Beyond pills, patches, and exercises…

 

 

Following 3 general contractors repairing a crack in my drywall I was informed that it would continue to happen because the problem was with the foundation of my house.  If I did not have the problem addressed I could then expect to experience water infiltration with subsequent water damage as well as continued structural and cosmetic damage.

Following 3 mechanics replacing missing oil in my vehicle I was informed that I would continue to have to fill the oil reservoir because the problem was not with the oil.

Following 3 Medical Professionals recommendation for prescribed pain medicine I was informed that I would continue to have a pain problem because the problem was not a lack of prescribed pain medicine, yet the treatment approach did not change.

Following 3 General Practitioners prescribing insulin to address my diabetes I was informed that I would continue to have a diabetes problem because the problem was not a lack of prescribed medicine, yet the treatment approach did not change.

Following 3 Medical Professionals treating Fibromyalgia, Rheumatoid Arthritis, Irritable Bowel Syndrome, Chronic Pain, Degenerative joint, Degenerative disc, Idiopathic Systemic illness…

How many examples could I think of?  The point of the post is to encourage the inquiry as to WHY.  As best stated by Dr. Sosman, 

“You see only what you look for; you recognize only what you know”

If your experience has been similar to the facetious examples above then I would encourage you to seek answers and other individuals with answers.  All professionals can be nice, helpful, and trustworthy but sometimes ineffective in treating the compensation rather than the cause.  Follow the breadcrumb trail of people with the same problem who are getting results.

(soapbox done) 🙂

 

Bone not healing? Is it receiving the correct stimulus?

I recently had the privilege to work with an individual who had suffered an ankle injury.  As a result of this injury the Fibula had suffered a fracture and was not healing.  Upon inquiry as to why, they were perplexed and stated they had not received any good answers as to why.  Here is another thought…

Bone growth is stimulated by weight bearing.  Each bone is designed to resist forces specific to the area in which the bone lives.

 

For example the tibia has great compressive strength but less strength when challenged with a lateral force.

 

So if I wanted to ‘break’ a tibia I would not load it from the top down or bottom up.  To ‘break’ a tibia I would load it from side to side.

Likewise a Fibula is designed to absorb and transfer stresses from top down and bottom up.  My question then becomes what is creating rotatory or side-bending forces in the Fibula.

As a result of the ankle injury the ankle had

Image result for calf stretch

become stiff and unable to bend (dorsiflex).

 

When this person would walk and the involved foot traveled behind them the foot would turn out.  This turning out of the foot was introducing excessive side-to-side and rotatory forces to the Fibula essentially ‘gaping’ the wound.

In theory, upon restoring the ankle mobility (talocrural, subtalar), and normalizing gait, the correct compressive forces at the fibula will help to provide the correct ‘weight bearing’ stimulus for the bone to heal while limiting the shear forces introduced by compensations from a stiff ankle.  Just something to ponder.

 

L4-5 versus L5-S1 and the subtalar joint hypothesis

I have never heard this mentioned before so if you choose to pursue or reference the following I would appreciate the credit :).

Subtalar joint high axis creates greater transverse plane (rotation ) to frontal plane (sidebend) calcaneal motion.

Subtalar joint low axis creates greater frontal plane (sidebend) to transverse plane (rotation) calcaneal motion.

L5-S1 articulation has greater frontal plane (sidebend) to transverse plane (rotation) motion.

L4-L5 articulation has greater transverse plane (rotation) to frontal plane (sidebend) motion.

Therefore:

because L4-L5 has greater capacity to tolerate rotation versus L5-S1:

Subtalar joint high axis tolerated better at L4-L5 versus L5-S1 theoretically creating greater harm at L5-S1.

 

L5-S1 has greater capacity to tolerate sidebend versus L4-L5.

Subtalar joint low axis tolerated better at L5-S1 theoretically creating greater harm at L4-L5.

 

Following video is nontechnical overview of motion preference via facet joints in the spine.  Not focused on lumbar region by itself.

 

SI joint pain and the subtalar joint. Hypothesis 2

Motion in a joint moves perpendicular to the axis.  For example reference the following image.

Image result for joints move perpendicular to axis hinge

 

Image result for subtalar joint axis

 

 

The subtalar and sacroiliac (SI) joint share a very interesting property.  The axis appears to be similar with the  subtalar joint highly utilized in the frontal and transverse planes.

 

 

 

 

 

Image result for sacroiliac joint axis

The sacroiliac joint also is highly utilized in the frontal and transverse planes as evidenced by an oblique axis anterior to posterior like the subtalar joint.

 

 

 

 

Therefore given a “normal” subtalar joint, without ‘energy leaks up the kinetic chain’, a 1:1 ratio of frontal to transverse plane motion would reach the SI joint asking for a similar response.  Everything in this scenario would be happier than the following.

