Once a Student - Always a Student

So if you have ever read my blog before you probably know that I am a big fan of The Manual Therapist and Dr. Erson Religioso, III, DPT. Its true and I have learned a lot from him, his blog and his videos. One of his mainstays is the ability to be dynamic, open-minded, and ever evolving and that is why he calls the way he practices The Eclectic Approach.

These are great qualities for clinicians and I have tried to adopt this style of practice myself. I learned about basic resets and repeated movement exams/treatments from Dr. E's material. I thought I had a pretty good handle on the basics. However, ask any expert in anything...The basics are basic but they are not basic. What? I mean that even if you try or practice sometime a hundred times...there is still something new to be learned or nuance to be perfected over time. So what is the point?

Well I have been struggling with some neck pain and muscle spasm for the last week as a result of my brazilian jiu jitsu training. I hadn't really done much for it because most clinicians suck at self-assessment and treatment. I at least made sure that I didn't have any fractures or other major red flags which thankfully I do not. So instead I set up a consultation with Dr. E and I was able to learn a few things even though we technically didn't do anything that I didn't already know! Check it out!

So what did I learn about using repeated-motions that I didn't know before?

• I wasn't aware that I was compensating out of fear-avoidance when attempting to treat myself using repeated-motions (specifically on repeated cervical extension with retraction)
• I didn't realize how profound of an impact there would be by correcting this
• A little bit of resistance while performing the repeated-motion like an active PNF can be immensely helpful for getting to end-range.
• I was not aware of how quickly I was going with my repeated-motions. Slowing down the pace of movement seemed to help lower the perceived threat and opened up my range of motion.
• I didn't think this had much an impact previously, I used to let my patients go to town doing their repeated motions as quickly as possible. There were some cases where the repeated-motions didn't net the effect that I was looking for and this could be why.

So what is the moral of today's post? Don't be afraid to get a second opinion or second set of eyes when trying to treat yourself as a clinician. Doing so doesn't make you a bad clinician, dumb, or incompetent...It just means you are currently a patient and not a clinician. Secondly and more importantly, ALWAYS keep an open mind and be prepared to learn something new every day, every hour, every minute. Lifelong learning = lifelong enjoyment.

This isn't quite what I had in mind.

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Movie Monday: How to Buddy Tape Your Fingers!

Good Morning Readers! I hope nobody has a case of the Mondays...Today we have our second installment of Movie Mondays. This video will share with you a common, basic, easy but often screwed up taping technique. Athletic Trainers are pretty much the experts at taping athletes and have been for over a decade now.

However, some tape jobs like this can be done by individuals themselves. Which could obviously come in handy when an athletic trainer is not present or when you participate in a sport where it is not common for athletic trainers to be present. This is a great taping technique when a person has suffered an injury such as a minor interphalangeal or metacarpophalangeal (finger) sprain and needs additional support to allow participation while the injury is still healing. This could be done with several types of tape from light stretchy stuff, to somewhat flexible elastikon to a more restrictive but cheap and common athletic/white/coaches' tape. It just depends on the amount of support you want versus the amount of movement or function you want/need.

Additionally, this could be used prophylactically in sports where the fingers are at risk for injury when isolated...I'm looking at you football linemen, rugby & judo players, brazilian jiu jitsu athletes, or grapplers of all shapes and sizes.

There are a lot of taping techniques that an athlete could apply themselves and I hope in the future I can share some more of them with all of you. However, somethings like an ankle tape job are not very feasible for an untrained person to do alone. Especially when you could save time and money by getting a decent ankle brace instead. That sort of product or scenario doesn't exist for this tape job.

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Movie Monday: The Vertical Compression Test

Howdy Readers! Today is Monday and hopefully the beginning of a new tradition here at Eat.Run.Rehabilitate.! I hope to continue to upload and post videos weekly and sometimes even biweekly if I get overly ambitious. I have been trying to take some time and pre-record some videos so that way when I do have time to do some editing and posting it will allow me to be more caught up on everything.

