SpineFITyoga.com

Author: chad reilly

  • Kinesio Tape Smells Like Placebo

    Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review. J Physiother. 2014 Mar;60(1):31-9. Parreira Pdo C, Costa Lda C, Hespanhol Junior LC, Lopes AD, Costa LO.

    Abstract
    Questions: Is Kinesio Taping more effective than a sham taping/placebo, no treatment or other interventions in people with musculoskeletal conditions? Is the addition of Kinesio Taping to other interventions more effective than other interventions alone in people with musculoskeletal conditions? Design: Systematic review of randomised trials. Participants: People with musculoskeletal conditions. Intervention: Kinesio Taping was compared with sham taping/placebo, no treatment, exercises, manual therapy and conventional physiotherapy. Outcome measures: Pain intensity, disability, quality of life, return to work, and global impression of recovery. Results: Twelve randomised trials involving 495 participants were included in the review. The effectiveness of the Kinesio Taping was tested in participants with: shoulder pain in two trials; knee pain in three trials; chronic low back pain in two trials; neck pain in three trials; plantar fasciitis in one trial; and multiple musculoskeletal conditions in one trial. The methodological quality of eligible trials was moderate, with a mean of 6.1 points on the 10-point PEDro Scale score. Overall, Kinesio Taping was no better than sham taping/placebo and active comparison groups. In all comparisons where Kinesio Taping was better than an active or a sham control group, the effect sizes were small and probably not clinically significant or the trials were of low quality. Conclusion: This review provides the most updated evidence on the effectiveness of the Kinesio Taping for musculoskeletal conditions. The current evidence does not support the use of this intervention in these clinical populations.

    My Comments:

    It’s bad news for your intervention when review papers start looking at hundreds of patients with a number of conditions and conclude it probably doesn’t do anything good, for any of them.

    Kinesio Tape is that colorful tape you see applied to people’s body parts, often in fancy patterns, with an intent to make them heal better.  It doesn’t surprise me in the least, however, that researchers are now concluding that it has no clinical benefit. Kinesio tape has been around for years, and this paper says it was first created by a Japanese chiropractor in the 1970s.  I noticed it really got popular in and after the 2012 Summer Olympics, where Kinesio Tape was prominently displayed on a number of beach volleyball players.  And sure enough, a quote from this paper is:

    “It seems that the growing use of Kinesio Taping is due to massive marketing campaigns (such as the ones used during the London 2012 Olympic Games) rather than high-quality, scientific evidence with clinically relevant outcomes.”

    “The widespread use of Kinesio Taping in musculoskeletal and sports physical therapy is probably further reinforced by the authors in some of the included trials concluding that Kinesio Taping was effective when their data did not identify significant benefits.”

    So in other words, Kinesio Tape is popular because of good marketing and poor researchers.  I think another problem is just a lack of critical thinking skills on the part of medical practitioners (which sadly includes a lot of physical therapists) who should know better.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Strength Better than Stretch for Plantar Fasciitis

    High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2014 Aug 21. Rathleff MS1, Mølgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL.

    Abstract
    The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia-specific stretching vs shoe inserts and high-load strength training in patients with plantar fasciitis. Forty-eight patients with ultrasonography-verified plantar fasciitis were randomized to shoe inserts and daily plantar-specific stretching (the stretch group) or shoe inserts and high-load progressive strength training (the strength group) performed every second day. High-load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow-ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6-52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9-36) in the strength group and 16 points (95% CI: 0-32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function.

    My comments:

    Great paper!  I have been stressing importance of strength training in place of and in addition to stretch (depending on whether the patient has too much range of motion or too little in various joints of the foot). I began doing this based on a number of studies showing muscle weakness and atrophy as well as my experience in my physical therapy clinic treating patients with plantar fasciitis, but this is the first study ever addressing the effects of strength training in the treatment of plantar fasciitis.

    Those with plantar fasciitis generally have tight calves. Some stretching is often a good idea, and strength vs stretch needn’t be an either/or affair.  However, only stretching has been shown to inhibit muscle strength, and good strength training exercises performed through a full range of motion often stretch while they strengthen giving a 2 for one effect.  Researchers in this study went after the 2 for one effect by having subjects do single calf raises on a block, but did so with a folded towel under the toes so that there would be greater toe extension and thus greater tension through the plantar fascia at the top of the motion.  At the bottom of the calf raise, the calves are stretched if you go down far enough, which would do much correct the tight calf muscles often associated with the condition.  It is unknown if the towel under the toes trick makes the calf raise more effective than a normal calf raise. Initially, I was skeptical, but I tried it and it did feel like it increased plantar fascia tension so maybe there is something to it. However as I reflect upon it logically, I wonder if stretching the plantar fascia is a good idea at all.   The plantar fascia is a passive structure that supports the arch of the foot, such that if it is loose, either the muscles will have to work harder, or the arch will collapse slightly, neither of which seem to be a good idea.  As such it would be better to just stretch the calves, which have been shown to be tight in those with plantar fasciitis, while the plantar fascia itself has been found to be of normal length.  

    The protocol used in the study was 3 sets of 12 reps, worked up to 5 sets of 8 reps of single leg calf raises using books in a backpack to increase resistance performed once every other day.  The stretching program it was compared to was performed 3 times per day every day and is probably the industry standard as described by Digiovanni.

    The unfortunate thing for the profession is that while this study is new and pertinent it probably won’t be seen in the average physical therapy clinic for another 15-20 years, and by then the research will be on to something better, with most therapists still hung up on the latest fad in soft tissue mobilization or needle poking.  Evidence based medicine really should be more than a catch phrase.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Plantar Fasciitis: One Cortisone Shot = 19X Risk of Rupture

    Risk factors affecting chronic rupture of the plantar fascia. Foot Ankle Int. 2014 Mar;35(3):258-63. Lee HS1, Choi YR, Kim SW, Lee JY, Seo JH, Jeong JJ.

    Abstract
    BACKGROUND:
    Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis.

    METHODS:
    We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups.

    RESULTS:
    Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33.

    CONCLUSION:
    Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture.

    My comments:

    I’ve advised against cortisone injections for tendon injuries for a long time. In my opinion, they are about the only thing you shouldn’t do. Everything else is at worst a pseudoscientific waste of time, but cortisone shots leave tendons worse off than no treatment at all.  The plantar fascia has not historically been considered a tendon. However, now it’s being described as an aponeurosis, which is a “white flattened ribbon like tendinous expansion”. In my experience, it responds considerably better to tendinitis type strengthening protocols than it does to more traditional treatments of stretches and orthotics.