Image result for pes planus

 

 

 

 

 

 

 

The axis of the subtalar joint in the above picture has changed from “normal”.  The axis now has allowed for greater frontal plane motion than transverse.  Let’s say this ratio is now 2:1 frontal plane to transverse plane.  A subtalar joint with a 2:1 ratio now communicates to the sacroiliac joint (SI) joint asking for a 2:1 ratio of frontal to transverse plane.  The sacroiliac joint does not have much motion to give ~4 degrees.  Therefore it will begin to steal motion from above or below itself while being abused by moving contrary to it’s 1:1 axis.  Therefore we now have SI dysfunction from the subtalar joint.

 

SI joint pain and the sub talar joint. One hypothesis.

Let’s consider two positions of the calcaneus acting at the subtalar joint.

Image result for rearfoot varus

The image on the left demonstrates the calcaneus medially under the tibia creating a ‘longer leg’ by supinating the foot and lifting the tibia vertically.  The subtalar joint is stiff with this foot type and does not wiggle side to side and twist very well, but it could loosen up with the right stimulus.

 

The image on the right demonstrates the calcaneus laterally under the tibia creating a ‘shorter leg’ by allowing the tibia to drop down and in.  The subtalar joint is usually not the problem with this foot type and often times the calcaneus is able to wiggle side to side and twist very well.

 

 

 

From the foot types above we now have 1. a longer leg, and 2. a shorter leg.  This leg length discrepancy creates compensations from the ground up causing SI dysfunction on the ‘shorter side’.  I like this idea but not as much as the future post that will pose another hypothesis.

A link to a video I watched on youtube provided me with the idea of subtalar joint dysfunction, leading to leg length, leading to SI dysfunction.

https://www.youtube.com/watch?v=U94YPI4PNww

The bullied bunion.

A bunion is when the big toe travels laterally toward the rest of the toes.

 

The purpose of this post is to help clarify one simple idea.  The big toe is a ‘reactive’ joint.  Meaning the big toe is responding to the stimulus that is being placed upon it.

If we approach the problem of a bunion knowing that it is not the fault of the big toe, then any intervention addressing the big toe without pursuing ‘why’ becomes limited in its efficacy.

Understanding how the foot works becomes paramount in addressing this problem.  Knowing that the rear foot and the mid foot function creates a healthy or harmful environment for the big toe is necessary to sleuth out the ‘villain’.

Searching GOOGLE for ‘bunion surgery’ I was surprised to see a Physician reviewed article stating “Wearing shoes that are too small or too narrow in the toe area is the most common cause of bunions.”  I wholeheartedly believe that this statement is not true and dangerous in not pursuing a true cause for this condition.

I have seen many surgical corrections or ‘bunionectomy’ procedures that guess what… begin to develop another bunion!  I would implore you to seek out a movement professional who understands biomechanics and the foot in order to help solve the real reason why the big toe is being bullied.

Foot Orthotic Paradigm shift

I have embraced the paradigm concerning foot orthotics that the aim or intervention goal is to ‘bring the ground up’ to accommodate the dysfunctional foot.  In other words change the ground to accommodate the foot.  This has presented me with difficulties when addressing a rigid foot type such as an uncompensated rear foot varus.

When changing this paradigm to ‘consider modifying the orthotic to change the foot before it hits the ground, options seem to present themselves.  In other words change the foot to accommodate the ground.  Here is an example.

If I have a foot type where the subtalar joint does not evert, how can I change ‘the ground’ to make the subtalar joint evert?Image result for rear foot varus

 

I do know that when you see an everted subtalar joint in stance then the problem is with the forefoot.  Therefore the forefoot can create and influence frontal plane load on the rearfoot during stance.

So If I have a subtalar joint that will not evert, what if I create a forefoot varus?  Depending on the degree of post I introduce under the forefoot I should be able to introduce a rectus position to the calcaneus and provide a stimulus of eversion when transitioning from heel strike -> to foot flat -> to midstance.

No I can attack those pesky IT-Band issues with greater efficacy!  Hooray!

Changing the paradigm of ‘bringing the ground up’ to ‘changing the foot type’ opens up possibilities in fabrication of orthotics.  Subtalar eversion would then require me to create a forefoot varus by essentially looking from the ground up as though I were creating a forefoot valgus.  Probably why the body adapts by creating plantarflexed first ray’s in the presence of a rearfoot varus.

This post is truly ‘thinking out loud’.  I ultimately believe creating dysfunction to address dysfunction is not the right way, yet I do feel that continuing to creatively problem solve and entertain ‘out of the box’ thinking is important.

Piriformis Syndrome and the big toe bailout.

