The Vasti

Do you treat runners? Do you treat folks with knee pain? Patellar tracking issues? Do you treat the quadriceps? Do you realize that the vastus lateralis, in closed chain, is actually an INTERNAL rotator of the thigh (not a typo), and many folks have a loss of internal rotation of the hip? Do you give them “IT band stretches” to perform?

In this short video, Dr Ivo demonstrates some needling techniques for the quads and offers some (entertaining) clinical commentary on the IT band. A definite view for those of you who have needling in their clinical tool box.

 Gastroc Anyone?

 An interesting and innovative rehab tip for a torn branch of the tibial nerve innervating it, along with some requisite anatomy.

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/

Reciprocal Inhibition anyone? Thanks to The Manual Therapist (Erson Religioso) for this great post.

What they are doing here is taking advantage of what Sherrington know many years ago. Activating a muscle (agonist for a movement) will inhibit the muscle with the opposite action (antagonist for a movement), through a disynaptic, post synaptic pathway. It is a great way to gain additional movement and remove or reduce muscular inhibition. Try it!

Remapping the Cortex: How Rehab Exercise does it.

Below are two studies that we recently incorporated into 2 neurologic gait cases during one of our global teleseminars on www.onlineCE.com.  You can find that lecture there in a few weeks but we have dozens of our other presentations available there presently. 

Injury to a body part starts a reorganization of the brain cortex. We know this occurs from a plethora of studies but most of them are based on injury induced changes and not from treatment-induced means.  These studies support the treatment induced changes that occur in the central nervous system, and they are profound and give us comfort and validity in our work. The findings of these studies should not be a shock to you if you are in the work of manual therapy and rehab. 

The one study used transcranial magnetic stimulation to map the cortical motor output area of a hand muscles on both sides in 13 stroke patients in the chronic stage of their illness before and after a 12-day-period of constraint-induced movement therapy.

What they found was “post treatment the muscle output area size in the affected hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb”. As the study showed, this suggested a recruitment of adjacent brain areas. Even at 6 month follow up examinations “the motor performance remained at a high level, whereas the cortical area sizes in the 2 hemispheres became almost identical, representing a return of the balance of excitability between the 2 hemispheres toward a normal condition.”

The second study (2) looked at limb immobilization in 10 right-handed subjects with right upper extremity injury that required at least 14 days of limb immobilization. Subjects underwent 2 MRI examinations post injury, 48 hours and 16 days post immobilization. Cortical thickness of sensorimotor regions and FA of the corticospinal tracts was measured.  The findings showed “a decrease in cortical thickness in the left primary motor and somatosensory area as well as a decrease in FA in the left corticospinal tract. In addition, the motor skill of the left (noninjured) hand improved and is related to increased cortical thickness and FA in the right motor cortex.”

These studies suggest the findings are associated with skill transfer from the right to the left hand. It was suggested that immobilization induces rapid reorganization of the sensorimotor system. 

Rehab works, but everyone here on The Gait Guys already knew that. It is just nice to know the specifics of “how”.  

Please go to these articles and get the specifics for yourself. Don’t take our word for it ! 

references:

1. Stroke. 2000 Jun;31(6):1210-6.Treatment-induced cortical reorganization after stroke in humans. Liepert J1, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C.

2. Langer N, et al “Effects of limb immobilization on brain plasticity”Neurology 2012; 78: 182–188.

 

This simple screening test becomes a form of exercise.

Last week we explored the “Lean” test to see how your QL and gluteus medius were paired. Today we look at a simple CNS screen for your “central pattern generators” or “CPG’s”. If you do not pass, then the exercise becomes the rehab exercise. If you (or your client) does not have good coordination between the upper and lower extremity, then they will not be that efficient, physiologically or metabolically.

The “cross crawl” or “step test” looks at upper and lower extremity coordination, rather than muscular strength. If performed for a few minutes, it becomes a test that can look at endurance as well.

It is based on the “crossed extensor” response, we looked at last week. That is, when one lower limb flexes, the other extends; the contralateral upper limb also flexes and the ipsilateral upper limb extends. It mimics the way things should move when walking or running.

