Jun 23, 2014

The Effects of a Foot-Toe Orthosis on Dynamic Balance Pt. 2

Greetings Everybody! I wanted to take a moment today to follow up with my original post regarding my recent research study with some of our final findings. While we have finished the study and I have completed my thesis...this information is far from completing its journey through the peer-reviewed process.

Nevertheless, here is a quick rundown/recap: We had 63 healthy and physically active college age students between the ages of 18 and 29 years that volunteered for this study. All participants were randomly allocated into one of three groups by an online random group allocation generator. We hoped to have more subjects in this study but I ran out of time to recruit more and I needed to cut my losses if I wanted to finish the study and graduate on time. One group received the foot-toe orthosis (Correct Toes - FTO ) and the control shoe (Lems Primal 2 - SO), one group received the control shoe only, and one group was a true control (CON) that received neither intervention. The following table displays our group demographics...ideally I wish we could have made the groups perfectly even and had more subjects overall.
Screenshot 2014-06-23 at 3.43.22 PM.png
Just to review, we used the Lower Quarter Y-Balance Test (YBT-LQ) as our measure of dynamic balance. I’m not going to go over all of the procedures and what not again because you can find all of that information in the above link from the original post. So why don’t we just get down to the fun part...The Findings.
Screenshot 2014-06-23 at 3.49.21 PM.pngThere is a lot of numbers in that table...and it isn’t very pretty. Nevertheless, it does tell us some important information. After adjusting for baseline scores (ANCOVA) there were significant differences between the post-intervention scores on the YBT-LQ. This means that there was a statistically significant difference (p=.001) between the groups at follow-up testing. Also, these YBT-LQ scores are the composite scores. That means they are the maximum reach directions for each reach direction(anterior, posteromedial, and posterolateral), and then normalized for apparent leg length.

Pairwise comparisons revealed that the FTO group was significantly different (p=.001) from the CON group. There was also a significant difference (p=.034) between the SO and CON groups. Additionally, the FTO group was significantly different (p=.007) than the SO group. The FTO group had a strong effect size of .70 while the SO group had a moderate effect size of .45. Phew, that paragraph sounded a lot like a journal article...So lets use a pretty graph to highlight this information even further and it is much easier on the eyes.

So what does this all mean? The purpose of our study was to see if the foot-toe orthosis had any effect on dynamic stability. Our results were the first to show that this type of orthosis could be used to increase dynamic balance with 4 weeks of use in a healthy, young-adult population. These results were similar to other interventions to increase dynamic balance/postural stability using mediums such as textured surfaces, insoles and traditional orthoses. However, due to the difference in metrics and intervention choice...direct comparison isn't really feasible.

There are several theories abound for why such interventions may be efficacious such as increase afferent input to the feet/toes and the potential for passively increasing the base of support. However, it was beyond the scope and aim of this study to determine why they work and unfortunately we didn’t enough measures to control well enough to check on some of these theories.

We do know that when wearing the foot-toe orthosis the base of support is certainly increased, yet pre and post data collection was done without the use of the foot-toe orthosis. This means the increased dynamic balance was not reliant upon the foot-toe orthosis. Additionally, the control shoe only group saw an increase in dynamic balance as well.

This could be attributed that the control shoe was technically advertised as a“minimalist” shoe by manufacturer and despite a lack of universal definition for a minimalist shoe...I would have to agree that this shoe was minimally cushioned, zero drop (ramp from heel to forefoot), offered no support to the foot beyond grip, and had a wider toe box than most traditional footwear. This design could potentially work to increase dynamic balance through increasing the base of support and allowing better afferent input.

In conclusion, our results suggest that the use of the foot-toe orthosis and the control shoe may increase dynamic balance in a healthy and college-aged population. The moderate to strong effect sizes associated with our results are promising; However, it is imperative that future research be conducted to investigate the effects in differing populations such as the elderly, the injured, and people with neuropathic conditions such as diabetes. It must also be investigated on whether these findings have any impact on injury risk and to determine what the long-term effects of use. This information could help researchers or clinicians investigate potential treatment or prophylactic approaches.