Anyways, today's video is going to be about the Vertical Compression Test. This is another test that I learned from Jay Dicharry's Anatomy for Runners book. I've said it before and I'll say it again...not a bad book to have around for reference! This is a great way to go about assessing a person's overal posture on their postural stability and its effect on the entire kinetic chain. Check out my video below!

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What To Look for When Looking at Running Gait

Howdy Readers! A lot of people like to talk the talk when it comes to assessing running gait/form. However, a lot of what people seem to say regarding gait sometimes boils down to just that...all talk. Some people look at a still frame or picture of an individual running and make claims based off of one moment in time. Somebody hook these people up with Miss Cleo because they must be able to look into the past and the future! Amazing!

In reality, there are very specific things that you should be looking at from very specific reference points. Specifically, to best evaluate a person's running gait you would want to be able to evaluate their form from both frontal plane and sagittal plane views. Do you know what they are already? Well I didn't have this handy dandy knowledge until after I attended the Healthy Running conference (see my review here) and learned this from Dr. Mark Cucuzzella and Jay Dicharry, MPT, CSCS.

 Before this I put most of my faith into my clinical assessments and often shied away from visual gait assessment. You shouldn't try to separate these two entities...they should be combined together to draw conclusions. There were two main reasons for this. One, I didn't have a nice high-speed camera for this. It is pretty difficult to be sure of what you are seeing unless you have the ability to record at higher frame-rates. Secondly, I didn't have this nice little handy-dandy checklist that I am about to share with you. Note: Please remember to compare left to right for these items when possible.

Frontal View
Back when I first started running, on the left in the white.
Excessive Heel Strike!!

The Frontal View

• Step Width
• Narrow, Neutral, or Wide?
• Arm Movement
• Abducted, Cross-over, or In-line?
• Trunk
• Ipsilateral, Neutral, or Contralateral tilting/lurching?
• Hip Stability
• Adduction vs.  Abduction?
• Internally vs. Externally Rotated?
• Neutral?
• Dynamic Knee Alignment
• Valgus vs. Varus vs. Neutral?
• Midstance Foot Position
• Supinated vs. Pronated vs. Neutral
• Cadence
• Slow? Excessively Quick?
• Other Abnormalities?

The Lateral View.

The Lateral View

• Vertical Displacement
• <4cm li="" limited="">
• 4-6cm = Optimal
• >6cm = Increased
• Arm Movement
• Excessive anterior/forward motion
• Neutral
• Excessive posterior/backward motion
• Torso Orientation
• Anterior vs. Posterior vs. Neutral
• Lumbopelvic Posture
• Lordosis vs. Neutral vs. Flat
• Hip Extension during Toe off
• 15-20 degrees = normal
• 5-15 degrees = limited
• <0 degrees="severely" li="" limited="">
• Knee Excursion during Stance
• >25 degrees = flexed
• 20-25 degrees = optimal
• <20 degrees="stiff</li">
• Foot Strike Pattern
• Heel vs. Midfoot vs. Forefoot
• Neutral Contact point vs. Foot contacts anterior to COM (Center of Mass)

We all run different, but there are general things that we should look for and look to avoid for all running gaits!

Conclusion: There you have it folks! A simple check list to use for each view! I don't really use a posterior view anymore but you could still use the frontal view checklist for a lot of the same things that you might see on the posterior aspect. Additionally, don't assume that a duck is a duck when performing these analyses. Just because a person runs with zero hip extension does not necessarily mean that they have zero hip extension! Check their passive mobility! This could easily be a stability or motor control problem. 

Another example of this could be that just because you see something like excessive dynamic knee valgus don't assume they have a weak set of glutes! It could be due to poor ankle dorsiflexion that produces compensatory subtalar joint pronation and then causes compensatory knee valgus. Practice these assessments to work on being able to assess these things individually but quickly. You want to get to the point where you notice the "abnormal" instead of having to check for "normals" everywhere. 

