Trying to avoid a knee replacement. The story of a forefoot equinus.

I remember working with someone that presented with a foot type referred to as a ‘forefoot equinus’ which appears as the following…

This foot type does not allow the tibia to travel forward over the talus a.k.a the shin to travel over the ankle.  It is as if the ankle is stuck in a ‘stepping on the gas’ position appearing pointed down.  The ankle may travel up or ‘dorsiflex’ but will rarely enter into ‘dorsiflexion’ consequently not allowing the knee to bend forward past the toe.  As a result, when the ankle cannot travel forward, it will utilize a different plane of motion to allow for functional activity such as gait.  You may notice someone with this foot type walking with their foot rotated out accomplishing in the transverse plane (rotation) what cannot be accomplished in the saggital plane (forward/backward).

The foot will then pull the knee along that path introducing a lateral and rotatory force into the knee joint thus accelerating the degeneration.  At the time I saw this person they looked something like this during standing.

Image result for severe genu valgum

The knee looks bad so it must be the problem?  No.  The knee is just doing what the foot has been telling it to do for many years.  Understanding movement is critical in sleuthing the villain.  Do you think after this person receives a total knee replacement that it will solve their problems?  That foot is still the same, hiding in the background until addressed.

 

Animal testing reveals Opioid use amplifies pain rather than dulling it

In a publication entitled “Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation” researchers have discovered what Patients and movement professionals already know.

An opioid sets off a chain of immune signals in the spinal cord that amplifies pain rather than dulling it.  In summary, after approximately 1 week worth of moderate opioid dosage it resulted in doubling the time of hypersensitivity.  Even after the opioid left the animal’s system it was hypersensitive for twice the duration (12 weeks vs. 6 weeks) compared to that of the animal who was not administered an opioid.

Image result for glial cells

 

The hopeful finding is that researchers have proposed an idea of what is taking place and are in the process of developing a pharmaceutical to block imflammasome created by glial cells.  I know, another pill, yet at this point there are no quick fixes.

Living in America, a country in Opioid crisis, research in this area is overdue and paramount in addressing individual and community health.

 

 

  • Drug overdoses have since become the leading cause of death of Americans under 50, with two-thirds of those deaths from opioids.”
  • In 2012, 259 million prescriptions were written for opioids, which is more than enough to
    give every American adult their own bottle of pills.
  • The prescribing rates for prescription opioids among adolescents and young adults
    nearly doubled from 1994 to 2007
  • 48,000 women died of prescription pain reliever overdoses between 1999 and 2010.

After reading a few of these statistics taken from various sources, I have more questions rather than answers.  I try to be critical without being cynical, yet how has it reached this point.  Wasn’t research performed prior to the prescription process?  Haven’t medical professionals observed the negative effects in their patient population?  And why has the research performed on rats just been performed in 2016.  Oxycodone has been around since 1939 but was heavily prescribed as early as 1996.  Surely we can learn from this going forward.

Balance and the inner ear. ‘a toss around on the ground’

A respected movement professional once made a perplexing statement that I believe I now understand better.  They said something to the effect of, ‘all of us would benefit from the occasional toss around on the ground’.

Over the years I have appreciated the positives of many movement professions.  Feldenkrais, Pilates, Yoga, etc.  I marvel in hindsight in summary about how much I am pretty much just rolling around on the ground.  Interestingly enough I almost always end up feeling great.

As I age I have noticed when playing with my kids, or working on the house, that I find myself experiencing dizziness during change of head positions more than ever before.  One day after competing with my daughter performing somersaults, I experienced a surprising amount of dizziness and loss of balance that took longer to recover than I had remembered.  I realized a whole area that I had neglected in addressing age related changes affecting movement, in particular balance.

Just like my posting on balance, the vestibular system may experience agerelated sensory degeneration documented since the 1970’s.  I am a firm believer of the plasticity of the body meaning given the right stimulus the vestibular system has the capacity adapt to the imposed demand.