    When stretch and orthotics fail to fully resolve symptoms, as they frequently do, the next step is often one or more cortisone injections.  Cortisone is known as a catabolic steroid, which is the opposite of an anabolic steroid athletes take to make their muscles stronger.  Catabolic steroids make muscles and tendons weaker; this has been known for decades.  To me, this just doesn’t sound like a very smart thing to do for a condition known to result from intrinsic foot muscle weakness just adjacent to and/or around the plantar fascia.  This study found that there were not any factors (including BMI, high or low arches, amount of time spent standing, etc.) significantly associated with plantar fascia rupture, with the exception of cortisone injections. What’s more, the risk with cortisone was considerable.  They found that a single cortisone injection to the plantar fascia increased the risk of rupture by 18.8 times (not 18% but 1,880%) which is huge in medical terms; 2 injections increased the risk 34.6 times; and 3 or more injections increased the risk of plantar fascia rupture a whopping 125.8 times!

    With plantar fasciitis being a very painful condition, people understandably want a quick fix. However, a cortisone shot on average only gives temporary comfort at the expense of increased risk of long term pain. This study showed a very high increase in risk of plantar fascia rupture which can lead to permanent disability.  So my advice is: just don’t do it.  It’s much better to tough it out for a few weeks, do your physical therapy exercises which hopefully include a fair amount of foot, leg and hip strengthening exercises and EMS as opposed to just stretching, orthotics and various soft tissue techniques (which are so 1990s) but still better than a cortisone injection.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Foot Muscle Fatigue Causes Loss of Foot Arch

    Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyogr Kinesiol. 2008 Jun;18(3):420-5.  Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J.

    Abstract
    Our purpose was to assess the effect of foot intrinsic muscle fatigue on pronation, as assessed with navicular drop, during static stance. Twenty-one healthy young adults participated. Navicular drop was measured before and after fatiguing exercise of the plantar foot intrinsic muscles. Surface electromyography of the abductor hallucis muscle was recorded during maximum voluntary isometric contractions (MVIC) in order to find the baseline median frequency (MedF). Subjects then performed sets of 75 repetitions of isotonic flexion contractions of the intrinsic foot muscles against a 4.55 kg weight on a custom pulley system. After each set an MVIC was performed to track shifts in MedF. After a MedF shift of at least 10%, navicular drop measurements were repeated. Subjects exhibited 10.0+/-3.8mm of navicular drop at baseline and 11.8+/-3.8mm after fatigue (p<0.0005). The change in navicular drop was significantly correlated with change in MedF (r=.47, p=.03). The intrinsic foot muscles play a role in support of the medial longitudinal arch in static stance. Disrupting the function of these muscles through fatigue resulted in an increase in pronation as assessed by navicular drop.

    My comments:

    This study goes along with my last blog, but rather than showing paralysis of the foot intrinsic muscles causes a loss of foot arch, these researchers found that merely fatiguing the muscles did the same, though to a lesser degree (~16% vs ~50% in the earlier study). As before, the take home message is that physical therapy programs for conditions such as plantar fasciitis and posterior tibial tendinitis need to address foot intrinsic muscle strength to be fully effective.

    The problem is that it is hard to overload the muscles in the feet, especially the foot intrinsic muscles.  This is why I have been using EMS to target and strengthen those muscles. This was a method I first read about in the Charlie Francis training system, where he discussed EMS for the rehabilitation of track and field injuries. He did this specifically by having his athletes do the EMS while they stood on the electrodes (standing on the electrodes keeps your feet from cramping) for 10 minutes for a 10 second on, 50 second off duty cycle.  I tried it myself and have since used it with all my plantar fasciitis patients. Everyone agrees it works the foot intrinsic muscles much harder than can be achieved with active exercise.  The best part is most report they feel better immediately afterwards due to the pain relieving qualities of EMS.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Foot Intrinsic Muscles Important for Foot Arch

    Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 2003 Nov-Dec;42(6):327-33. Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M.

    Abstract
    Much of the work describing support of the medial longitudinal arch has focused on the plantar fascia and the extrinsic muscles. There is little research concerning the function of intrinsic muscles in the maintenance of the medial longitudinal arch. Ten healthy volunteer adults served as subjects for this study, which was approved by the University Investigational Review Board. The height of the navicular tubercle above the floor was measured in both feet while subjects were seated with the foot in a subtalar neutral position and then when standing in a relaxed calcaneal stance. Subtalar neutral was found by palpating for talar congruency. Recordings of muscle activity from the abductor hallucis muscle were performed while the subjects maintained a maximal voluntary contraction in a supine position by plantarflexing their great toes. An injection of lidocaine (1% with epinephrine) was then administered by a Board-certified orthopedic surgeon in the region of the tibial nerve, posterior and inferior to the medial malleolus. Measurements were repeated and compared by using a paired t test. After the nerve block, the muscle activity was 26.8% of the control condition (P =.011). This corresponded with an increase in navicular drop of 3.8 mm. (P =.022). The observation that navicular drop increased when the activity of the intrinsic muscles decreased indicates that the intrinsic pedal muscles play an important role in support of the medial longitudinal arch.

    My comments:

    This is a facinating study from 2003, which demonstrated that the smaller muscles inside the foot are very important for supporting the foot arch.  The study demonstrated this by injecting lidocaine into the nerve controlling those muscles, thus temporarily paralyzing them. Doing so they found the the navicular bone drop (used to measure foot arch) increased from ~6mm to 9 mm (a 50% increase).  Thus foot muscle weakness in real life would significantly increase stress on other arch supporting structures including the plantar fascia and posterior tibial tendon,  likely contributing to plantar fasciitis and posterior tibial tendinitis, respectively.

    This fits in with other studies I have blogged on that found patients with plantar fasciitis do, in fact, have smaller and weaker foot intrinsic muscles in addition to tighter and weaker calf muscles. It would also explain why current treatment protocols focusing on stretch and orthotics but ignoring strength training are only marginally successful.  So the take home message for those with foot pain, physical therapists, and others treating foot injuries is that foot intrinsic muscle strength needs to be restored. This will lessen stress on the foot arch and help promote optimal recovery from conditions like plantar fasciitis and posterior tibial tendinitis.  This should also go a long way towards preventing more debilitating conditions down the road, such as acquired flat foot deformity.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Runners with Patellofemoral Pain, Have Altered Hip and Knee Rotational Stress

    Patellofemoral joint stress during running in females with and without patellofemoral pain. Knee. 2012 Oct;19(5):703-8. Wirtz AD1, Willson JD, Kernozek TW, Hong DA.

    Abstract
    Patellofemoral pain (PFP) is a common complaint among female runners. The etiology for PFP is frequently associated with increased patellofemoral joint stress (PFJS) and altered hip and knee joint kinematics during running. However, whether PFJS during running is increased among runners with PFP is unknown. The primary aim of this study was to compare PFJS during running among females with and without PFP. We also compared hip and knee transverse plane kinematics during running due to their potential influence on patellofemoral contact area and PFJS. Three dimensional hip and knee running kinematics and kinetics were obtained from 20 females with PFP and 20 females with no pain. Patellofemoral joint stress during running was estimated using patellofemoral contact area and a sagittal plane patellofemoral joint model previously described. Patellofemoral joint stress, PFJS-time integral, and hip and knee transverse plane kinematics at the time of impact peak and peak ground reaction force were compared between groups using a multivariate analysis of variance. The results show that peak PFJS and PFJS-time integral were similar between groups. Peak knee flexion angle and net knee extension moment were not different between groups. However, females with PFP demonstrated hip internal rotation that was 6° greater (P=0.04) when ground reaction forces were greatest. The extent these results are influenced by compensations for pain is unclear. However, if increased PFJS contributes to the etiology or exacerbation of PFP, interventions to minimize altered transverse plane hip kinematics may be indicated among runners who demonstrate this characteristic.