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Are Your Shoulders Ready for Brazilian Jiu Jitsu?

I have been keeping busy down here in Miami, Florida. I am about a quarter of the way through my first semester as a PhD student and I have been kept busy with teaching my first class (Introduction to Athletic and Sport Injuries) and by being a research assistant for my adviser as well. I have also had the opportunity to keep myself busy yet physically active by taking back up a long-lost but much loved hobby of mine: Brazilian Jiu Jitsu (BJJ).

BJJ took a backseat for me after training regularly during my bachelor's degree. It stayed on the back burner as I worked on my master's degree but my schedule has normalized enough to allow me to resume training. My sports medicine breadth of knowledge has grown and advanced while my BJJ was placed on hold, and because of that I feel that I have a expanded view on the biomechanics of the sport that I didn't necessarily have previously.

Specifically, I am going to touch briefly on a bit of injury prevention for anyone out there that may be into BJJ or for those of you that may treat people that participate in BJJ (actually this stuff applies to everybody not just BJJ guys). Nevertheless, this post is definitely geared more for the BJJ practitioner and not the clinicians out there...this may not even be new information for those who have visited this blog before.

While I am not somebody that you should go to for submission or any BJJ advice for that matter...I feel that I can give some good insight to help you stay on the mats. Specifically, when I was training I often saw a lot of people struggle with shoulder injuries. In fact, traumatic shoulder dislocations and subluxations were more prevalent than one might assume. Perhaps one wouldn't be surprised considering this is a sport where people enjoy catching each other in joint locks and submission-holds that work by forcibly placing one another's joints at their respective end ranges of motion. So when it comes to a sport where we are already pushing the limits with our body (within reason) then we need to ensure that we are not already at risk of damaging ourselves or our training partners.

I'm no Kenobi.

Having strong, mobile, and stable shoulders is just as important for your ability to submit as well as your ability to not get submitted. The status of your shoulders can also have repercussions up and down the kinetic chain. This is evident when a shoulder issue can manifest itself as a grip strength (I won't be touching on it in this post but proper grip strength can also play a huge role on proper shoulder stability) problem. Not to mention proper shoulder function, especially based upon the tests that I am about to show you, is entirely interdependent on proper function of the elbow joint, glenohumeral (shoulder) joint, the scapula (shoulder blade), the thoracic spine, and arguably the neck or cervical spine as well.

You can bet this guy needs some help, even if he doesn't have symptoms...yet.

So what is a quick an easy way to check for potential shoulder dysfunction? If you know me by now you know I am a fan of the Selective Functional Movement Assessment (SFMA) and think its a great way for everybody to look at movement despite the fact that we may all treat movement in many different ways. So that is where these tests originate!

1) Upper Extremity Pattern #1

What does this shoulder position look like?

This test requires adequate motor control and mobility of many different segments including: Shoulder internal rotation, shoulder extension, and horizontal adduction of the shoulder. Additionally it requires elbow flexion and thoracic spine extension/rotation. Any issues found here indicate a potential stability and/or mobility problem. One must not assume that it is a mobility/flexibility issue that needs stretching or cranking on.

Looks a lot like our test above...If you can't easily put your own arm here, how do you expect it to feel when does it for you?

What is a passing test? The ability for the finger tips to reach the inferior angle of the contralateral scapula without excessive scapular winging of the moving arm, without excessive effort, no deviations in starting posture, and a symmetrical result when compared to the other side. A failing test would require a local biomechanical assessment and to break down of the components of the movement to search for the weakest link. This is a normal range of motion to be able to move through. Deficiency here can lead to increased strain, tension and shearing forces through your upper extremity and its soft tissues.

#2) Upper Extremity Pattern #2

For this test you need adequate shoulder external rotation, shoulder abduction, shoulder flexion, and elbow flexion on top of thoracic extension/rotation as well. To pass this test you must be able to reach your fingers to your contralateral scapula. Where at on the scapula? The midpoint of the spine of your scapula is our targeted destination. However, you need to look for symmetry of movement from side to side, check out how much effort is required, and if there is any deviation of posture to achieve this position. Additionally, a person is not allowed to "crawl" their hands up or down their back for either test. It has to be done with one smooth motion and without "warming" up.

