Is It Time to Replace Your Running Shoes...or Time To Get an Evaluation?

Today's blog post is a tiny rant inspired by overhearing this conversation time and time again between runners...

"Yeah its about time for me to replace my shoes, my 'insert body part here'  has been acting up lately and 'insert symptoms here'. I definitely just need to get some new shoes."

While I concede the fact that slowly overtime the properties of your shoe will change and that will affect the kinetics or forces acting upon your body during activity. However, it is inane to think the real problem is your shoes. More likely is the fact that you probably have an underlying dysfunction that becomes sub-clinical with rapid change in kinetics (new shoes) that can allow the symptoms to alleviate.

Some people may argue that if this system isn't broke then don't fix it. If you have the money to constantly spend on shoes for every fabled 300-500 miles then maybe this is your thought process. On the other hand, what about the possibility that this potential dysfunction or running form issue could be detrimental in terms of potential performance. Even worse, this true dysfunction could eventually manifest into a much larger problem that isn't easily fixed with a new pair of shoes.

Want to know what the better solution is in my mind? Find yourself a clinician (athletic trainer, physical therapist, chiropractor, or doctor) that is experienced with runners, running biomechanics and assessing the entire body. We don't want to find somebody that is going to point out that your shoulder blades are dysfunctional (maybe...we do!?) but perhaps you have a dysfunctional hip or back issue that is manifesting itself as pain or injury at the foot or ankle? There is also the potential for somebody to suffer from a general medical issue that is not musculoskeletal related or potentially related to nutrition/lifestyle choices.

Do yourself, your running performance and your wallet a favor and refrain from buying tons of shoes and save up to get yourself a consultation with an expert clinician.  Don't just settle for anyone but ask around and find somebody that has some of the aforementioned qualifications.  That is my rant of the day!

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The SFMA Course Review, 9/5/13-9/6/13

This past weekend I had the pleasure of attending the Selective Functional Movement Assessment(SFMA) certification course in St. Louis, Missouri. More specifically, the course was hosted on the beautiful campus of Logan Chiropractic College/University.  Logan did a great job of hosting this seminar and they were very accommodating and even had snacks/refreshments/coffee available. The only thing I could think to gripe about was my poor cellphone service in the basement classroom that we used. ;)

I was first introduced to the SFMA by a mentor of mine during my senior year of my undergraduate when he attended an SFMA course himself. He gave me some background about what it was and what they were trying to teach and ever since then I had wanted to learn it myself. Reading the book Movement by Gray Cook and becoming FMS certified didn't help my anxiousness either.

For those of you that don't know what the SFMA is..."The Selective Functional Movement Assessment (SFMA) is a series of 7 full-body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain. When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contribute to the associated disability. This concept, known as Regional Interdependence, is the hallmark of the SFMA.

The assessment guides the clinician to the most dysfunctional non-painful movement pattern, which is then assessed in detail. This approach is designed to complement the existing exam and serve as a model to efficiently integrate the concepts of posture, muscle balance and the fundamental patterns of movement into musculoskeletal practice. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain." -SFMA.com

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Guest Lecture on Dry Needling (Videos Included!)

I am finishing up my last year of graduate school and for one of my courses we have guest speakers from other health professions come and present to our entire athletic training graduate program. This week we had a pleasure of a having a local Physical Therapist(PT) come and present to us on Dry Needling.

Dry Needling is a practice that is growing in popularity in the United States and more and more clinicians are getting trained in it. Athletic Trainers, at least in my state, do not have it in their practice acts to perform dry needling so we must refer out to others that are able to do so. I have referred a patient to this particular PT for dry needling in the past and they had great results from the treatment.

This PT presented on the background of Dry Needling and discussed how it differed from traditional acupuncture (local twitch response on trigger points vs. meridian therapy), and we learned how he incorporated this "modality" into his clinical practice. We also discussed related research to dry needling and it was a pretty informative lecture. Ultimately, he presented the case of undergraduate athletic training student (that is doing a clinical rotation at his clinic)and their chronic injury that coincidentally mirrored that of the patient's that I referred to him. He then went on to utilize dry needling on this student in front of us as part of his lecture, I whipped out my camera to get some video footage of it for all of you!

Before I show you all the footage I will present you with his case:

History:
A 23 y.o. college student has been experiencing R side LBP that began insidiously and has been progressively worsening over the past 2 years. He also reports occasional radicular symptoms to his R posterior thigh area. He rates the intensity of his symptoms between 3/10 - 8/10 that worsen with prolonged sitting in class and while driving. He also notes that he avoids heavy lifting activities at the fitness center including dead lifts and squats. His symptoms are generally decreased with ambulation.