    My comments:

    This study looked to see if there was increased patellofemoral compressive stresses during running on women with and without patellofemoral pain.  They did not find any significant differences.  However in their comments they noted that the mathematical model they used did not account for internal and external rotation stresses at the hip and knee (which were found to be significant) and thus their model might have underestimated real life patellofemoral stress.  Most significant findings were hip internal rotation that was 6 degrees greater than normal, and a subsequent knee external rotation of 4.8 degrees.

    The findings are inline with earlier research that notes hip external rotation and hip abduction strength is particularly weak in runners suffering patellofemoral pain and as such physical therapy programs programs should make use of progressive resistance exercise to the hips, legs, and core to complement ones running program.  Passive modalities and/or various massage techniques are likely to have little effect outside of psychological comforting and placebo.  EMS, however is a useful to both decrease pain and further increase strength to targeted muscles.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Cervicogenic Headaches Reduced Most with Strength Training

    Effect of neck exercises on cervicogenic headache: a randomized controlled trial. J Rehabil Med. 2010 Apr;42(4):344-9. Ylinen J1, Nikander R, Nykänen M, Kautiainen H, Häkkinen A.

    Abstract
    OBJECTIVE:
    To compare the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain.

    METHODS:
    A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity.

    RESULTS:
    At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache (p < 0.001). In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group.

    CONCLUSION:
    All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of training to be undertaken by patients with severe cervicogenic headache.

    My comments:

    A cervicogenic headache is one that originates from tissues in the neck, as opposed for instance to a migraine, and is often the result of holding the neck and head in stressful daily postures, often looking down (cervical flexion) or a forward head posture (lower cervical flexion combined with upper cervical extension).  Both postures increase muscular strain and strain on cervical joints and discs much more so than a neutral cervical posture with the head level and centered (front to back) over the shoulders.  Keeping a neutral posture requires a degree of awareness and also some muscular strength and endurance.  These researchers found both strength and endurance exercises helped to decrease headache intensity, as well as neck, shoulder and arm pain more than stretching alone.

    The strength group was slightly better off than the endurance group. The cervical strength exercises were all isometric against a theraband in all directions, while the endurance group did dynamic exercise in supine only.  Both groups also did upper body  weight training exercises with dumbbells, the endurance group for 3 sets of 20 reps with a 2 kg (4.4 lb) dumbbell, while the strength group did 1 set of 15 but with ever increasing intensities as they got stronger.  Both groups also did bodyweight and core exercises including squats, sit-ups, and back extensions.  All three groups did the same stretches.

    With some of the differing variables it’s hard to say what part of the strength and endurance programs led to the reduction in headaches, so those with cervicogenic headaches have no reason to be apprehensive about weight training.  While the results were good, the study was over a year long. I have noticed considerably faster reductions in pain in my physical therapy programs when exercises performed in this study are combined with specific postural exercises, biomechanical counseling, and ergonomic adjustments at home and in the work place.  EMS helps a lot to decrease pain and increase strength in the near term while the patient is waiting for the exercises and ergonomic changes to take effect.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Foot Orthotics Help Some with Patellofemoral Pain

    Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med. 2009 Mar;43(3):169-71. Collins N1, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B.

    Abstract
    OBJECTIVE:
    To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy.

    DESIGN:
    Prospective, single blind, randomised clinical trial.

    SETTING:
    Single centre trial within a community setting in Brisbane, Australia.

    PARTICIPANTS:
    179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months.

    INTERVENTIONS:
    Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy.

    MAIN OUTCOME MEASURES:
    Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks.

    RESULTS:
    Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks(relative risk reduction 0.66,99%confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks.

    CONCLUSION:
    While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses.

    My comments:

    I like this study because one of the authors, Tom McPoil, was one of my favorite professors when I was at the NAU physical therapy program.  The researchers found foot orthotics were moderately successful in decreasing patellofemoral pain at least in the near term. This is presumably because overpronation of the foot, which is most common in those with patellofemoral pain, is lessened with foot orthotics with arch supports.  While orthotics were better than flat inserts alone, when combined with multimodal physical therapy they did not add any additional improvement.  At 52 weeks out, however, the orthotics were not better than flat inserts and still did not add any additional benefit to the physical therapy treatment. The physical therapy only group had slightly better improvement, though this was not statistically significant.

    The physical therapy group included exercises of the legs and hips (relatively low intensity) which I would expect still conferred the greatest benefit.  They also did patellar mobilization, patellar taping, and bio feedback, all of which I expect to provide only psychological benefits.  Interestingly, 40% of the physical therapy group had side effects resulting from the patellar taping, including skin irritation and blistering,  despite excluding participants with known allergies to tape.  “Marked improvement” in all the treatment groups was only found to be in the 50-60% range at 52 weeks out. There is still much to be desired with the treatment protocols in order to fully resolve pain and restore full levels of function in the majority of patients.  Newer research seems to indicate that patellofemoral pain is associated with, and perhaps results from, more proximal strength deficits. In my experience, it is better resolved with a greater use of high intensity progressive resistance exercise of the core, hips, and legs while also utilizing EMS to acutely decrease pain while strengthening faster than can be done with exercise alone.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Total Knee Functional Outcome Measure Doesn’t Measure Function

    Comparison of self-reported knee injury and osteoarthritis outcome score to performance measures in patients after total knee arthroplasty. PM&R. 2011 Jun;3(6):541-9 Stevens-Lapsley JE1, Schenkman ML, Dayton MR.