Jun 21, 2014

Álvaro Pereira Plays Defender Without Reciprocation

If you live under a rock or have been hanging out at Walter White's hide-a-way cabin then you probably haven't noticed anything strange. However, Twitter, Facebook, the global news, armchair quarterbacks, and the world player's union has been up in arms about Álvaro Pereira's head injury in the world cup match between Uruguary and England.

In case you didn't see it...Pereira suffered a blow to the head that rendered him unconscious. Nevertheless, he was allowed to continue to play despite that the team physician for Uruguay motioned for a substitution for Pereira. I won't delve too deeply into a play-by-play of the event but Pereira exhibited these obvious signs and symptoms of a concussion:

  • loss of consciousness
  • poor/altered balance and motor control
  • Mood Swings
    • Angrily signed to decline substitution
    • repeated apologized for being "dizzy"
  • Self-reported anterograde amnesia, couldn't remember much directly after being hit
    • "It was like the lights went out a little bit."
Nevertheless, Pereira continued on and was allowed to play. FIFA has come under much scrutiny in the past couple of days because of this. My first reaction however is instant disapproval and disappointment with the medical staff and Pereira's own teammates. I shouldn't jump to conclusions because I do not know the true policies and procedures for the medical staff, team and the individual.

Regardless, knowing what I know and what the medical staff should know this decision was inexcusable. This stage...the WORLD CUP...sets a huge precedent for children, young athletes, parents and coaches alike of how concussions are/should/could be treated. It is disappointing and unacceptable. 

I honestly make the argument that if I was the team doctor or physio/AT and this event occurred in front of my eyes then I would interrupt the game until Pereira was substituted or I have to be dragged off the field forcefully without Pereira and be relieved of all responsibilities related to this event. I don't know how a teammate, comrade or brother-in-arms would comfortably feel OK with him continuing to play. This wasn't a possible head injury with shades of grey...it was an obvious one that was black and white and clear as day.

Some might argue that Pereira made his own choice, he is a professional, and that this is his life and he should be allowed to make this decision. To me that is akin to saying that a boxer should be able to continue after being knocked out if they want, to allow a race car driving to continue after racing after sustaining life threatening injuries or allow mentally impaired (drugs or alcohol) individuals/patients with brain damage to make their own decisions.

 There is a reason people have living wills, are not allowed to drink and drive or get tattoos under the influence of alcohol and etc. I have never met or evaluated an athlete that wanted me to remove them from competition after sustaining a head injury. They are all brave, courageous and have an incredible drive to compete but they can also make utterly ridiculous and stupid decisions at the same time.

I know that some of you may not agree with this whole-heartedly or may be vehemently against my opinion. However, I am trained to do no harm. Protect and prevent my patients from hurting themselves and others or potentially injuring themselves further. We wouldn't allow Pereira to continue to play with a fracture but one might be able to argue that the risk of permanent bodily harm or death is more likely with the injury that he did sustain that he was allowed to play with. Pereira is a defender on the field but where were the people that should have been defending him? I guess that is enough ranting for one weekend.

Jun 17, 2014

Do I Believe in Chiropractic Medicine?

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Supposedly this is a painting of the first chiropractic "adjustment"
That is the question that was asked of me recently by a client. This question was offered to me in a hushed manner as if it was a taboo or risky thing to ask somebody.

In reality, I can understand the demeanor of the question due to the previous issues between the chiropractic profession and societies like the American Medical Association.

Curious to what my answer was? I told her that I do NOT believe in chiropractors...Pause...I also do not believe in physical therapists, athletic trainers, medical doctors or osteopaths. However, I do believe in critical thinking, sound clinical reasoning, clinicians that get results, evidence based practice, and the scientific method. There will always be good eggs and bad eggs in any profession. There will always be some patients that will respond to some clinicians/treatments/therapies/exercises better than others. It doesn't mean they are bad but they weren't appropriate at that moment in time.

I think she has lost her marbles.

As Charlie Weingroff would say, "I don't care if all you do is spread peanut butter on somebody, if it makes them move better or with less pain from baseline to post-testing."