Imaging(who cares, right?):
x-rays were unremarkable, L-Spine MRI revealed moderate disc bulge at L4-L5 level

Self-Report Measures:
Modified Oswestry Disability Questionairre: 14/50 = 28%
Fear Avoidance Belief Questionairre - Work Subscale: = 13

Significant Past Medical History: R ACL reconstructive surgery ('11)

Objective Findings:
ROM:  
repeated trunk flexion = no change in sx, repeated extension = pain that increased with repetition, repeated R side gliding = no change in symptoms, repeated L side gliding = no change in symptoms
Sensation: 
B LE = intact to light touch and pin prick throughout
MSR:
B patella and B Achilles = 2+
Strength:
R knee ext = 5/5, R knee flex = 5/5, R hip abd = 4-/5, L knee ext = 5/5, L knee flex = 5/5, L hip abd = 4+/5
Mobility: 
moderate thoracic spine hypomobility; moderate lumbar spine hypermobility w/ pain provocation
Palpation:
severe R glut max, glut medius, and piriformis hypertonicity w/ pain provocation; elicitation of local twitch response w/ palpation
Assessment: Myofascial Pain Syndrome related to poor strength and stability of lateral hip musculature and core stabilization and hypomobility of the thoracic spine.

Treatment: Dry Needling of the "trigger points" found in the gluteus maximus and gluteus medius. Followed with IASTM of the surrounding musculature and appropriate rehabilitative exercises for strength and stability. There wasn't a true home exercise program recommended to this patient but I would expect that he usually gives them one. I am curious how patients would respond to light IASTM prior to the dry needling instead of doing the opposite.

Here are the two videos! Enjoy! Anyone else have experience with dry needling via patients or personally? I haven't felt it but I am curious to how it feels! I have witnessed it to be an effective treatment but I am still apprehensive about "trigger points" as a topic or entity or our ability to detect them reliably.

Gluteus Maximus Dry Needling

Gluteus Medius Dry Needling (Really Long Needle!) Shorter Video

This weekend I am off to St. Louis to officially get trained in the Selective Functional Movement Assessment (SFMA) and I am very excited! I was introduced to this by my mentor during my senior internship as an undergraduate and have wanted to take this course since then. If you have read Gray Cook's movement you are probably familiar with the system but if you aren't then the simplest way of describing it is to call it a movement based evaluation system. System and movement are the keywords in that sentence. It is the medical professional evaluative half of the Functional Movement System (brother to the Functional Movement Screen). I will write a course review next week and post it here!

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HEP for the HIP: Self Hip IR mobilization!

This is a quick video that I shot in the Athletic Training clinic the other day when working with a basketball player. This is a self-hip internal rotation mobilization that I have my patients perform on their own.

This helps to maintain the benefits gained from treatment and manual therapy when working with me in the clinic.  Ideally, this would be done about once an hour for a single set of 10-20 reps but it can be hard to have a student-athlete comply with this and fit it into their busy schedules.  I also have some of them do this before practice and lifting weights for temporary mobility gains.

This is done by the athlete applying an active-assisted hip internal movement while simultaneously providing slight distraction/traction. Check it out!

I have this athlete using an Edge Mobility Band in this video but they could also do this without the band. However, I feel that using the band is more efficacious due to the better hand-hold and compression provided by it.

In other news, I found an old but good video about pain by Lorimer Moseley on "Why Things Hurt". It is actually a pretty funny video and I am sad that I have only just now found this video. For some of you this will be old but for some of you it may be new. This guy's book is on my current to-read list.

Enjoy and Happy Monday!

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Tuesday Morning's Interesting Finds!

Sweetclipart.com

Eat.

Head on over to Yelling Stop to see Tucker Goodrich's post on the ketogenic diet of a top endurance athlete.

Run.

Like breaking down and analyzing the gait of others? Head over to see Pete Larson's latest post and RunBlogger to analyze some elites in SloMo.

Rehabilitate.

Check out Mike Reinold's latest post on what GIRD is and is not.

Do you train CrossFit or treat people that do? Are you aware of the risk for Exertional Rhabdomyolysis? Get educated on this risk right here.