This is not the same as Upper Extremity Pattern #2 but it IS the same. Get it?

If you want a quick and easy way of doing this if you are unsure of your anatomical landmarks just grab yourself a tape measure and assess the distance from your longest finger tip to the first wrist "crease" or wrinkle of your wrist just below your palm. Got that measurement? Okay well you want your hands to be within 1.5 times that measurement to be considered acceptable and don't forget to switch arms and check both ways.

So what do you do if fail these tests? That is a debate for another day but you honestly need more information. However, if you want to use a trial-and-error method then all you need to do is try something out like flopping on a foam roller, lacrosse ball, or getting a massage and seeing if there is  a difference afterwards. How will you know if there is a difference? Retest! Mobility may work may not fix this so don't assume that is what it is! It could just as easily be a motor control or stability issue. Here is a sample of what breaking down one of these tests looks like.

While these tests are far from all-inclusive or the be-all-end-all they are a great starting place to screen or assess for potential risk of injury. If you can do this it doesn't mean you won't injury your shoulder or that you are 100% good to go but if you can't I do know that you deviate from normal into abnormal. Abnormal or dysfunction in my book is the same as pathological and may lead to future injury down the road. Get to work on bullet-proofing your shoulders before it is too late and you are under the scalpel.

!!Update!!

 Some people asked for a video to help clarify a few questions that they had regarding this post and I have finally gotten the time to deliver. Here it is...

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Three Non-Negotiables for Running

Running a half-marathon indoors is as boring as it sounds.

Howdy Folks! Howdy? Why do I say that? I don't know but here in Miami everything keeps on thinking that I am saying "How ya doing", so perhaps I need to find a new greeting. Nevertheless, lets get back on track. Speaking of track...Do you run, work with runners, or want to run? I wrote today's post to share with you all some concepts that I learned from Jay Dicharry and Mark Cucuzzella at the Healthy Running seminar.

So guess what...? There is a lot more to running that going in circles around a track or bombing down trails in the woods. How about we break it down and discuss three critical components to running?These are critical for running "better" without taking a hit to your economy or risk of injury. I didn't say these three concepts will make you the best runner or prevent 100% of injuries. However, if you don't have these three things then you my friend are missing a few pieces of the puzzle.

1. Runners Need Mobility. Not More but Not Less.

What the heck does that mean? It means you need just enough mobility to move what needs to be moved without creating a compensatory movement pattern. It also means that going above and beyond that threshold may not be beneficial. We are talking Goldilocks here, not too tight and not too loose. We need you to be just right. The good thing here is that "just-right" probably fluctuates between body type, activity type (sprinter vs. distance vs. hurdlers), and running form. However, there are some minimums. We need enough mobility to allow our legs to extend behind us. This requires adequate hip extension, ankle dorsiflexion, and first ray dorsiflexion. We need other joints to be mobile as well but these are the essentials. How much? We are looking for 15-20 degrees of hip extension, 30 degrees of ankle dorsiflexion and another (ankle is already dorsiflexed to 30 degrees before measuring great toe mobility) 30 degrees of metatarsophalangeal (MTP) dorsiflexion of the first ray on top of that. These are not "normal" ranges of motion for these joints but these are the amount needed for running.

2. Runners Need Stability.

If you try to drive a car with poor alignment very far then you are in for a hard a time. The human body is no different. You need a stable and properly aligned "chassis" for efficient energy transfer. This means you need enough "core" control or stability to maintain your alignment while running, for the entire run. You need to be stable from stride 1 through mile x/the finish. This requires stability in all three planes and not just the sagittal plane where many of us tend to hangout. I see poor stability as a common fault for many of us. It is challenging to have proper motor control, especially for long periods of time. We do not want unstable levers to interact with and try to control high/rapid forces.

