral malleolus - distal fibula) extends further down than the bone on the inside of the ankle (medial malleolus – fibula). This difference gives the inside of the ankle (medial side) more stability than the outside of the ankle (lateral side).

At a symptomatic level, most ankle sprains appear to resolve completely without rehabilitation. In reality, ankle sprains that have not been rehabilitated correctly are usually susceptible to further injury.

Anatomy of an Ankle Sprain

The outside (lateral side) of the ankle achieves its stability from a three-ligament complex. These three ligaments are the:

• Anterior Talofibular ligament (ATFL)

• Calcaneofibular ligament (CFL)

• Posterior Talofibular ligament (PTFL)

In an inversion sprain, the Anterior Talofibular ligament (ATFL) is the most commonly injured. Ligaments in the ankle are named according to the bones to which they connect. In this case, the Anterior Talofibular ligament connects to the talus bone of the ankle as well as to a long bone of the lower leg - the fibula. The function of the ATFL is to prevent forward (anterior) displacement of the ankle (the talus).

In a severe ankle sprain another ligament called the calcaneofibular ligament (CFL) may also be damaged. This ligament connects your heel bone (calcaneous) with the fibula. This is a stronger ligament than the ATFL, and is not damaged as easily.

Both the ATFL and the CFL are usually damaged in motions where the foot is both pointed down (plantar flexed) and rolled out (inverted). Considerable instability in the ankle can occur when both these ligaments are injured.

The posterior talofibular ligament (PTFL) is not injured very often, except when there is a complete dislocation of the ankle (talus). The PTFL is the strongest ligament in the lateral complex.

Another sprain injury that is becoming more prevalent is called a “High Ankle Sprain” (syndesmotic ligament complex). In this injury, the ligament and connective tissue between your shin bones (tibia and fibula) are torn. This is a serious injury that may require surgery to resolve.

Not Just Ligaments

An ankle sprain may also result in damage to other structures. You may also experience damage to connective tissue, tendons, muscles further up the ankle, and even to the bones (possible fractures). This is why, with a severe ankle sprain, it is important to see a medical professional who can determine exactly which structures have been injured, and then provide treatment recommendations.

Treatment of Ankle Sprain

There are a number of things you can do to treat ankle injuries.

Just After The Injury

Immediately after spraining your ankle, it is important to do everything you can to reduce the swelling in the ankle. The faster you can implement treatment, the faster you will recover. An ankle sprain injury that is addressed quickly will often resolve in short period of time. If the injury is ignored, the ankle sprain could be prolonged for extensive periods of time.

So, immediately after the injury, while still in the acute stage - use RICE - rest, ice, compress, and elevate!

• R = Rest: During this stage, it may be necessary to take all weight off of the injured ankle. In such cases, crutches are commonly used. In my opinion, it is important to quickly return to weight-bearing as soon as possible to improve healing. I have found that reintroduction of weight-bearing stresses tends to decrease recovery time. When should you do this? As soon as possible, but not too soon! Rest is also essential.

• I = ICE : See our Blog about icing. Ice for at least 20 to 30, minutes 4 to 5 times per day to reduce swelling.

• C = Compression: Compression (with an ACE wrap) reduces both swelling and bleeding. With a Grade 3 sprain, wear a brace at all times until you are able to bear weight on your ankle.

• E = Elevation: Elevating the injured area acts to reduce swelling and bleeding.

Once you have used “RICE”, it is very important to introduce motion into the ankle as soon as possible. Depending on the degree of injury, the patient could be asked to perform gentle ankle circles, or if able to do so, write the alphabet with their feet. Light calf stretching and using a stationary bicycle may also be beneficial.

If you are going to use medication (NASID’s) to reduce inflammation, be sure not to use them for more than seven days. Using anti-inflammatory medications for long periods of time inhibits tissue remodeling. See our Blog about Recommendations to Reduce Inflammation without Medication.