Test - Intervention - Retest.

That is starting to be my new gold standard for how I feel about different clinicians. I could turn this into a profession bashing fest but its almost like discussing stereotypes...they just are not true for everybody. Not to mention it would be unprofessional of me. ;-) 

I am also biased towards systems of evaluation like SFMA/FMS/PRI/MDT because they guide treatment and funnel down issues to specific dysfunctions. This is a step in the right direction compared to trying to guess why somebody strained a hamstring, or treating all shoulder impingements the exact same way.

In conclusion, when you really start to look at stuff on a broader scale you will notice that the overlap between professions of physical medicine is constantly increasing and the points of distinction really aren't that distinct. I also see the need for more clinicians to be willing to work together. Do not let ego get in the way of referring to another provider just for the sake of keeping your cash flow constant. The real future is who can become distinct by delivering the best outcomes and results to the patient. This is customer service after all.

Jun 10, 2014

Please Leave Your Poor Hamstrings Alone!

"Tight Hamstrings, The Epidemic That Never Existed."

 -Dr. Erson Religioso, DPT

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Trying to touch my toes at my first SFMA seminar.
This little nugget of knowledge developed during a conversation that my good friend Dr. E of The Manual Therapist and I were having together after his recent post. It is crazy how many times you will hear people mention how tight their "hammies" are or how often you can look at people exercising in public and the only thing they stretch is their hamstring group after some light arm circles. It is bewildering to me sometimes.

I think there is a real epidemic in progress and is growing at an exponential rate. However, the epidemic is NOT hamstring tightness...The real epidemic is a plethora of people, old and young alike, that can not touch their toes. Touching your toes without bending your knees is...or should be a fundamental human movement pattern. I know many of us fear lumbar motion and especially extreme lumbar flexion but spinal (that includes lumbar) motion is completely normal and necessary. We aren't talking about lumbar flexion under load here.

On top of the population of people that can not touch their toes...there are plenty of people that can do so. However, I didn't say everyone that could do this was able to do it satisfactorily. Using the Selective Functional Movement Assessment (SFMA) standards a person should be able to touch their toes without bending the knees, should have a uniform spinal curve throughout all of the spinal segments, have a sacral angle of > 70 degrees, and should utilize a posterior weight shift or hip hinge to achieve this goal. An inability to achieve this pattern satisfactorily represents an inability for athletic movements such as the deadlift, and an inability to reflexively stabilize the spine.

So what does this have to do with hamstrings? Most people that can not touch their toes often jump the gun and assume that it is due to posterior chain tightness or tight hamstrings. In reality, this is rarely the case. In fact, I would recommend you always get a second opinion or never evaluate yourself. I actually made this mistake myself and it was evident in a previous post where I did an SFMA video of my own multi-segmental flexion (toe touch pattern). I was wrong in my assessment and I actually had a core stability/motor control dysfunction.

This wasn't evident to me because during a certain breakout assessment I falsely associated the sensation of neural tension to equal soft tissue tension. I didn't realize my mistake until I was auditing the SFMA certification course for the second time. I volunteered myself to be the case for teaching the multi-segmental flexion breakouts. This SFMA course was being taught by Behnad Honarbakhsh, MPT, BHK, CSCS, CAFCI, CGIMS, DO (c) (whom I thought was brilliant) and low and behold in front of the entire class he humbled me and showed me my true dysfunction. Nobody knew that I was humbled because I didn't discuss my prior self-assessment. However, I probably hadn't touched my toes since I was a toddler before elementary school. Michele Desser and Dr. Todd Arnold quickly took me out into the hallway and had me perfom rolling and core stability exercises for about 5 or so minutes. They then brought me back into the seminar and showcased how I went from being about 14 inches from touching my toes down to about 2 seconds. Later that night, back in the hotel room I practiced some more on my own and was able to touch my toes.

So lets find out where I went wrong really quick to showcase how you can check to see if your hamstrings are tight or not.

Step 1. Check to see if toes can be touched. If not, continue on. 