You need to be stable from beginning to end.

3. Runners Need Strength & Power.

You're a runner, right? The prime example of an "endurance" athlete. Pure cardio, pure aerobic metabolism, purely about getting in the miles or minutes. Wrong. Runners need proper levels of strength and power as well. There is plenty of evidence to show that weight training can be very beneficial to endurance athletes and runners! Your hips (glutes) need to be able to propel your entire body up and forward...very very quickly, many many times. In addition, vertical ground reaction forces (vGRF) in running peak at about 2.5x body weight! Think about that for a second...That would be the equivalent of a 150lb runner doing a single leg back squat with 225lbs on the bar for a total of 375lbs through one leg!

What about plyometrics? Economic running is very plyometric in nature...it is all about how well you can store and release elastic energy! If we are going to have stable levers from non-negotiable #2 then lets take advantage of that and apply some large forces through them!

Gravity is relentless. You need to be strong because we are always fighting it.

In Conclusion

Take these three concepts in isolation and they make sense. Look at them in combination and they make even more sense! Hey wait a minute! How do these things even help runners? Well, overall these are needed to better our running economy and that is done by addressing two key concepts of economic running form.

• Better Storage and Release of Elastic Energy
• Minimized Loading Rates

Now we just need to take these conceptual ideas and put them into practice, right? Stay tuned for future posts where we will discuss how to evaluate and address these issues.

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Healthy Running Course Review

Hold on a second guys....Okay, there. Sorry. I had to come down from what I imagine being on cloud 9 feels like. I have had one crazy, jam-packed, and exciting month so far. The month concluded with two pretty big events. First of all, I finally got around to popping the question...and thankfully she said yes.

On top of that I had the opportunity to travel to Portland, Oregon to attend one of the newly established Healthy Running Courses. In addition to being a course participant I was invited to present the findings of my research on Correct Toes and Lems during one of the lunch breaks! So I wanted to write up a post with my thoughts and feelings regarding this new continuing education course that is geared toward medical professionals, running coaches, and fitness professionals that deal with endurance athletes. There was even a few purely recreational runners in attendance as well!

I was pretty nervous in this photo but not as nervous as I was for the next one...

This was a pretty nerve wracking moment.

Additionally, in about a week I will begin a road trip with my new fiance in order to move to Miami. There we will reside for the next 4 years or so while I begin work on my PhD from the University of Miami. A lot of culture and geography shock in my life lately...

Pretty Sweet geography around Portland. I am very jealous of everyone that lives here.

So where do I actually begin with this course review? Initially, before the course actually began I had wanted to create a large, and detailed write-up about this course. I wanted to share a lot of the information that was discussed, reviewed and learned throughout the weekend. However, at the time I didn't realize just how vast, over-reaching, and yet enjoyably specific the content would be. I could actually write or should I say it would require me to write MANY blog posts to cover everything. Instead, I figured that I would share with you all my general thoughts and feelings.

I arrived on Friday afternoon in Portland and was given a tour of the Correct Toes' office and the clinic (Northwest Foot and Ankle) of Correct Toe's creator, Dr. Ray McClanahan, DPM. Northwest Foot and Ankle/Correct Toes was the host for this conference and boy were they ever a hospitable group of people.

This group went above and beyond and I think this added to the overall open and friendly feeling that existed at this course. This wasn't one of those CEU courses where people sit next to each other and only talk the bare minimum, ignore each other in the halls, and bust ass to leave at the end of the day. I felt like this course, it's instructors, and the participants all fostered a very open, inviting, and collaborative format. On Friday evening, there was a dinner and drinks at a local restaurant to work as an ice breaker before the next morning's festivities.

A family physician, massage therapist, podiatrist, athletic trainer, chiropractic student, certified athletic trainer, and a physician from Canada all at one table the night before the conference. Talk about collaboration...Talk about stories...Talk about Passion.