Manual Therapy for an Ankle Sprain

Manual therapy can make a huge difference in the recovery and prevention of an ankle sprain. By manual therapy, I am referring to techniques such as Active Release, Graston Technique, Massage Therapy, Fascial Manipulation, Manual Manipulation, and other manual procedures. In my opinion, these procedures are essential in the rehabilitation of an ankle sprain since they all act to break down and prevent scar tissue formation.

Manual therapy also speeds healing by increasing blood supply, oxygen, essential nutrients, and displace waste products that accumulate after an injury. This is especially important in treating ligaments because they generally have a very poor blood supply to begin with.

It is Important to Treat More Than Just the Ligaments

Earlier, I mentioned that there might be damage to several types of structures after an ankle sprain, especially the connective tissue, tendons, muscles, and nerves. The following is list of structures that are often injured in a lateral ankle sprain (inversion sprain).

Ligaments

• Anterior talofibular ligament (ATFL) – Most common injured structure.

• Calcaneofibular ligament (CFL) – Second most commonly injured structure.

• Posterior talofibular ligament (PTFL)

Tendons

• Peroneal tendon

o With an inversion sprain, it is common for the tendons of the peroneal muscles to be injured. It also common for the peroneal tendon to move out of its normal position (subluxate) during the recovery stage of an ankle sprain.

Muscles

• Peroneus brevis muscle – Longitudinal tears of the peroneus brevis are commonly associated with lateral ankle sprains.

• Peroneus longus muscle – These muscles often show a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a person more susceptible to future injuries.

Both muscles, evert the foot at the tarsal joint, and plantarflex the foot at the ankle.

Retinaculum

• Peroneal retinaculum -

o During a lateral ankle sprain, the foot rolls inwards with considerable force. This forceful action can tear the peroneal retinaculum. This retinaculum is a band of connective tissue that keeps the peroneal tendons in place. When a tear in the retinaculum occurs, patients will notice a snapping sensation in the lateral ankle. Conservative treatment is 4 to 6 weeks in a short leg cast. However, a severe tear of the retinaculum is not a candidate for standard manual therapy and may require corrective surgery.

Nerves

• Superficial peroneal nerve - This nerve is atrisk for traction injury during a lateral ankle sprain (inversion sprain).

Treating Iliotibial Band Syndrome

2012-01-23T12:52:00.010-07:00

The first thing practitioners must do in treating Iliotibial Band Syndrome (ITBS) is to take a complete history and perform a biomechanical analysis. The biomechanical analysis evaluates the patients gait and movement patterns for alteration in any normal movement. This will give the practitioner an initial hypothesis as to which structures are involved.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction or alteration of the tissue. The practitioner will feel an alteration in normal tissue consistency, it could feel ropy, rigid, thickened and there will often be a lack of tissue glide between adjacent structures. Once the area to be treated has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions (Active Release,Graston Technique, Massage Therapy, and Fascial Manipulation).

Fascia and ITB Syndrome

When we evaluate a case of ITBS, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle, knee, and hip motion.

In the case of ITBS, some of the fascial connections we should consider are in the Lateral Line(see Anatomy Trains by Thomas Meyers).

The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.

Lateral Line

· Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus,gluteus medius, and tensor fascia latae).

· The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.

· The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, andscalenes).

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating ITBS with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic ITBS problem if you do not consider, and treat, the fascial interconnections.

The key is to any therapy is to address any structure affecting movement patterns in the kinetic chain.

What ever the form of treatment it must be specific and based upon the individual requirements of each person. Treatment should not be a cookbook approach. Practitioners need to find the specific tissues that are restricted or thickened and physically work them back to their normal consistency.

Exercise is Essential

Often getting professional help in the way of manual therapy is essential to get a complete resolution of ITBS, but just as important is exercise. Without the right exercise program the probability of this condition returning is very high.

There are three important areas which must be addressed when prescribing exercise routines for ITBS, strength, flexibility, and balance.

Why strengthening exercises are essential:

Every time you injure yourself, your body lays down new tissue to repair itself. The new tissue is initially very fragile, thin, and easily torn or re-injured. Strength or weight training places stress upon these new tissues, causing them to go through a process of remodeling. In this process, the new tissue literally converts from one type of collagen to a different type which is up to 10 times thicker and 10 times stronger. However, this collagen conversion only occurs when you apply continued stress upon the tissue as you do in weight- and strength–training exercises.