  • Stand (or have your client stand) in a place where you will not run into anything.
  • Begin marching in place.
  • Observe for a few seconds. When you (or your client) are flexing the right thigh, the left arm should flex as well; then the left thigh and right arm. Are your (their) arms moving? Are they coordinated with the lower extremity?
  • What happens after a few minutes? Is motion good at 1st and then breaks down?
  • Now speed up. What happens? Is the movement smooth and coordinated? Choppy? Discoordinated?
  • now slow back down and try it with your (their) eyes closed

If  movement is smooth and coordinated, you (they) pass

If movement is choppy or discoordinated, there can be many causes, from simple (muscle not firing, injury) to complex (physical or physiological lesion in the CNS).

  • If movement is not smooth and coordinated, try doing the exercise for a few minutes a day. You can even start sitting down, if you (they) cannot perform it standing. If it improves, great; you were able to help “reprogram” the system. If not, then you (they) should seek out a qualified individual for some assistance and to get to the root of the problem.

The Gait Guys. Giving you information you can use and taking you a little deeper down the rabbit hole with each post.

The Foot Tripod; Part 2

Here we go. More stuff you can use today. Pay attention to the subtleties of this simple, yet effective exercise we use on a daily basis.

Have a great Friday

Ivo and Shawn

Defective Running Shoes as a contributing Factor in Plantar Fascitis in a Triathlete

Wilk B, Fisher K, Guitierrez W: JOSPT 2000;30(1):21-31

http://www.jospt.org/issues/articleID.407/article_detail.asp

Overview: Case study of 40 yo male triathlete who developed R sided plantar fascitis after completing a half ironman (2K swim, 90K bike, 21K run). The study describes the factors contributing to the injury, the rehab process, and shoe construction along with the symptoms of plantar fascitis.

Authors Conclusion: A running shoe manufacturing defect was found that possibly contributed to the development of plantar fascitis. Assessing athletic shoe construction may prevent lower extremity overuse syndromes.

What The Gait Guys Say: Plantar fascitis is something we see clinically many times in our practices. It is often due to overpronation of the midtarsal joint (talo-navicular and calcaneo-cuboid) in midstance, with insufficient supination from late midstance through preswing.  Thus, this over pronation causing overloading of the plantar fascia and windlass mechanism, resulting in increased torsional forces and micro-tearing at it’s proximal calcaneal (and sometimes distal) attachments. This causes local pain, swelling and inflammation, particularly at the calcaneal attachment site, which is alleviated by rest, ice and analgesics. As we have shared many times now, this over pronation does not have to be a local cause, it could be necessary from insufficient internal rotation of the hip or from other factors.

In this study, the Right shoe upper was canted medially on the midsoles, believed due to it not being glued perpendicularly (as we often see inspecting a shoe from behind, especially Asics Kayano’s in our experience). The authors state they felt this contributed to excessive inward rolling of the right foot, contributing to overpronation.

The authors make the following recommendations about shoe inspection:

  • The shoe should be glued together securely
  • The upper should be glued straight (perpendicular) onto the midsole. The shoe, viewed from behind should have a horizontal heel counter and vertical upper
  • The sole of the shoe should be level to the surface on which it is resting (ie no medial to lateral motion should be present) You can test this by attempting to “rock” the shoe from side to side
  • The shoes should not roll excessively inward or outward when resting on a level surface (ie when rolling from P to A) You can test this by rocking the shoe from A to P
  • Air and gel pockets should be inflated evenly. This can be tested manually by pressing into them and checking for uniformity.

A nice rehab protocol is also outlined over a 4 week period.

Bottom Line: It pays to be shoe nerd. Shoes can help or hurt. We see manufacturers defects in shoes every day and tell clients to return the shoe; in fact some we collect  to use to show people. A rearfoot varus in a shoe will help to slow pronation. This may actually be beneficial for overpronators but detrimental for supinators. Some defects can be helpful but try and find defect free shoes. Stay away from “2nds” at cheapie stores and online specials. There is usually a reason they are being sold so cheaply. EVA’s have a shelf life and will break down over time. You must be able to not only recommend the appropriate shoe for your patient, based on their evaluation and gait analysis, but you need to inspect their footwear carefully and teach them to do the same.

The original shoe nerds….Shawn and Ivo