The next morning I woke up early before the conference to enjoy some local coffee while watching the last couple stages of Le Tour de France. Talk about the type of weather that makes you fall in love with a place.

Portland at 6:30AM...Peaceful at worse.

I was probably the first course participant to arrive on Friday morning but the food and beverages that were catered for breakfast beat me (lunches were also provided and catered, the second day we had Chipotle for lunch!).

Upon arrival to my seat I found some sweet swag in my goodie bag...I was very delighted when I began to rifle through the contents. Actually, I am sure everyone enjoys free stuff.

Pieces of swag included: Free Newton Energy Running Shoes, Almond Butter sample, and an item by a company called "Back Joy" that is supposed to be used for periods of long sitting to promote better posture. On top of that, Correct Toes included a tank top, a pint glass, a small ball for self myofascial work on the foot, and a couple pens and pads of paper for taking notes. I love free pens.

The blue thing is the Back Joy device. I am still in the process of testing it out but so far I think I like it.

On top of all of the above swag, this course is taught using Jay Dicharry's book as the course text, Anatomy for Runners, and as a result we were all provided a free copy of it. This didn't bother me because I already own the book and I was a huge fan (Check out my previous review here.) of it. Therefore, I won't mind sharing this book with somebody else to help pay-the-knowledge-forward.

So what about the actual course? How does a person even begin to delve into a two day, sixteen hours continuous hours of knowledge bombs, and information into one post? The first things that come to my mind is stuff like: amazing, engaging, Broad without being skimpy on details, and specific without being needlessly detailed.

The names behind putting on this course are very notable and respected in the running community: Dr. Mark Cuccuzzella, Jay Dicharry, Ian Adamson. We also had Kevin Rausch, PT of Rausch PT show up on the second day to help out during labs and to answer any participant questions. If you are familiar with the world of running injuries, research, gait analysis and running footwear then you probably know who they are. If you don't recognize their names then you NEED to get familiar with them and their work. Especially if you consider yourself somebody that works with runners, endurance athletes, or anybody that runs in their respective sports. Period.

Dr. Mark. "1 second, here is another knowledge bomb for you all."

I love listening to Dr. Mark Cucuzzella talk whether it is on podcasts or videos and in person was no exception. This guy knows so many people, is educated on so many different topics, and is very open minded. I was very happy to be able to finally meet him and if you ever get the chance to hear him speak you will learn how captivating he can be with his knowledge of research, running history, personal anecdotes, and funny stories.

On top of having a passion for running it seems he has a bigger passion for just helping people...including kids too! Oh and if you're going to go for an "easy" group run with these guys after course then you better have some regular mileage under your belt. I am just starting to get back to running now after a long period of time off and I got dropped really quickly! A little sad considering I was probably the youngest person at the conference and easily the youngest person on the group run.

Jay's devilish grin before dropping some knowledge bombs himself.

Jay Dicharry is a physical therapist that now practices in Bend, Oregon at Rebound Physical therapy. Jay used to be the head of the running research/gait analysis lab at the University of Virginia. Jay's name is stamped all over the world of research for gait analysis and running related studies. At one point during the course Jay showed us a quote that he once wrote for a text book. He then went on to bash it to highlight the need (and his ability) to critically think, remain open-minded, and the importance to stay current with research.

Jay claims to talk fast but he uses tons of analogies and metaphors to help convey long and arduous ideas or topics into concise and easy to understand statements. To me this means he understands what he is talking about inside and out. On top of this, Jay isn't a frilly clinician. What does that mean? To me Jay is the straight to the point, knows what we do and don't know, and isn't looking to find the "coolest" or most "flavor of the moment" treatment approach. He just goes with what he knows and with what works to provide favorable outcomes. Jay provided us the information on what we need to know, what we need to look at, and how we can be the most effective clinicians without the use of his expensive and fancy equipment.