Exercise example: Because the iliotibial band is formed from the deltoid complex, having strong balanced hips is essential for a full resolution of ITBS. One of my favorite exercises to increase hip strength is the Bulgarian Split Squat.

Why Flexibility exercises are essential:

During the regenerative or repair phase of an injury, your body creates and lays down collagen to repair the injured area. When the injured person performs the correct stretching exercises, the majority of new tissue will be laid down in the same direction as the tissue that is being repaired - thereby allowing this tissue to properly perform its function.

Exercise example: We suggest that patients combine stretching with self myofascial release (foam rollers). The following is an example of an ITB stretch, and a foam roller video you will find very useful.

Why balance exercises are essential:

Proprioceptive or balance training is a fundamental requirement that should not be ignored in Rehabilitation Therapy. Your ability to balance depends on feedback from your auditory, visual, proprioceptive (sense of body position), and vestibular systems (relating to the sense of equilibrium). All of these systems must be trained to achieve optimal results. As with all injuries your nervous system is often affected. Training these systems, ensures a greater chance of a complete recovery.

Hamstring Injuries - Myofascial Considerations

2012-01-23T12:40:00.008-07:00

Fascia is everywhere, weaving through, and interconnecting every component of our body.

Muscle fibers originate from, and insert into, fascial fibers. These fascial fibers, in turn, insert into multiple regions of the bone, and even into adjacent muscles. These additional points of contact and control provide the muscle with the ability to generate force in multiple directions.

Only certain sections of the muscle contract when performing an action. Force is not generated from just the origin and insertion points, but also through the numerous fascial connections.

Muscles work together as functional units that coordinate their actions across multiple joints. Depending on the degree of motion required, and amount of force that is needed, each muscle will contract only specific areas of the muscle, rather than the entire muscle. These very specific motions are largely coordinated by the neurological receptors embedded in the fascia, and not by the brain.

Fascia is full of two types of neurological receptors -mechanoreceptors and proprioceptors. A mechanoreceptor is a sensory receptor that responds to mechanical pressure or distortion. A proprioceptor is a sensor that provides the brain with information about joint angle, muscle length, and tension.

Motion is coordinated by the feedback of the neurological receptors in the fascia when tension is transferred from one area to the next. (Previously these receptors were only thought to be located within just the muscles).

Fascial Lines and a Hamstring Injury

When we evaluate a hamstring injury, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating motion. It is important to look at the big picture, and take into consideration that multiple muscles, working across multiple joints (all of which are interconnected by fascia) are all required to coordinate these motions.

In the case of a hamstring injury, the fascial connections we should consider are in theSuperficial Back Line (see Anatomy Trains by Thomas Meyers). The following is a short synopsis of the posterior line. I have also included a link to the Anatomy Trains dissection video about the posterior line – Thomas Meyers Superficial Back Line Video.

Superficial Back Line

Beginning at the bottom of the foot with the plantar fascia. This fascia passes over the heel bone (c alcaneus) and inserts into the Achilles tendon.
The Achilles tendon is formed by the calf muscles (Gastrocnemius and Soleus). There are direct fascial connections into the hamstrings.
There are fascial connections directly into the sacrotuberous ligament, which runs into the sacral fascia.
Connections from the sacral fascia run directly into the back muscles (erector spinae) from the low back (lumbar spine) up through the mid back (thoracic spine) into the neck (splenius and semispinalis capitus).
Fascial connections then continue up the neck to the fascia on the skull (nucal line). This continues along the scalp fascia to the forehead just above the eyes.

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating a hamstring injury with all the right techniques (ART,Graston, Massage etc.) and find that you still have not resolved a chronic problem you need to consider, and treat, the fascial interconnections

Functional Hamstring Exercises

2012-01-23T10:06:00.007-07:00

It is very important that the hamstrings are trained in same manner that they function during real life activities. The hamstrings work in synergy with multiple muscles and do not act as a singular isolated muscle. For example, to mimic hamstring muscle function during running the hamstrings need to be training in both open and closed kinetic chain movements. Closed chain exercise will mimic the stance phase of running, and open chain exercises can mimic the swing phase of running (eccentric actions).