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Bilateral Femoral Acetabular Impingement In a Collegiate Soccer Player

Today's case comes to us from one of my colleagues and classmates, Kathryn Deterding, ATC. Kathryn consulted with me about this case and then went on to implement a treatment protocol based off our discussion.

http://www.eorthopod.com/images/ContentImages/hip/femoroacetabulr_impingement/hip_FAI_intro01.jpg

A Case of Bilateral Femoral Acetabular Impingement(FAI) and Labral Tears in a Collegiate Soccer Player. 

 

History: This was a 21 year old male collegiate soccer player. In the fall of 2011 he began to experience hip pain that he played through. In the upcoming spring of 2012 he was diagnosed with bilateral FAI and tried to rehabilitate his injury to prepare for the fall season of 2012. The fall season was just as painful as the previous season. This athlete then underwent two different surgical procedures in the winter of 2012. One for each hip, in attempt to lessen his FAI and correct additional labral tears of the hip. The athlete had minimal rehab for a month or so after his surgeries and refrained from heavy activity for a few months. 

Upon increasing activity to prepare for the fall 2013 season of soccer the athlete began to experience the same pain and symptoms. He consulted with an orthopaedic surgeon during the preseason and the physician told him that he may not see any improvements and that this was something that he most likely was going to have to live with.

It was at this point that Kathryn and I discussed the athlete's case together and came up with a plan of care.  The first thing that I did was discuss thought viruses with the athlete and talked about how current neuroscience is teaching us that pain is not necessarily patho-anatomically based but is a construct of the central nervous system. The athlete admitted to thinking that all of this discussion was a load of hogwash and didn't buy into any of what I said. Nevertheless, we continued on with our plan of care.

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Case of The Week: Persistant Postural Headache

Today's case is hot off the press. Hot as in I just saw and treated this patient today.

History: This was a 22 year old collegiate softball player this plays catcher. She has a previous history of occasional headaches that weren't associated with general medical illness. Four days prior to seeing my this patient began suffering from an unusually strong headache. The pain was focal behind her eyebrows and began while she was busy studying and reading in the evening. The patient took ibuprofen but found no relief from it.

Day 2: The patient awoke the next morning with the headache again. This lingered throughout the day and ibuprofen still provided no relief. The headache was severe enough to cause nausea and dizziness as a result. The patient then tried Excedrin which provided minor relief enough to allow her to fall asleep that night.

Day 3: The patient awoke with the same searing headache and once again took Excedrin. This time it only provided minor relief for an hour or two at most. As the day went on the pain increased and induced nausea once again. This night the patient was unable to find sleep at all.

Day 4: A repeat of the previous day began with daybreak and this student-athlete had a lot of reading and studying to do for school. These activities only exacerbated her symptoms even more. Over-the-counter medications now provided no relief and her symptoms continued into the next day when she consulted with me.

Observation: On day 5 of this the patient presented me with her history and symptoms. Upon inspection she had a forward head posture, Bilaterally elevated and protracted shoulders, and an excessively forward slouching posture. I like Jay Dicharry's acronym for this postural presentation "F.A.T.S." aka female adolescent texting syndrome.

Treatment:  I began her treatment much like I do most of my treatments and that was with some light instrument assisted soft tissue mobilization (IASTM). I did IASTM along a cervical pattern and a little bit of her upper traps as well.

Next, I had her do some foam rolling rolling of her thoracic spine to help with increasing thoracic extension and to promote better posture. After this, I had the patient lie supine on the treatment table and had her perform 15-20 cervical retractions into the table. While she would hold the retraction into the table I would apply a light bilateral - posterior to anterior force with the pads of my index fingers just lateral to her C2 spinous process.

The next technique I applied was passive cervical retraction using my right shoulder to her forehead with manual traction/distraction by gripping the occiput with my right hand. I held this for about 20 seconds and did a few repeated retractions as well.

I then instructed the patient on how to perform repeated cervical retractions to cervical extension with manual overpressure. I had her do this for a set of twenty and instructed her that this would be her home exercise program to repeat. Here is a quick video on how these look.

After completion of this I asked the patient how she felt. She told me that her headache was completely abolished and that she an indescribable sensation of clarity. She felt as if she could see further and think more clearly...Funny how pain can cloud our judgement sometimes?

I educated the patient on proper posture and ergonomics for reading and studying. I also lectured her on the necessity to repeat her HEP because of the transient benefits from my treatment.  I told her that she should be able to self-medicate without medication and all that she needed was some quality movement.