So what did we actually learn? A lot. I've read Jay's book at least 3 times previously and I still learned a ton from this conference. Just check out this list of learning objectives that are listed for this course:

• Discuss the pathophysiological process behind running injuries and the new treatment concepts relating to these pathologies. 
• Improve his\her clinical efficiency through a better knowledge of objective diagnostic assessments and their place in the clinical exam of an injured runner. 
• Discuss the new theories behind tissue stress, adaptation and preventive stress.  
• Recognize the relationship between running biomechanics and the risk of injuries. 
• Build a program to help an injured runner return to running using the theoretical principles relating to different energy systems, cross-training and warm-up.
• Discuss the science behind running shoe technology, plantar orthoses, flexibility and strengthening in the prevention and treatment of running injuries. 
• Discuss the science and practical application of aerobic development, speed training, and periodization. 
• Describe the principles and be able to teach efficient running form including supplemental drills. 
• Evaluate a patient for movement dysfunction during a clinical visit and provide simple corrective measures.              
• Discuss clinical Injury assessment and exam and specific corrective exercises. 
• Describe practical gait analysis, cues, and corrections. 
• Discuss Nutrition for health and performance.
• Prescribe footwear to complement the patient’s current movement pattern and how to safely transition them to more functional footwear

Dang. That is a lot of information...and they really did deliver but obviously some points were more in depth and detailed than others...As Doctor Cucuzzella put it, It was enough information for us as clinicians to apply but left more for us to learn about. It was entry level exposure on some topics while others were definitely advanced. Enough for us to think about a trip down the rabbit hole if curious. Here is a better Day 1 vs. Day 2 Split of what was discussed. I took this stuff right from their website...

Day 1:

Anthropologic Basis of Running

Training Principals
Aerobic development
The role of intensity
Recovery principals, practice and overtraining syndrome
​Coordination and peaking
Warm up and cool down
Nutrition for performance

Footwear
Performing for ultra-endurance, movie and Q&A
Evolution, Design and Technology of footwear
Influence of footwear on gait
Relationship of footwear to injury
Fitting Issues and adaptive devices

Efficient Running Workshop
Stability / Mobility / Strength
Movement patterns for efficiency and injury reduction
​Form drills to re-enforce motor skills

Day 2:

Assessing the Injured Runner
    Triad of Running Injuries
    Tissue specificity – micro-anatomy
    Baby biomechanics
    Building the perfect runner: how strength and mobility impacts form
​    Identifying and fixing problems
    Optimizing the runner: building a paradigm from distance to sprinting
Medical Issues in Endurance Sports
    Heat and Hydration for the Athlete
    Cardiac Issues 
Assessing the Injured Runner Workshop
​    Clinical running analysis: the Visual Gait Tool in case studies & hands on practice
    Clinical mobility and stability assessment lab
​    Evaluation and treatment workshops - physical exam and exercise prescription

In conclusion, this was a great course. I learned a lot and it definitely left me feeling more confident in my ability to evaluate, and treat running injuries. Additionally, I feel like I took my visual gait analysis skills to a whole different level. I learned things that I may have been thinking or doing previously may have been flawed and reaffirmed a lot of other stuff that I was already doing. It was amazing to get some insight into the "information" that people try to tweeze out of a gait analysis and to find out what you really CAN and CANNOT derive from watching somebody run.

Dr. Ray McClanahan, DPM, myself, and Jay Dicharry, MPT, SCS.
These two guys combined have 4000x the brain power that I do. 

One other point that I loved during the conference was the focus on or the overlap of injury reduction/prevention versus enhancing running performance. Sometimes certain issues held these two ideas under the same umbrella and for other areas they had a direct inverse relationship. This helped when thinking about an individual's goals...and when you start with the finish you can provide a more focused plan. I really do recommend this course.

There is still way too much garbage information out there regarding running form, running footwear, running injuries and endurance training. I urge any interested medical professional, running coach or even motivated runners to see if one of these courses are being hosted near you. If you can't do that then your next best starting spot is probably with Jay's book, Anatomy for Runners. 

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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.

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.

There 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.

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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.

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Do I Believe in Chiropractic Medicine?

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.

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