Why can't I? We don't know. Don't blame the hamstrings yet.

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Step 2. Remove Parts and Compare Left to Right. 

Here I unweight one of my legs and check for change. Nothing. Continue on. Still not the hamstrings.

Step 3. Long Sitting Test - Unload body parts. 

Now the hips and below will not be bearing weight and only the spine will be partially loaded against gravity. Still can't touch the toes? Continue on. (Still not the hamstrings despite my P.E. teachers scolding me for my tight hamstrings as a kid)

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Step 4. Unload More, Check Left to Right, and begin Active versus. Passive Comparison.

In this test you are looking for & 70 degrees of hip flexion with both knees remaining straight, feet dorsiflexed, and hips neutral. An inability here STILL is not due to tight hamstrings.

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Step 5. Checking Passive Motion compared with Active Motion from the previous step. 

An inability here to increase motion here beyond what you achieved actively = Ding. Ding. Ding. Winner Winner, Chicken Dinner. You DO have tight hamstrings! There are a few more steps you may take after this finding to pinpoint where the mobility dysfunction is located. However, If you increase more than 10 degrees compared to active but still do not reach normal hip flexion (now 80 degrees instead of 70) then you have a mobility and stability/motor control dysfunction present! If you find that you go from ~40 degrees to normal like I do below then you sir...DO NOT HAVE TIGHT HAMSTRINGS. You have a stability/motor control dysfunction. Continue on to step 6.

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Step 6. Now you must find out how poor your motor control deficit is.

To pinpoint this you regress yourself to the most basic form of stability and motor control...rolling around on the ground. If you can not roll from supine to prone with each of your different limbs then you have a primitive motor control dysfunction. Restoring the ability to roll may fix your inability to touch your toes. However, at this point we are encroaching on the area of the 4x4 matrix of the SFMA. If you aren't in pain currently then I would recommend you finding an FMS certified professional and get screened and start with working on your most dysfunctional issues there first.

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Look at me now...Just a tiny bend in the knees. Working on it. No hamstring stretching needed.

In conclusion, don't evaluate yourself and if you do...Get it rechecked by another set of eyes. The plumbers pipes always leak. Don't be that plumber. Secondly, practice your systems of evaluation or assessment if you have one so you can own it. If you don't use a system how can you be sure you aren't throwing spaghetti against the fridge and hoping that something sticks? What are your metrics for improvement? It has been said a million times and I'll repeat it. You do not need to use these metrics but you should be using something to set a baseline, intervene, and then compare to baseline to check for change.

Jun 5, 2014

Tibial Internal Rotation Mobilization w/ The Edge Mobility Band

I have had a few people ask me lately about using the Edge Mobility Band for tibial internal rotation. I kept trying to refer them to a previous video that I had made about this very topic. However, they couldn't seem to find the video on my blog or on my YouTube channel. Turns out I never edited the video or posted about it on my blog. Oops.

Therefore, this is a quick post and video to show you how I use the Edge mobility band to work on mobility deficits when it comes to tibial IR. A few things before I share the video...

-The band is not a necessity for this technique but I find that it helps enhance its efficacy and the ability to grip the skin.
-The band doesn't need to be wrapped on so tightly that it cuts off blood flow.
-This technique should be pain free.
-You are looking to get at least 20 degrees of tibial internal rotation via the SFMA to be functional...Don't confuse a mobility issue with a motor control issue here. (Active vs. Passive differentiation)
-Do more than the two sets of ten that I did for this video. I filmed this quickly on my phone while at work tonight using one of my coworkers. In the first segment of the video he is actually trying to internally rotate his tibia. He definitely isn't functional afterwards but there is a marked improvement afterwards. Rinse and Repeat this continuously for a few days to weeks to restore full motion.

I am curious what others do for mobility issues regarding tibial IR and subtalar inversion/eversion issues...Please share if you have some input!

Jun 1, 2014

5 Tips For Improving Great Toe Mobility and Stability

The foot on the right is far from ideal, but its great toe position is better

In my previous post I discussed the importance of the "big", "1st", "great" toe, or hallux. I finished that post with a promise to share some ideas and methods for enhancing the health of your foot/toes and here I am to make due on that.