I feel that this case highlights a few important things, some are repeat themes to my blog so far:

• Pain can be debilitating even if it from seemingly common and minor issues such as headaches or migraines.
• A rapid onset of pain can usually be rapidly reduced
• Sometimes the best medicine is movement
• This patient wasn't ill and her body wasn't short on OTC meds like ibuprofen or acetaminophen. These drugs aren't helping to fix your pain, just mask it.
• Posture can be paramount but it is not as simple just remembering to sit up straight.
• Patient education and empowerment 
• Patients shouldn't have to rely on my hands or treatments. We should teach them how to carry on the benefits that we provide them and how to treat themselves in the future.

*Case Update*

I just consulted with the patient again and it is the day after my treatment session with her. Her headache did not return later that evening even after heavy exertion at softball practice.  She still feels great and not even a slight migraine to complain about.

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Empathy: Better to Have too Much or too Little?

This is a short post today that I am typing up on my cell phone.  I'm on the team bus riding back from a football game where I just had to tell a college freshman that their first season of collegiate athletics was over after playing only one game.

This athlete most likely completely ruptured their ACL today and will probably need season ending surgery. This wasn't the first patient that I have delivered this news to and I'm sure it won't be the last. They took the news very well compared to others and didn't visibly weep.

Despite the athlete taking it so well I found myself trying to decide how empathetic I should be towards him. The mother of the athlete was openly weeping and so I tried to answer any questions that I could for the family and athlete.  I also tried to be as positive when discussing the future.

Seeing that this athlete is a freshman I have only known them for less than a month at this point. I don't have a lot of history with them and I don't know their personality very well yet. This will change as they will be forced to spend the next six months at least rehabilitating this injury after surgery.

I am writing this post because I find myself wondering if I was too cold, too invested or neither. Actually, I'm wondering if it's better to be one or the other? Maybe it's better for the patient to be overly empathetic and better for my own psyche to be a little desensitized.

The true answer probably lies somewhere in the middle and depends on the situation, the athlete's personality, and the severity of injury. I'm curious how others deal with these types of situations and thought processes. This isn't something that is explicitly taught or discussed in school. Perhaps this is related to why there is such a high rate of burnout in health care professions?

Thoughts or comments? I'd love to hear what y'all think.

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A Few Friday Finds!

Eat:

Earlier this week Mark Sisson discussed or should I say ranted about the haters of people choosing to go or live a gluten free life. His thoughts on this topic parallel very well with my own. Although, haters gonna hate.

Run:

Dr. Gangemi aka the "Soc Doc" did a Q&A over at the Natural Running Center. Questions ranged in topics from NSAIDs to orthotics to minimalist shoes. Check it out here.

Rehabilitate:

I have been seeing a lot of patients and athletes lately with chronic issues and chronic pain. These are often accompanied by mindsets that Dr. Erson Religioso, DPT calls "Thought Viruses".  I have had some success in addressing this with some people and other times I've failed to explain it properly and end up offending the patient. Here is Dr. E's latest post on his to five most commonly encountered thought viruses and the way he goes about addressing them. 

Have a happy Friday! 

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Case of The Week: Bilateral Plantar Fasciosis

Today's post is centered around a patient that I have been working with lately. This athlete is a sophomore collegiate runner that competes in middle distance running events.

History:

This patient is now a 19 year old male that began running in 4th grade. He was in a running club affiliated with his grade school and was soon running around 160miles a year. He began to suffer minor injuries during middle school and somebody had prescribed him orthotics. He struggled with stress fractures, hip pain, and plantar fascia pain all through middle school. Despite these issues, he still managed to run a 4:43 Mile as an 8th grader.

Throughout high school he continued to struggle with injuries such as hamstring strains/tendonosis, spinal stenosis and low back pain, chronic ankle instability and piriformis issues. He also struggled with plantar fasciitis/osis during this time as well.

Once this athlete got to college he tried to transition to minimalist footwear in attempt to "correct" his heel strike. He did not suffer at all until halfway through his first cross-country season when he had a week long flare up of pain that was similar to his previous plantar fasciitis/osis. He was fine again until the beginning of his first indoor track season. The pain became unrelenting despite being prescribed new orthotics and undergoing an expensive shockwave therapy procedure. The patient decided to just cross train and rest for the remainder of his freshman year as a collegiate runner. 

This is where I entered the picture and had a few small conversations with this athlete regarding his plantar pain and I gave him a few exercises to perform on his own such as a self-mulligan mobilization with movement technique for ankle dorsiflexion and repeated end-range plantar flexion prior to runs. The patient used these few exercises all summer long until he returned for his sophomore year with good results but was not completely pain free.

I heard that he was still struggling with his plantar pain and offered to help him with a proper evaluation and treatment plan.

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