    Abstract
    OBJECTIVE:
    To characterize patient outcomes after total knee arthroplasty (TKA) by (1) examining changes in self-report measures (Knee Injury and Osteoarthritis Outcome Score [KOOS]) and performance measures over the first 6 months after TKA, (2) evaluating correlations between changes in KOOS self-report function (activities of daily living [ADL] subscale) and functional performance (6-minute walk [6MW]), and (3) exploring how changes in pain correlate with KOOS ADL and 6MW outcomes.
    DESIGN:
    Retrospective cohort evaluation.
    SETTING:
    Clinical research laboratory. PATIENTS (OR PARTICIPANTS): Thirty-nine patients scheduled for a unilateral, primary TKA for end-stage unilateral knee osteoarthritis.
    METHODS:
    Patients were evaluated 2 weeks before surgery and 1, 3, and 6 months after surgery.
    MAIN OUTCOME MEASUREMENTS:
    KOOS, 6MW, timed-up-and-go (TUG), and stair climbing tests (SCT), quadriceps strength.
    RESULTS:
    Three of 5 KOOS subscales significantly improved by 1 month after TKA. All 5 KOOS subscales significantly improved by 3 and 6 months after TKA. In contrast, performance measures (6MW, TUG, SCT, and quadriceps strength) all significantly declined from preoperative values by 1 month after TKA and significantly improved from preoperative values by 3 and 6 months after TKA; yet, improvements from preoperative values were not clinically meaningful. Pearson correlations between changes in the KOOS ADL subscale and 6MW from before surgery were not statistically significant at 1, 3, or 6 months after TKA. In addition, KOOS Pain was strongly correlated with KOOS ADL scores at all times, but KOOS Pain was not correlated with 6MW distance at any time.
    CONCLUSIONS:
    Patient self-report by using the KOOS did not reflect the magnitude of performance deficits present after surgery, especially 1 month after TKA. Self-report KOOS outcomes closely paralleled pain relief after surgery, whereas performance measures were not correlated with pain. These results emphasize the importance of including performance measures when tracking recovery after TKA as opposed to solely relying on self-reported measures.

    My comments:

    My experience agrees with this study as do a number of other studies which find that patients are generally very satisfied after total knee replacement largely because they feel better. However, performance measures (how well they can walk, balance, strength and endurance) are often still well below where they should be in comparison to age-matched healthy control subjects.

    This paper found that self reported surveys of performance, often required by insurance companies for authorizing physical therapy treatments, do not capture the true level of functional impairments. This leads to early discharge from treatment before normal function is restored, resulting in long term impairment. As this paper states, objective performance measures like gait speed, timed up and go, stair, squat, strength and balance tests should be the criterion in which function is measured. Pain is certainly important, but pain is best captured on a pain scale, and as this study found the KOOS functional test correlated more with pain than with function.

    I’ve noticed a number of insurance companies are using this discrepancy to deny treatment when the patient is still making objective improvements. The patient still has performance impairments but they are not captured in their “outcome measure” questionnaire, so the insurance company denies further treatment. It reminds me much of that movie Sicko. While this particular paper is regarding function after total knee replacement, I would be surprised if it isn’t much the same regarding to every other body part.  I’ll have to look that up.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Low Back Pain, Hip Strength, and IT Band Tightness

    The relationship between hip abductor muscle strength and iliotibial band tightness in individuals with low back pain. Chiropractic & Osteopathy. 2010 Jan 13;18:1. Arab AM, Nourbakhsh MR.

    Abstract
    BACKGROUND:
    Shortening of the iliotibial band (ITB) has been considered to be associated with low back pain (LBP). It is theorized that ITB tightness in individuals with LBP is a compensatory mechanism following hip abductor muscle weakness. However, no study has clinically examined this theory. The purpose of this study was to investigate the muscle imbalance of hip abductor muscle weakness and ITB tightness in subjects with LBP.
    METHODS:
    A total of 300 subjects with and without LBP between the ages of 20 and 60 participated in this cross-sectional study. Subjects were categorized in three groups: LBP with ITB tightness (n = 100), LBP without ITB tightness (n = 100) and no LBP (n = 100). Hip abductor muscle strength was measured in all subjects.
    RESULTS:
    Analysis of Covariance (ANCOVA) with the body mass index (BMI) as the covariate revealed significant difference in hip abductor strength between three groups (P < 0.001). Post hoc analysis showed no significant difference in hip abductor muscle strength between the LBP subjects with and without ITB tightness (P = 0.59). However, subjects with no LBP had significantly stronger hip abductor muscle strength compared to subjects with LBP with ITB tightness (P < 0.001) and those with LBP without ITB tightness (P < 0.001).
    CONCLUSION:
    The relationship between ITB tightness and hip abductor weakness in patients with LBP is not supported as assumed in theory. More clinical studies are needed to assess the theory of muscle imbalance of hip abductor weakness and ITB tightness in LBP.

    My comments:

    In my opinion IT Band Syndrome is over diagnosed and greatly over discussed on the internet in comparison to how often it really happens. I think this has a lot to do with foam roll salesmen trying to create a problem that they can then treat. However, I think both the problem and the response to rolling on said foam rolls is largely psychological. Greater trochanteric pain syndrome (GTPS), often misdiagnosed as trochanteric bursitis, is a real problem and is secondary to hip abductor weakness, tendon tearing and tendinopathy. Such weakness is also strongly associated with knee pain/patellofemoral pain syndrome, and a comorbidity with low back pain. As such, it is no surprize that hip weakness, but not IT band tightness, is associated with low back pain. Taking this into account, physical therapy exercise programs should include hip abduction exercises as part of a comprehensive rehabilitation program for back pain, as well as knee and hip pain. Probably, it isn’t a bad idea to include it when training for a general fitness program as well. In contrast, IT band stretches are probably a waste of time.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Decreasing Low Back Pain While Driving

    Seat inclination, use of lumbar support and low-back pain of taxi drivers. Scand J Work Environ Health. 2005 Aug;31(4):258-65. Chen JC, Dennerlein JT, Chang CC, Chang WR, Christiani DC.

    Abstract
    OBJECTIVES:
    Epidemiologic evidence supporting optimal seating is limited and inconsistent. This cross-sectional study was conducted to examine the association between seat inclination, use of lumbar support, and the prevalence of clinically significant low-back pain among taxi drivers
    METHODS:
    A digital inclinometer was used to measure inclinations of seat surfaces (theta(seat)) and backrests (theta(back)), and calculate the back-to-thigh angle (theta(back-thigh)). Structured interviews were conducted to gather information on the use of lumbar support and the prevalence of low-back pain that had led to medical attention or absence from driving in the past month. A multiple logistic regression analysis was used to estimate the prevalence odds ratio (OR) with adjustment for age, body mass index, professional seniority, monthly driving hours, and the intensity of exposure to whole-body vibration.
    RESULTS:
    Among 224 drivers, the mean theta(seat), and theta(backrest) were 14.5 (SD 9.6) and 95.1 (SD 2.7) degrees, respectively, resulting in theta(back-thigh) of 80.6 (SD 9.3) degrees. Fifty-five percent used a lumbar support regularly, but 25% reportedly had significant low-back pain. The prevalence of low-back pain was 23% among those with theta(back-thigh) 91 degrees. The adjusted OR comparing those with a theta(back-thigh) of < or = 91 degrees to those with a theta(back-thigh) of >91 degrees was 5.11 [95% confidence interval (95% CI) 1.07 approximately 24.4]. For regularly using drivers versus those not using lumbar support, the prevalence of low-back pain was 18% versus 34%, with an adjusted OR of 0.33 (95% CI 0.16 approximately 0.68). Neither theta(seat) nor theta(backrest) alone was significantly associated with low-back pain.
    CONCLUSIONS:
    The epidemiologic observation of this study was consistent with the results of prior biomechanical studies on appropriate seat inclinations and the use of lumbar support. Prospective studies are needed to confirm the true beneficial effects of these seating parameters.