Closed kinetic chain exercises – These are exercises where, in the case of the lower extremity, the foot is in constant contact with the ground. Examples would be: Lunges, squats, dead lifts, power cleans. These exercises focus on the co-contraction of multiple groups of muscles at the same time. They also involve multiple joints at the same time: those being the ankles, knees and hips.

Open kinetic chain exercises – These are exercises where the leg/foot is free to move and is not in contact with a surface. These exercises are usually non-weight bearing.

Numerous researchers recommend that your hamstrings should be 60 to 80% as strong as your quadriceps.

Strengthening Your Hamstrings

Strengthening your hamstrings is an essential component in reaching a full recovery from an injury. These are only a few of the strengthening exercises we recommend to our patients.

Romanian Dead Lift - This is a great closed kinetic chain exercise for training the hamstrings in eccentric contraction. Starting with low loads, for rehabilitation training, then building up to higher levels for athletic training.

· Stand straight with your lumbar spine in slight extension, with a barbell or dumbbells in your hands. Feet should be shoulder width apart, legs are straight, but not hyper extended.

· Flex forward from the hips moving the barbell or dumbbells down the front of your legs. Do not bend your knees all motion needs to come from the hips.

· As you lean forward, the hamstrings will lengthen, placing them under considerable eccentric load.

· Continue to lower the weight until you can no longer hold your back in the extension position. This will probably be when the weight is at the middle of your shins.

Single Leg Dead Lift – This is a similar exercise to the Romanian dead lift but is performed one leg at a time holding a dumbbell with both hands.

· The same procedure is used except that the back leg can be raised off of the ground for balance

B – Skip Drill

This is a common running drill that is great for strengthening the hamstrings (pawback). Follow this link to view a video on how to perform B-Skips. When doing this exercise, emphasis should be placed on pawing and driving the hip through. (Youtube Video of B-Skip Drill).

Stretching Your Hamstrings

Stretching after a hamstring injury is extremely important. Initially, stretching may have to be done passively within a pain free range of motion. To get a better idea of why stretching is so important, consider this. During the first two days to six weeks after an injury, collagen is formed and laid down to repair the injured area. If an injured person is performing the correct stretching exercises, the majority of the collagen will be laid down in the same direction as the tissue being repaired. This makes the repaired tissue stronger and more capable of performing its function. If the individual is not stretching, the tissue will be laid down in more random patterns, leading to the development of weaker tissue that is easily re-injured (scar tissue).

A word of caution, be careful not to be too aggressive with stretches after an injury. Do not stretch past the point of mild discomfort, doing so may delay healing and cause further injury.

Psoas Stretch

The psoas is a very important muscle to stretch if you have had a hamstring injury or wish to prevent one from occurring. There is an antagonistic relationship between the psoas muscle and your gluteal muscles. Essentially when the psoas become short and contracted it turns off your glute muscles. Your glutesand your hamstrings are your primary hip extensors. Therefore when your glutes get turned off, more of the load is placed on your hamstrings which then become susceptible to injury.

There are several ways that you can stretch out the psoas with either static or dynamic stretches.

Psoas Stretch: Core performance video on dynamic psoas stretch

Note: that after the psoas muscle is stretched out the gluteal muscles should be worked to regain activation of the muscle. This will help to take stress off of the hamstring.

Balance and Proprioceptive Training

Whenever a sprain/strain injury occurs it is not just the ligament, tendon, or muscle fibers that are damaged. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) are essential for postural control.

Both Golgi Tendon Organs and Muscle Spindle Cells are sensory neurons(proprioceptors). Sensory neurons monitor muscle and tendon motion (contraction and stretching) and relay this information back to your brain. This creates a feedback loop system that allows your body to discern its position and postural orientation. Joint receptors are located in joint capsules and respond to deep pressure and to other stimuli such as stress or change in position. They are also part of your body’s neurological feedback loop system.