Yes, the big toe when working properly is a powerful ally in addressing Piriformis Syndrome.  Why?  Early and overpronation of the foot require the Piriformis to work hard to control the femur from too much internal rotation.

During the stance phase of gait the Piriformis receives help in two phases.  When the heel strikes, and when the foot travels over the big toe. (these things happen at the same time on opposite feet)Image result for gait cycle

When the foot travels over the big toe an effect referred to as the ‘Spanish Windlass’ takes place where the plantar fascia supinates or pulls an arch into the foot.  Up the kinetic chain this allows for external rotation or a ‘shortening’ phase for the Piriformis.  During the stance phase of gait the Piriformis should act as the following:

  • heel strike = Piriformis rest (shortening)
  • foot flat = Piriformis working
  • heel off = Piriformis rest (shortening)

So 2 x break and 1 x work.  In a person that pronates too early and their foot does not travel over their big toe then the piriformis is under increased workload.  Issues of entrapment can result in ‘Sciatic’ pain from the facilitated Piriformis.

If you suffer from Piriformis syndrome, experiment with heel strike as well as allowing the foot to hinge over the big toe as you deliberately push off during gait.  See if this gives your ‘Piriformis’ a break.

This is surely not the only reason, but a commonly overlooked one.

Image result for spanish windlass foot

In reference to the previous post, the foot type associated with piriformis syndrome is often opposite of that associated with IT-band syndrome.  Rigid foot versus a loose foot in the kinetic chain.

IT-Band Syndrome Why? Cause and reactive foot types

As I continue to post and consider links in the kinetic chain I am sure that I will need to change previous thoughts and ideas.  I feel as though I would like to continue to share ideas as I think of them with the hope of stimulating thought and creating additional paradigms to help sleuth obstacles in our pursuit of moving better.

So without further adieu, IT-Band Syndrome… Why?  Quick answer is, the stimulus of femoral internal rotation, as thought of from the ground up, is not being provided during a loading phase to trigger the hip muscular complex.

What?  Well let’s look at a severe progression of IT-Band Syndrome that is a common presentation of someone seeking medical help for knee problems.  Image result for genu valgum

In this picture we can see the angle of the right knee pre-surgery.  If you look at the tibia, it is rotated out, or rotated right.  In thinking of the hip, the femur is rotated in relative to the tibia.  So every time this person is loading their right leg, the Gluteus complex receives some stimulus to fire at the expense of the knee.  The IT-band has adapted, or has been over-utilized, thus creating an externally rotated tibia so that the femur can internally rotate and recruit the glute.

Why would it do this?  Let’s think of it in terms of the feet.  If this person had a rigid foot type whereby they appear to have a high arch then the stimulus for rotation would be absent during loading of the right foot.  Does this hypothesis sound crazy?  Let’s look.  Look at the post operative picture.  Which foot has a high arch?  The right foot has a high arch compared to the left.  This person, if weight bearing, is in the loading phase of the right foot when the arch should be least suggesting a foot type that creates a rigid/arched foot.  This person had their knee fixed surgically but did they ever look at the foot/cause?

If this is true then common foot types causing IT-Band Syndrome (or what the fellow in the picture may have) would be…

Uncompensated Rearfoot varus (rigid foot)

Rigid Forefoot Valgus (rigid foot)

Pes Cavus  (rigid foot)

Reactive foot types following an externally rotated tibia seem to be more

Forefoot supinatus

Forefoot varus

Supinated Back Pain? Part 2

As we have mentioned in a previous post, motion primes muscle.  In Part 1 of Supinated Back Pain? we identified a Supinated/rigid/arched foot’s effect in limiting the motion that subsequently triggers the hip musculature to work.

If the hip cannot capture this required motion to work from the foot, interesting things start to happen.  The motion of rotation for the hip to work is required and will take place.  The question is what will happen to create it.

I discussed with someone suffering from back pain on the right lowest region of the back.  They explained how their back pain would sometime radiate into the buttocks of the right side and keep them awake at night.

Image result for arm swing gaitWhen watching this person walk it was apparent that their upper torso rotated to the right when their right foot was flat on the ground.

They were loading their hip musculature with motion from the top down.  They would over-rotate their torso ‘out’ to make the femur rotate ‘in’ relative to the pelvis.

As a result they were abusing the area where they complained of their back pain.

Hopefully this allows us to appreciate how the body will compensate and allow us to perform the task we ask of it.  The body may not perform it in the most efficient way.  Whether it is the way we are made, or the way our bodies have adapted to our lifestyle, it is extremely beneficial to have a general understanding of how it moves to address some of our common concerns.

On a side note, the medial model of treatment had been imaging of the low back and prescriptions to address the pain.  Surgery was another option on the list to address what they had assumed was a bulging disc.  When asked, ‘Did anyone watch you walk’?  The answer was simply, ‘no’.