    My comments:

    This study was half as I would have expected and half new to me. Taxi drivers who used a lumbar support were less likely to have low back pain than those who did not (18%, vs 34%). This is in line with Stuart Mcgills study on lumbar supports lessening low back pain in airline seats, and is immediately obvious when someone with low back pain and a bad seat adds the right size lumbar support. What was new to me was that neither seat angle nor backrest angle were individually related to low back pain, while together they were. Drivers were less likely to have pain if the angle between the seat and backrest was greater than 91 degrees (9% vs 23-37% in those with a lesser angle). For example, if your seat were declined rearward 10 degrees (from horizontal) , then the backrest would need to be reclined greater than 102 degrees from horizontal such that the drivers thigh to torso angle would be greater than 91 degrees (making an obtuse rather than acute angle). Alternatively: if the seat was perfectly level, the backrest of the seat would only need to be reclined a 91 degrees in order for the driver’s thigh and torso to form the appropriate angle.

    So the take home is lumbar supports do decrease low back pain, as does having seat to backrest angle being at least 91 degrees. Seat position though is a bit of a tradeoff. I frequently caution against reclining the backrest too much as it sometimes forces people to excessively reach forward for the steering wheel, which puts more stress on the neck, shoulder, and eventually the low back again. As such, when providing physical therapy treatment for low back or neck pain it’s worth taking a look at car or truck seat position to make adjustments to decrease stress on the spine. The patient can then make similar seating adjustments at work and home to further decrease static stress on the spine.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFITyoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Running Volume Increase Effects on Injury

    Can GPS be used to detect deleterious progression in training volume among runners? J Strength Cond Res. 2013 Jun;27(6):1471-8. Nielsen RO1, Cederholm P, Buist I, Sørensen H, Lind M, Rasmussen S.

    Abstract
    There is a need to ascertain if an association exists between excessive progression in weekly volume and development of running-related injuries (RRI). The purpose of this study was to investigate if GPS can be used to detect deleterious progression in weekly training volume among 60 novice runners included in a 10-week prospective study. All participants used GPS to quantify training volume while running. In case of injury, participants attended a clinical examination. The 13 runners who sustained injuries during follow-up had a significantly higher weekly progression in total training volume in the week before the injury origin (86% [95% confidence interval: 12.9-159.9], p = 0.026) compared with other weeks. Although not significant, participants with injuries had an increase in weekly training volume of 31.6% compared with a 22.1% increase among the healthy participants. The error of the GPS measurements in open landscape, forest, and urban area of volume was ≤6.2%. To conclude, no clinically relevant measurement errors of the GPS devices were found for training volume. Based on this, GPS has a potential to detect errors in training volume, which may be associated with development of RRI. Based on the results from the current study, increases in weekly training progression may become deleterious at a weekly increase above 30%, which is more than the 10% rule currently used as a guideline for correct progression in weekly volume by runners and coaches. Still, no clear evidence for safe progression of weekly volume exists. But it seems likely that some individuals may tolerate weekly progressions around 20-25%, at least for a short period of time.

    My comments

    This study didn’t find statistical significance in volume as related to injury but the trend was towards more injuries as people increased their training volume above 30% per week. The traditional wisdom is to tell runners not to increase volume more than 10% per week. However, the traditional wisdom has no research behind it whatsoever. So I’ll take a non-significant trend over traditional wisdom (which is often long on tradition and short on wisdom) any day of the week. In addition, they referenced the Bruist et al study, which found no difference in injury rates between runners who increased their training volume 10% per week vs 24% per week. So taken together it seems, at least for novice runners, the 10% increase in volume is is too conservative and likely holds back peoples’ fitness levels; greater than 30% is too aggressive, so 20-25% seems reasonable to me.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Marathon Runners, Running >30 Km/Wk Decreases Risk of Injury

    Weekly running volume and risk of running-related injuries among marathon runners. International Journal of Sports Physical Therapy. 2013 Apr;8(2):111-20. Rasmussen CH, Nielsen RO, Juul MS, Rasmussen S.

    Abstract
    PURPOSEBACKGROUND: The purpose of this study was to investigate if the risk of injury declines with increasing weekly running volume before a marathon race.
    METHODS:
    The study was a retrospective cohort study on marathon finishers. Following a marathon, participants completed a web-based questionnaire. The outcome of interest was a self-reported running-related injury. The injury had to be severe enough to cause a reduction in distance, speed, duration or frequency of running for at least 14 days. Primary exposure was self-reported average weekly volume of running before the marathon categorized into below 30 km/week, 30 to 60 km/week, and above 60 km/week.
    RESULTS:
    A total of 68 of the 662 respondents sustained an injury. When adjusting for previous injury and previous marathons, the relative risk (RR) of suffering an injury rose by 2.02 [95% CI: 1.26; 3.24], p < 0.01, among runners with an average weekly training volume below 30 km/week compared with runners with an average weekly training volume of 30-60 km/week. No significant differences were found between runners exceeding 60 km/week and runners running 30-60 km/week (RR=1.13 [0.5;2.8], p=0.80).
    CONCLUSIONS:
    Runners may be advised to run a minimum of 30 km/week before a marathon to reduce their risk of running-related injury.

    My comments:
    This was an interesting study with researchers finding elevated risk for injury if marathoners ran less than 30 km per week (18.6 miles) as they trained for their marathon. You hear a lot of talk of overuse injuries and these investigators found there was also risk of being underprepared for a race, and better yet they quantified how much was enough. People training less than 30 km per week being 134% more likely to be injured than marathoners who ran more. Those who ran more than 60 km (37.3 miles) had no additional risk reduction but were not of elevated risk.

    Also noted in the study was that first time marathoners were at higher risk for injuries than those had run them before. Those with prior running injuries were more likely to get injured. Surprisingly younger runners (those under 35) were more likely to get injured than older ones. Most common injuries were of the knee, foot and ankle.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Reversing Disc Protrusions, McKenzie Mostly Correct in Theory

    Disc prolapse: evidence of reversal with repeated extension. Scannell JP, McGill SM. Spine (Phila Pa 1976). 2009 Feb 15;34(4):344-50.