What appears to be just a simple hamstring tear often involves some damage to several neurological structures. The good news is that the nervous system is very good at repairing itself given the right type of exercises.

That is why every patient that comes to us for a hamstring tear is also given exercises that involve balance training. Balance training helps to repair neurological damage, substantially decreasing the chance of re-injury

For more information, go to www.releaseyourbody.com. If you would like information about our clinic please see www.drabelson.com.

References

Boyle M. FunctionaL Training for Sports. Human Kinetics 2003. ISBN 073604681X.

CooperDL, Fair J. Trainer’s corner: hamstring strains. Phys Sports Med1978; 8: 104.

Croisier JL, Forthomme B, Namurois MH, Vanderthommen M, Crielaard JM. Hamstring Muscle Strain Recurrence and Strength Performance Disorders. Am J Sports Med 2002; 30(2) : 199-203.

Garett W. The management of muscle strain injuries: An early return versus the risk of Recurrence. Clin J Sport Medicine 2002 12;3-5

Heiser T, Weber j, Sullivan G et al prophylaxis & management of hamstring muscle injuries in intercollegiate football players. Am J sports med 12 : 368-370, 1984

Jonhagen S, Nemeth G, Eriksson E. Hamstring Injuries in Sprinters: The Role of Concentric and Eccentric Hamstring Muscle Strength and Flexibility. Am J Sports Med 1994; 22(2): 262-266.

SafranMR, Seaber AV, Garrett WE Jr. Warm-up and muscular injury prevention: an update. Sports Med1989; 8: 239–249

SlocumDB, James SL. Biomechanics of running. JAMA1968; 205: 721–728.

Activating Your Hips

2012-01-22T21:51:00.003-07:00

A great deal of your core stability actually comes from your hips... an essential part of your kinetic chain and certainly not the part of your body that most of us would associate with dysfunctions and problems in your extremities (neck, shoulders, arms, hands, legs, feet, etc.).

Your hips also act as shock absorbers when you walk, run, or perform any action involving your legs. When your hip capsules and the muscles surrounding them move easily and freely, your body is able to store and release the force/energy generated when your feet strike the ground.

In contrast, a lack of hip motion (due to restrictions in either the hip capsule or the hip muscles) will often cause excessive force to be directed into the lower back and knees. This lack of force dissipation results in your body making compensations from your lower back into your neck and shoulders and can cause a series of chronic injuries.

This type of compensation is often seen in golfers who suffer from chronic shoulder injuries due to a lack of hip motion. Every time the golfer swings, he or she has to over-compensate for their restricted hip with excessive rotation of their shoulders. This usually results in neck, shoulder, and sometimes even jaw pain! Sound familiar?

Another major problem that occurs in conjunction with hip restriction is osteoarthritis. Restrictions in your hip prevent proper dissipation of force. Ideally this energy is stored and released with normal leg motion. However if, due to restrictions, the head of your femur (leg bone) is jamming directly into your pelvis (socket joint), you will see excessive wear and tear of the hip joint. This eventually leads to osteoarthritis, and in some cases, to a preventable hip replacement.

Basically if your hips are restricted, your body will compensate for this lack of motion by creating excessive motion in other parts of your body. Stress in your low back (due to lack of hip motion) causes compensations all the way back up to your shoulders and your neck.

The key point is that hip restrictions are often a contributing factor for many injuries which are distant from that area.

Shaping Your Glutes

2012-01-21T18:13:00.014-07:00

One of my patients the other day asked me what she could do to target her glute muscles. I told her that the best strategy was to do an overall full body workout. But I also gave her a specific exercises that works reallly well to strengthen and shape the glutes. This exercise is called the "One Leg Split Squat or Bulgarian Split Squat".

Click this line to play the video...

One Leg Split Squat or Bulgarian Split Squat

The one leg split squat or Bulgarian split squat is an excellent exercise for activating the glutes (external hip rotators). Besides shaping the glutes this is a key exercise in rehabing back, hip, knee, ankle and even foot injuries.