In reality, some people may already be too far gone to see much benefit from conservative methods of treatment. Unfortunately, with enough abuse from faulty footwear, poor biomechanics, and overuse some feet may require surgery. That doesn't mean that you may not find a decrease in symptoms or pain from conservative methods and all avenues to avoid surgical procedures should be explored in my opinion.

Instead of giving tons of in-depth and intricate details on things that you can do for better foot/toe mobility and motor control I am going to give some simple and easy ideas and concepts that can have a huge impact.

1) Avoid Shoes With a Tapered or Narrow Toe Box

The toes should be the widest part of the foot. This is often a rarity for people of developed nations and many think it is normal. However, if you look at a young child or toddler's foot it is likely that their foot still holds this true form. If you look at most footwear you will find that the toe boxes are often very constraining and the widest part of the shoe is usually not at the toes. They often come to a very distinct point about where the second toe is. One thing that I recommend when picking out a pair of shoes is to perform the "shoe liner" test. This is where you remove the liner or insole of the shoe and place your foot on top of it. If your toes splay over the edges then it is likely that the shoe is too narrow for your foot. This is very important for the developing feet of children and I think this video by Dr. Ray McClanahan does a great job of explaining this.

2) Avoid Shoes With a Toe Spring Design

If you view a shoe from a side profile you will notice that many conventional shoes will have a design where the sole will curve upward near the toes. This places the toes into an extended position relative to the metatarsals when at rest. I believe this was originally designed to help the shoe have a "rocker" effect to help people with poor ankle mobility.

3) Avoid Shoes With an Excessively Elevated Heel, "Ramp", or Heel-Toe Drop Design.

I attribute this shoe design and our cultures disdain for squatting (excessive sitting in chairs) to be major contributors to the poor ankle mobility that plagues many people and athletes alike. These three design flaws are discussed indepthly by Dr. Ray once again and he does a great job discussing them in this other video of his. You can do all the joint mobilizations, stretching, and flexibility work in the world but if you keep yourself or your patients in crappy shoes then you are fighting a losing battle.

4) Ensure Adequate Ankle Dorsiflexion

One thing that I have noticed in many patients with issues in the toes is that they are often accompanied by issues at the ankle, especially regarding decreased ankle dorsiflexion. Chicken or the egg here? I'm not sure but if a person lacks the ability to achieve full ankle dorsiflexion then their toes may be at risk for taking an extra beating. What about if you lack toe mobility as well? Good Luck. Here is a video I made for a quick and easy way to check and see if you have enough ankle dorsiflexion.

5) Increase foot intrinsic muscle strength/motor control

It isn't advisable to dive in headfirst and make drastic changes to your footwear in one fell swoop and expect all to be well. Even if you aren't going to change your footwear choices it is still probably advisable to work on intrinsic muscle strength/control. Here is another video I made previously showing some easy ways to improve foot/toe strength and mobility.

If you are still struggling with issues in your feet, ankles, or further up the kinetic chain and these simple tips aren't enough to resolve them then you may possibly need additional manual therapy from an athletic trainer, physical therapist, physiotherapist, podiatrist or chiropractor. There is also the possibility that a conventional approach may not be enough for some issues.

Some issues may require more time or help from products like Correct Toes. An foot-toe orthosis like them requires a post all to themselves but I personally have used it on myself, my patients and in research with some surprising success and outcomes. One thing that I will say is that I like how that product versus the cheaper generic types that you can find at say Walgreens or CVS will actually fit in your shoes, has multiple sizes, and can be modified for your foot shape.


Disclaimer: Please note that some of the links on this blog are affiliate links and I will earn a commission if you purchase through those links. I have used all of these products listed and recommend them because they are helpful and are products from companies that I trust, not because of the commissions that I may earn from you using these products.


All content on this blog is meant as instructional and educational. The author and guest authors of this blog are not responsible for any harm or injury that may result. Always consult a physician or another proper medical professional for medical advice.
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