    Abstract
    STUDY DESIGN:
    A basic science study that used a porcine cervical spine model to produce disc prolapse subsequently exposed to an extension protocol.
    OBJECTIVE:
    This study investigated whether extension or combined extension and side flexion could move the displaced portion of nucleus from the annulus towards the nucleus.
    SUMMARY OF BACKGROUND DATA:
    Previous research has established that repeated flexion can create disc prolapse, the question here is whether repeated extension can reverse the process.
    METHODS:
    The C3/4 segments of 18 porcine cervical spines were dissected and potted in cups. Specimens were preloaded, then axially compressed (1472 N), and repeatedly rotated in either pure flexion or combined flexion and side flexion at a rate of 0.5 degrees /s. Specimens that prolapsed were axially compressed and repeatedly and rotated into extension.
    RESULTS:
    Based on a blinded radiologist’s review of the radiograph images, all 18 specimens contained healthy discs before testing, but after testing 2 of the 18 specimens had endplate fractures, whereas 11 of the 18 specimens had prolapsed. Prolapsed nucleus was reduced in 5 of the 11 prolapsed specimens after the reversal testing, whereas the remaining 6 did not change. Subclassification analysis revealed that the prolapsed discs that centralized had significantly less disc height loss (P < 0.01). Neither the classification of the herniation (circumferential or radial) nor the angle of lordosis of the specimens was linked to the behavior of the specimens.
    CONCLUSION:
    This study showed that with repeated flexion, in porcine cervical spines, disc prolapse was initiated and that the displaced portion of nucleus can be directed back towards the center of the disc in response to particular active and passive movements/positions.

    My comments:
    This study is interesting as it backs up a central tenant of Robin McKenzie’s popular treatment for low back pain. The study reinforced that repeated spine flexion (forward bending) causes the nucleus of a spine disc to work rearward causing disc protrusions (bulges), and as discussed in my last blog, eventually extrusions (ruptured or herniated disc) where the gel-like nucleus of the disc squirts from the disc, generally resulting in severe pain and often numbness and tingling in the legs.

    In this study they (in agreement with McKenzie’s theory) found that repeated extension (backward bending) could sometimes reverse the process, helping to move the disc back to the center. I’ve met one of the primary researchers in this paper (Stuart McGill) and asked him if he started recommending repeated back extension to his exercise program in light of this study. He said he still didn’t, because the repeated extension would eventually result in arthritis in the facet joints of the spine. Rather, he thought laying prone (on one’s stomach) with the head raised either on two fists or up on elbows (at most) and staying in that position for as long as 15 minutes would likely have the same positive effect without stressing the facet joints of the spine. Since then, I have added this exercise/stretch to my physical therapy treatment programs of a number of my patients with low back pain. If it provides relief of symptoms I keep it, if it causes any irritation I discard it.

    McGill also cautioned that extension in this study only worked in 45% of the spines with prolapsed discs while 55% did not. Also, it seemed to work in spines with only moderate disc height loss, and not in those with severe disc height loss secondary to disc prolapse. The cut off was about 60%, in which those discs that had at least 60% disc height maintained benefited from extension, while those with disc height of less than 60% (average of ~45%) did not.

    What’s interesting is that while Robin McKenzie’s basic hypothesis has been largely justified by research, his diagnostic methods and treatment programs have not. In addition to other factors I discuss in my prior blogs, this is likely because repeated extension still works less than 50% of the time in those with disc protrusion as found in this paper. Like McGill cautioned, the extension forces in McKenzie’s more aggressive extension stretches may still be too great, potentially leading to additional spine problems. I still think McKenzie’s books are worth reading for physical therapists, as I think my own treatment programs benefited a lot after I started reading books about treatment methods I didn’t necessarily agree with. McKenzie was clearly ahead of his time, coming up with his hypotheses and programs well before the majority of this research existed.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • How to Herniate a Disc, and How Not to

    Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clin Biomech (Bristol, Avon). 2001 Jan;16(1):28-37. Callaghan JP, McGill SM.

    Abstract
    OBJECTIVE:
    To determine whether repeated motion with low magnitude joint forces, and flexion/extension moments consistently produce herniation in a non-degenerated, controlled porcine spine motion segment.
    DESIGN:
    Combined loading (flexion/extension motions and compressive forces) was applied to in vitro porcine functional spinal units. Biomechanical and radiographic characteristics were documented.
    BACKGROUND:
    While most studies performed in vitro have examined uniaxial or fixed position loading to older specimens, there have been few studies that have examined whether ‘healthy’ intervertebral discs can be injured by low magnitude repeated combined loading.
    METHODS:
    Porcine cervical spine motion segments (C3-C4) were mounted in a custom jig which applied axial compressive loads with pure flexion/extension moments. Dynamic testing was conducted to a maximum of 86400 bending cycles at a rate of 1 Hz with simultaneous torques, angular rotations, axial deformations recorded for the duration of the test.
    RESULTS:
    Herniation (posterior and posterior-lateral regions of the annulus) occurred with relatively modest joint compression but with highly repetitive flexion/extension moments. Increased magnitudes of axial compressive force resulted in more frequent and more severe disc injuries.
    CONCLUSIONS:
    The results support the notion that intervertebral disc herniation may be more linked to repeated flexion extension motions than applied joint compression, at least with younger, non-degenerated specimens. Relevance. While intervertebral disc herniations are observed clinically, consistent reproduction of this injury in the laboratory has been elusive. This study was designed to examine the biomechanical response and failure mechanics of spine motion segments to highly repetitive low magnitude complex loading.

    My comments:

    This was one of the earlier studies done that really figured out how spinal discs herniate and built upon the prior work of Gordon et al.  Gordon was one of the first to be able to reliably produce lumbar herniations in the lab through a combination of compression, and repeated spine flexion and rotation. It’s interesting because prior to this, researchers were unable to get spines to herniate in the lab like they would see clinically with patients.  Callaghan and McGill did so with just flexion and extension with varying levels of compression. What they found was with just 260 N of compression there were no disc herniations in 83700 cycles. At 867 N all discs herniated with an average of 70550 cycles. With 1472 N 3 out of 4 discs failed with a disc herniation while the 4th failed with an end plate failure, with an average of only 34974 cycles.  What both studies found was that discs didn’t herniate from large forces, but rather high repetitions of moderate loads.

    The above is still quite technical, so I’ll translate to layman’s terms: the spinal discs are like built like a jelly donut with a tough outer ring and a fluid core. If you bend the discs back and forth a lot with no load they hold up.  If you combine that with some compressive force, eventually the jelly will work its way towards the opposite side you are bending (generally forward) bulging your donut/disc towards the rear (known as a disc protrusion). This causes back or neck pain. Eventually the jelly squirts out the back of the donut (disc extrusion or herniation) often causing severe back and neck pain that often radiates into the arms or legs. This then leaves you with a flattened donut/disc predisposing you to arthritic changes in the spine, which is another problem.

    The bad thing is that it does take thousands of cycles to cause initial injury, allowing people to get away with bad postures and movement patterns for a long time (often decades), then once the pain starts it seems to come from nowhere at which point those bad habits are hard, though necessary, to break.

    Current physical therapy treatments for back and neck pain therefore have to address and lessen spinal motions throughout the day, and increase use of the hips, knees, and shoulders to spare the spine. Also generally needed is an increase total body fitness so that people have both the strength and endurance to maintain proper spine alignment (avoiding the above spine motions that cause disc herniations) all day long allowing tissues to heal. The exercises serve double duty by teaching proper motor control while they increase fitness. In addition, when properly applied, EMS is a powerful adjunct at both increasing core strength and endurance while immediately decreasing pain.