Working within your Aerobic and Anaerobic Zones

2012-01-20T12:58:00.005-07:00

Your warm-up, like all initial aerobic activity, needs to be performed within your aerobic zone. This is the range within which you want your heart to operate while you are performing your aerobic exercise. Think of your aerobic zone as the base which you must first establish for rehabilitation, and also for moving into the higher levels of performance in your chosen activity.

Calculating your aerobic zone - Use the following formula to calculate your aerobic zone

1. Subtract your age from the number 220.

For example, if I am 40 years old, then 220 - 40 = 180

2. Obtain the low end of your aerobic range by multiplying the result of step 1 by 0.6.

In our example: 180 * 0.6 = 108 3.

3. Obtain the high end of your aerobic range by multiplying the result of step 1 by 0.7.

In our example: 180 * 0.7 = 126

This is your aerobic heart rate zone within which you need to work to develop your aerobic capacity. It is the zone which will best speed your recovery from an injury. If you work above this zone you run the risk of injury. If you work below this zone, you will not achieve the maximum benefits provided by your aerobic warm-up.

Calculating your anaerobic zone - Calculate the ideal heart-rate for your anaerobic zone by using the following procedure:

1. Subtract your age from the number 220.

For example, if I am 40 years old, then 220 - 40 = 180.

2. Obtain the low end of your anaerobic range by multiplying the result of step 1 by 0.8.

In our example: 180 * 0.8 = 144

3. Obtain the high end of your anaerobic range by multiplying the result of step 1 by 0.85.

In our example: 180 * 0.85 = 153

This is your anaerobic heart rate zone within which you need to work to develop your anaerobic capacity. It is the zone which will best assist in increasing muscle mass, speed healing, and increase immunity to disease.

Interval Training and Anaerobic Zones

Interval training is the classic method for increasing your anaerobic zone. There are many books, references, and sports specialists who can help coach you through this process.

Find a good program that works for you and keep the following tips in mind as you start interval training:

Before doing any type of interval training, always warm up for at least 10 to 15 minutes within your easy or low aerobic zone.
Train within your anaerobic range for a maximum of 3 minutes.
Then return to your 0.6 to 0.7 (aerobic) level for five to seven minutes.Your heart rate should return to this 60%- 70% range when you are doing your aerobic training. If it does not, consider this to be an indication that you need to spend more time developing your aerobic capacity.

Note: I highly recommend purchasing a heart rate monitor if you are going to work on increasing your aerobic capacity. They are well worth the investment.

This information is derived from our Release Your Kinetic Chain Exercise Series - Shoulder To Hand. If you would like to more information or to purchase our books please go towww.releaseyourbody.com . If you would like information about our clinic in Calgary Alberta please go towww.kinetichealth.ca.

Focus on Core - Front-to-Side Bridge

2012-01-19T11:05:00.001-07:00

This exercise is excellent for strengthening your core and improving your neuromuscular responses. The key is to keep your core braced throughout this routine by bracing your rib cage to your pelvis. Do not allow your core to bend as you roll from one shoulder to the next. The Front-to-Side Bridge is an exercise that combines the movement patterns of both the front and side bridge, and acts to stabilize the shoulder, core, and lower extremity.

Click on the image to view instruction on how to perform this exercise…

Release Medial Epicondyle on Foam Roller

2012-01-18T00:40:00.005-07:00

Many golfers suffer from Golfers Elbow, caused by tightness in the medial aspect of the elbow. This myofascial release of the medial epicondyle will help you to avoid this syndrome. For best effect, accompany this exercise with the other forearm and elbow foam roller exercises in our shoulder to hand book.

Click on image for instructions on how to perform exercise...

Benefits of Cardiovascular Exercises

2012-01-16T11:10:00.002-07:00

Cardiovascular or aerobic exercises provide huge benefits to your circulatory, respiratory, and immune systems. Aerobic exercises play a key role in speeding healing, increasing performance, preventing degenerative conditions, and even preventing numerous types of cancer.

Weight-bearing exercises such as running and walking strengthen not only your muscles, but also your skeletal system, and help to decrease the risk of osteoporosis and other age–related diseases.

Aerobic or cardiovascular exercise is all about increasing your aerobic capacity, improving circulatory function, and increasing energy production. Aerobic exercise does this by increasing the density of capillaries in your muscles and by increasing the level of mitochondrial function in your cells. When you have more capillaries, your cells are able to obtain more nutrients for repair and work, and are able to get rid of waste by-products much more rapidly.

Your mitochondria are the principal energy producers in your cells. Mitochondria convert nutrients into ATP (adenosine triphosphate), a readily–metabolized form of energy used by all living cells. The more energy you have, the easier it is for your body to heal itself and power all the tasks you must perform each day.

Aerobic exercises also promote the loss of excess fat and increases your metabolic rate. In addition, aerobic exercises increase the sensitivity of your cells to insulin, and help your body to better regulate its sugar levels. This is very important for all of us to keep in mind since over 7% of our population now suffers from diabetes; and with increasing rates of obesity, more people are at risk than ever before.

Anaerobic exercise (exercising with reduced blood oxygen levels) is also very important for performance or athletic training. Just like weight training, anaerobic training also promotes the production of Human Growth Hormone (HGH). Research has shown that short intense bursts of anaerobic activity produces high levels of lactic acid. In a high–lactic acid environment, your body increases production of HGH. This means that when we combine anaerobic activity with weight training, we can substantially increase our HGH levels. Bottom line: we will be stronger, leaner, fitter, and healthier.

You should include at least half an hour to forty-five minutes of walking and running in your daily exercise regime. If your schedule is too busy for daily walking, then try to ensure that you walk or run vigorously at least three to four times a week.

Russian Twist with Medicine Ball

2012-01-15T01:55:00.006-07:00

Great exercise to help you perform actions that require stabilization of your upper extremity on your torso, such as a golf swing. This exercise really works and strengthens the rectus abdominis, external and internal oblique abdominal muscles, and the transversus abdominis.

Click on the image for instruction on how to perform this exercise.

This information is derived from our Release Your Kinetic Chain Exercise Series - Shoulder to Hand. If you would like to more information or to purchase our books please go towww.releaseyourbody.com . If you would like information about our clinic in Calgary Alberta please go towww.kinetichealth.ca.

Aerobic Warm-Ups and Injury Resolution

2012-01-13T13:29:00.007-07:00

It may sound a little strange when we tell you to “warm up” your entire body, especially when you feel that your pain is localized in one area like your jaw, neck, or shoulder, and you just want to get started on resolving that particular issue.

But this initial aerobic workout (lasting for 10 to 20 minutes) is one of the first things you should do before you ever begin working on your injured or restricted areas, and definitely before you begin any exercise routine.

Improving Cellular Function with Aerobic Exercises

Aerobic exercise is the fastest way to increase the strength and function of your cardiovascular system. By increasing the density of capillaries, you are able to get more nutrients into your muscular tissue, thereby helping them to heal and perform better.

The increased density of capillaries means that you are better able to eliminate the waste by-products of healing and metabolism from your cells, again allowing them to perform more efficiently.

Aerobic exercise also increases the function of mitochondria in your cells. This increased mitochondrial function immediately boosts your body’s ability to generate power and energy since your mitochondria are the principal energy generators for your cells.

Mitochondria convert existing nutrients into ATP (adenosine triphosphate), a form of energy that is readily usable by all the cells in your body. Your body uses this energy to perform all of its functions – from healing existing injuries, to eliminating waste, to powering your muscles when you walk, talk, or perform any action.

As we age, or when we injure ourselves, our ability to produce ATP decreases. Exercise is one of the few factors that will naturally increase ATP production to give you increased energy.

Aerobic Warm-Ups how they helped resolve my injury!

I have had a personal experience that showed me the importance of cardiovascular warm-ups as they relate to recovering from an injury.