    Updated: 1/25/2016

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Patellofemoral Pain Most Associated with Hip Weakness

    Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health. 2011 Sep;3(5):455-65. Meira EP, Brumitt J.

    Abstract
    CONTEXT:
    Patellofemoral pain syndrome (PFPS) is one of the most common conditions limiting athletes. There is a growing body of evidence suggesting that dysfunction at the hip may be a contributing factor in PFPS.
    DATA SOURCES:
    MEDLINE (1950-September 2010), CINAHL (1982-September 2010), and SPORTDiscus (1830-September 2010) were searched to identify relevant research to this report.
    STUDY SELECTION:
    Studies were included assessing hip strength, lower extremity kinematics, or both in relation to PFPS were included.
    DATA EXTRACTION:
    Studies included randomized controlled trials, quasi-experimental designs, prospective epidemiology, case-control epidemiology, and cross-sectional descriptive epidemiology in a scientific peer-reviewed journal.
    RESULTS:
    PFPS is associated with decreased hip strength, specifically at the abductors and external rotators. There is a correlation between PFPS and faulty hip mechanics (adduction and internal rotation).
    CONCLUSIONS:
    There is a link between the strength and position of the hip and PFPS. These patients have a common deficit once symptomatic. Hip strengthening and a coordination program may be useful in a conservative treatment plan for PFPS.

    My comments:
    This was a pretty informative review paper that summed up a growing body of research showing hip abduction and hip external rotation weakness is turning out to be more strongly associated with patellofemoral pain than any other factors.  Less so but still important however were associations with weakness in hip extension, hip internal rotation, knee flexion and knee extension.

    So basically if if you have patellofemoral pain you probably want to add some progressive resistance exercise throughout your hips and legs (and I’d add some core in there too), but an emphasis on hip abduction and external rotation strength is probably a good idea. What’s interesting is that this paper illustrates the importance of hip strength on pain and function at the start of knee problems, and it turns out to be really important nearer the finish as well.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Runners with Plantar Fasciitis Have Weak, Tight Calf Muscles

    Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med. 1991 Jan-Feb;19(1):66-71. Kibler WB1, Goldberg C, Chandler TJ.

    Abstract
    Plantar fasciitis is a relatively common injury that occurs in running athletes. The disease entity is a good example of an overloaded process of the plantar fascia at its calcaneal insertion. This study was designed to examine the strength and flexibility findings in the muscles that are put on tensile load during running, and which are responsible for controlling the forces on the foot during stance and pushoff, thus modifying the overload. Three groups of athletes underwent physical examination, including checking ankle range of motion in plantar flexion and dorsiflexion. Cybex peak torque measurements were taken at 60 and 180 deg/sec. The groups were a control group of 45 athletes with no symptoms, a group that included 43 affected feet with symptomatic plantar fasciitis, and a group that included the 43 unaffected contralateral feet. Analysis of data showed dynamic range of motion deficits in 38 of 43 affected feet, static range of motion deficits in 37 of 43 affected feet, deficits in peak torque at 60 deg/sec in 41 of 43 affected feet, and deficits in peak torque at 180 deg/sec in 37 of 43 affected feet. Statistical comparison of range of motion showed that the group with symptomatic plantar fasciitis was significantly restricted compared to both control and unaffected contralateral feet groups. Statistical comparison of peak torque showed that the symptomatic plantar fasciitis group was significantly lower than both other groups at both velocities. This study documents strength and flexibility deficits in the supporting musculature of the posterior calf and foot that are affected by plantar fasciitis. These anatomical and physiological alterations create a functional deficit in the normal foot biomechanics. This either causes or contributes to the overt clinical symptoms and should be addressed in the evaluation and treatment of plantar fasciitis.
    Quote from the conclusion:

    “The restoration of muscle strength and flexibility of the foot is thought be especially important in light of the findings of Nigg, Nigg, et all, and Robbins et all, which show that very little force can actually be attenuated by modifying the shoes of athletes with otherwise normal feet.”

    My Comments:

    The last study I blogged on was 11 years old, this one is 23 years old and is the single best paper I have read to date on plantar fasciitis. The research in the paper was both good and pertinent, and the introduction and concluding remarks are IMO spot on, and unfortunately 2/3 ignored.  Such that any physician, podiatrist, or physical therapist specializing in runners injuries or foot pain ought to read the entire text. What the researchers found was average ankle range of motion (ROM) runners with plantar fasciitis was limited 26.9% in their painful side comparison to their good side, but was limited 39% in comparison to healthy runners. Calf muscle strength (peak torque) measured at 60 degrees per second in runners with plantar fasciitis was limited 25.1% in comparison to their good side and limited 33.3% in comparison to healthy controls. They found even the “healthy” foot in runners with plantar fasciitis still had 17.4% less ankle ROM and 11.7% less strength than did control subjects.

    The authors clearly thought that strength loss, as well as ROM, was important to recovery of plantar fasciitis, yet today the typical treatment for plantar fasciitis is orthotics (which have minimal effect regardless of cost), stretches, later night splints, cortisone shots, and if that all fails surgery (which itself often fails). In 23 years since this paper there has yet to be controlled trial of foot intrinsic and LE strengthening exercise either alone or in combination with other treatments. That seems amiss to me.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Plantar Fasciitis Sufferers Have Weaker Foot Muscles

    Toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint in individuals with plantar fasciitis. J Orthop Sports Physical Therapy. 2003 Aug;33(8):468-78. Allen RH, Gross MT.

    Abstract
    STUDY DESIGN:
    Cross-sectional study.
    OBJECTIVE:
    To determine if a difference exists in toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint between individuals with unilateral plantar fasciitis and control subjects.
    BACKGROUND:
    Weakness of the dynamic longitudinal arch supporters and shortening of the plantar fascia have been suggested as etiologic factors for plantar fasciitis. METHOD AND MEASURES: Twenty subjects with unilateral plantar fasciitis participated in the study. Subjects had had symptoms for an average (+/-SD) of 19.9 +/- 33.2 months prior to participating in the study. Twenty control subjects matched for sex and age were also tested. Each subject was measured bilaterally for passive extension range of motion of the first metatarsophalangeal joint and peak resistance force observed during an isometric test of toe flexors strength.
    RESULTS:
    Subjects with unilateral plantar fasciitis demonstrated weaker toe flexors (P<.05) than the control subjects. A significant main effect for feet also indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet (P<.05) of subjects with unilateral plantar fasciitis. Passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet for subjects with plantar fasciitis.
    CONCLUSION:
    Results for our subjects indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis.

    My comments:

    This study is over 10 years old (my next planned blog is even older) and I find it interesting how you often have to look back into the history of research to come up with something new or better. What these researchers found was that the plantar fascia was NOT tight (as measured by toe extension). However, toe flexor muscle strength in those with plantar fasciitis was weak, with the painful foot being able to flex with 88 Newtons (N) of force compared to 96 N on their non-painful side. What’s more was that both the painful and non-painful foot was weak as compared with normal control subjects without pain, whose toe flexion strength ranged from 117-135 N. This tends to confirm the suspicions I had with regard to foot intrinsic muscle atrophy in an earlier blog on plantar fasciitis that found muscle atrophy in the painful foot in comparison to the non-painful foot, but did not compare to normal controls. This study shows that muscle weakness is worse on the painful side and worse still in comparison to normal controls, such that one might reasonably assume the same with muscle atrophy.

    The conclusion I am reaching, and using successfully in my physical therapy office, is that though the plantar fascia is technically a ligament, it has many similarities with tendinopathy and should be treated as such. Some stretch is likely still important, but a much greater emphasis should be placed on strengthening the muscles within the foot as well as outside through a combination of progressive resistance exercise and electric muscle stimulation.  Muscle weakness being much of the problem would explain why both OTC and custom orthotics have such little effect on plantar fasciitis.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Plantar Fasciitis Associated with Foot Muscle Atrophy

    Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs. Chang R, Kent-Braun JA, Hamill J. Clin Biomech (Bristol, Avon). 2012 Jun;27(5):500-5.

    Abstract
    BACKGROUND:
    Due to complexity of the plantar intrinsic foot muscles, little is known about their muscle architecture in vivo. Chronic plantar fasciitis may be accompanied by muscle atrophy of plantar intrinsic foot muscles and tibialis posterior compromising the dynamic support of the foot prolonging the injury. Magnetic resonance images of the foot may be digitized to quantify muscle architecture. The first purpose of this study was to estimate in vivo the volume and distribution of healthy plantar intrinsic foot muscles. The second purpose was to determine whether chronic plantar fasciitis is accompanied by atrophy of plantar intrinsic foot muscles and tibialis posterior.
    METHODS:
    Magnetic resonance images were taken bilaterally in eight subjects with unilateral plantar fasciitis. Muscle perimeters were digitally outlined and muscle signal intensity thresholds were determined for each image for volume computation.
    FINDINGS:
    The mean volume of contractile tissue in healthy plantar intrinsic foot muscles was 113.3 cm(3). Forefoot volumes of plantar fasciitis plantar intrinsic foot muscles were 5.2% smaller than healthy feet (P=0.03, ES=0.26), but rearfoot (P=0.26, ES=0.08) and total foot volumes (P=0.07) were similar. No differences were observed in tibialis posterior size.
    INTERPRETATIONS:
    While the total volume of plantar intrinsic foot muscles was similar in healthy and plantar fasciitis feet, atrophy of the forefoot plantar intrinsic foot muscles may contribute to plantar fasciitis by destabilizing the medial longitudinal arch. These results suggest that magnetic resonance imaging measures may be useful in understanding the etiology and rehabilitation of chronic plantar fasciitis.

    My comments:

    Researcher’s noted that foot intrinsic muscles were 5% smaller on the painful foot of people with plantar fasciitis. In this study they compared the good foot to the bad foot on the same person. However, I would expect the relative atrophy to be greater when compared to healthy controls. In my physical therapy office, I have noticed people with plantar fasciitis haven weakness in both legs, with the painful side often being the worst. Still, it’s a very interesting study. The authors pointing out that plantar fasciitis isn’t just an injury associated with a loss of range of motion, but one associated with a loss of foot intrinsic muscle strength that can benefit from strengthening as well as typical rehabilitation programs that focus solely on morning foot stretches and orthotics (which turn out to do a lot less good than people think), was an interesting point.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Plantar Fasciitis: Orthotics Don’t Help Much

    Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006 Jun 26;166(12):1305-10. Landorf KB, Keenan AM, Herbert RD.

    Abstract
    BACKGROUND:
    Plantar fasciitis is one of the most common foot complaints. It is often treated with foot orthoses; however, studies of the effects of orthoses are generally of poor quality, and to our knowledge, no trials have investigated long-term effectiveness. The aim of this trial was to evaluate the short- and long-term effectiveness of foot orthoses in the treatment of plantar fasciitis.
    METHODS:
    A pragmatic, participant-blinded, randomized trial was conducted from April 1999 to July 2001. The duration of follow-up for each participant was 12 months. One hundred and thirty-five participants with plantar fasciitis from the local community were recruited to a university-based clinic and were randomly allocated to receive a sham orthosis (soft, thin foam), a prefabricated orthosis (firm foam), or a customized orthosis (semirigid plastic).
    RESULTS:
    After 3 months of treatment, estimates of effects on pain and function favored the prefabricated and customized orthoses over the sham orthoses, although only the effects on function were statistically significant. Compared with sham orthoses, the mean pain score (scale, 0-100) was 8.7 points better for the prefabricated orthoses (95% confidence interval, -0.1 to 17.6; P = .05) and 7.4 points better for the customized orthoses (95% confidence interval, -1.4 to 16.2; P = .10). Compared with sham orthoses, the mean function score (scale, 0-100) was 8.4 points better for the prefabricated orthoses (95% confidence interval, 1.0-15.8; P = .03) and 7.5 points better for the customized orthoses (95% confidence interval, 0.3-14.7; P = .04). There were no significant effects on primary outcomes at the 12-month review.
    CONCLUSIONS:
    Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device. The customized and prefabricated orthoses used in this trial have similar effectiveness in the treatment of plantar fasciitis.

    My comments:
    I’ve seen a number of studies that compared inexpensive over the counter orthotics to expensive custom made orthotics for plantar fasciitis, and they found there was no difference for the patient. This study was much the same. In fact, the over the counter orthotics came out very slightly ahead of the custom made ones with regards to both pain reduction and improved function (by about 1%), though the difference was not statistically significant.

    What was more interesting is that this was the first, and still only, study to compare real orthotics to placebo “sham” orthotics. What they found was that 3 months out, the real orthotics decreased pain only 7-8% better than the sham ones, which was statistically significant but it had the authors question whether orthotics of any kind were worth the effort for plantar fasciitis. I have to admire the honesty coming from the researchers who are Podiatrists with a long history of researching plantar fasciitis and other foot problems.  At 12 months out there was no statistical significance between any of the three groups (custom, over the counter, or sham). The good news is that all three groups did improve over time, but it seems orthotics whether custom made or not only have a minimal beneficial effect. Certainly it seems the custom made orthotics are not worth the expense, with over the counter ones being relatively inexpensive and maybe worth trying on before you buy, or maybe not.

    I’m of the opinion that plantar fasciitis should be treated more like tendinopathy, with a greater focus on strengthening muscles of the lower leg and foot with a combination of progressive resistance exercise for the larger muscles and electric muscle stimulation for the foot intrinsics (which most certainly works the foot muscles more intensely than towel bunches do). I notice a pretty good benefit from both clinically, but as of yet, there no research on either strengthening nor EMS for plantar fasciitis. The similarities of the condition with various tendinopathy conditions, along with my outcomes, makes me think it’s worth pursuing.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.