I am speaking about an injury for which most people would never perform an aerobic workout. A few years ago I suffered from a severe case of Bell’s Palsy (weakness of the nerve that innervates and controls the muscles for facial expression) on one-half of the face.

Bell’s Palsy left me with the muscles of one-half of my face paralyzed and expressionless. I was told it would take 3 to 6 months before normal nerve function would be restored!

I was unwilling to live with this condition for that long and immediately researched means for reducing this time frame. One of the first things I did after getting Bell’s Palsy was to get on my road bike/wind trainer for at least 20 to 30 minutes each day. I followed this up with TMJ massage and a variety of jaw, neck, and shoulder exercises.

To everyone’s amazement, I recovered fully, with complete neuromuscular control of the muscles in my face, within about a month. I am convinced that my daily aerobic exercise is one of the major reasons I got over this condition in about a third of the normal time. The aerobic exercises I did every day resulted in increased circulatory function and improved mitochondrial activity (energy production)!

So take the time to do your aerobic warm-up before doing rehabilitative exercise programs...you will be amazed at the difference it makes in your healing, recovery, power, and strength development!

So What is a Good Warm-up?

A good warm-up should include all the large muscles of your body and include movements that increase your heart rate and breathing. This is a good opportunity to listen to your body, and recognize any injury, tight spots, or restrictions that you may have to accommodate during your exercise routine.

Go for a brisk 10–to–20 minute walk. Make sure you move your shoulders and swing your arms. Good upper extremity motion takes the stress off your back and helps you to store and release energy from your core. Don’t walk at a slow pace, this will not achieve the desired results and is actually quite hard on your back compared to brisk walking.
Jog, or run for 10 to 20 minutes. If you are not a runner, start with a brisk walk interspersed with a few short jogs. If you are a runner, make sure you maintain a good upright posture with good shoulder movement, and make sure you land on the middle of your feet. No toe or heel running as this deactivates your gluteals and causes a lot of other problems. Treadmills are fine but do not increase your elevation too much.
Swim for 20 minutes. If you are doing the front crawl, make sure you breathe from both sides. You don’t want your warm- up to create neuromuscular imbalances because you breathe from just one side of your body.
Use an elliptical or ski machine for 10 to 20 minutes. Both are good for reinforcing a cross-crawling pattern, which helps establish good neuromuscular control, as well as for warming up all the big muscles of your body.
Ride a stationary bike for 10 to 20 minutes. This option is not my first choice due to the lack of motion in the upper extremity. In terms of bike types, I prefer the use of upright bikes much more since you can maintain better posture, especially if you have a history of back pain.
Hula-hoop for 5 to 10 minutes. Most people may not think of this as an aerobic exercise, but it is! The hula-hoop is not only a lot of fun, but it is also a great way to learn how to properly brace your core – a key concept in core stability.

Massaging Trigger Points in Your Hand or Feet

2012-01-10T22:23:00.005-07:00

Trigger points are tender points in your muscles where you will find palpable nodules in tight muscle fibres. These are areas where blood flow has decreased, lactic acid has built up, and muscles have tightened up to form “knots” or “nodules” of tissue.

There are two types of trigger points - Active and Latent. When you compress an Active Trigger Point, it will refer pain to other areas of your body. Compression of a Latent Trigger Point will only cause pain at the point of compression, but will not refer pain. Trigger point massage focuses upon releasing the tightness in these hyper-irritable sports.

Use of a golf ball to apply pressure upon the trigger point to release the restrictions.

Apply Trigger Point Therapy

Roll the golf ball in firm, circular motions across the area for 10 to 20 seconds.

When you find an area that is particularly tender, use the golf ball and work this area for an additional 20 to 30 seconds until you feel a softening of the trigger point.

Monitor the level of pain on a scale of 1 to 10 (where 10 is excruciating pain). Do not exceed a level seven pain.
Ask yourself, “Would I be willing to do this again tomorrow?” If not, you are pressing too hard, so back off on the pressure.
Don’t be aggressive with your therapy.
Be consistent with your therapy. Perform the trigger point therapy
several times a day.

Click on the image for an example of how to perform this type of protocol.