Thus introducing ‘The Foster Maneuver’ a.k.a. the ‘Half Somersault’ for treatment of the inner ear dysfunction known as Benign Paroxysmal Positional Vertigo or BPPV.  Did you read that right?  A ‘Half Somersault’.  Just another piece of evidence and justification to the statement ‘all of us would benefit from the occasional toss around on the ground’.

 

So in summary as you continue to pursue independence through function and mobility, please continue to challenge the systems in your body to adapt and perform as they did in your youth.  Often we lose what we do not use.  Remember to change head positions as tolerated in your exercises.  Looking left, right, down, up, side-to side may help to restore the vestibular changes resulting from lack of use.

In case you are curious here is a link to the Foster Maneuver.

Total knee replacement and foot type. Through the lens of function.

I recently had the privilege to work with a person that presented with a dysfunctional foot type.  It looked similar to this…Image result for valgus knee flat feet

 

I was able to work with this person because an Orthopedic Surgeon performed a procedure entitled a ‘Total Knee Replacement’ on them secondary to complaints of knee pain and knee osteoarthritis.

This individual suffered from significant constant swelling past the expected duration, following a total knee replacement.  They also repeatedly complained of constant and high levels of knee pain at the ‘inside of the knee’.   Upon inquiry the individual stated ‘the surgeon never looked at my foot, why would he?’

 

Image result for valgus knee flat feet

When tested on a table, the new knee performed very well appearing well aligned and demonstrating good mobility through bending and straightening.  When standing everything changed.  The toes turned out while the arch collapsed thus pulling the talus in thus pulling the tibia in creating a lateral angle at the knee.

 

Please consider the interconnectedness of the body and motion segments.  Search for an opinion from a trusted movement professional that considers function, and/or the interconnectedness of the entire body.  A foot problem will lead to a knee problem.  If the foot problem is not addressed, the knee will continue to present with problems.  This is true throughout the entire body during movement and locomotion.

Medically this individual was offered 2 options to address their complaints.  Pain pills, and aspiration.

The interconnectedness of the kinetic chain!

The hip is the knee.  The knee is the ankle.

The hip consists of a ball and socket.  The ball is formed on the bone called ‘the femur’.  The femur also forms the top bone of the knee joint.  Therefore, any hip pathology or conversely knee pathology, will directly affect each other.  In the same sense, the lower portion of the knee joint bone called, ‘the tibia’ joins at it’s furthest portion to create the ankle joint.  Therefore issues in the ankle create knee issues because the ankle is the knee.  Issues in the hip create knee problems because the hip is the knee.  Knee pain diagnosis under the microscope i.e. MRI of the knee is ‘missing the forest for the trees’ when considering function and interconnectedness of the kinetic chain.  The ankle drives the knee because it is the knee.  The hip drives the knee because it is the knee.

Seek advice from movement professionals who have the understanding to view the kinetic chain to help sleuth the ‘problem’

Unhealthy Client Paradigms leading to Professional Paralysis

In addressing pain throughout my time as a movement professional I have ran into ‘professional paralysis’ countless times.  Being thwarted in my suggestions toward movement and exercise with the common response of ‘oh that hurts’, or, ‘I am going to pay for this tomorrow’.

In addressing these pitfalls I find it essential to transfer ownership to the client/patient.  I feel as though a large part of ‘professional paralysis’ stems from the paradigm that it is the role of the provider to ‘fix’ the person.  If you are seeking help for chronic pain, the bitter pill to swallow yet less disappointing paradigm to operate from, is that ‘no one can fix you’.

The good news is that ‘you can fix you‘.  The ‘fix’ happens from the inside out as with all ‘fixes’ in the body.  The path is not easy, oftentimes does not make sense, strategies will fail many times, but you will not see results by being a passenger in this car.

As a movement professional I have to be flexible often initially allowing for self-selection strategies with loose guidelines about the type of movement that I am after.  Developing this ownership and vestment into treatment begins to help break this unhealthy idea of ‘I am here for you to fix me’.

You CAN exercise.  No matter your pain state you CAN do something.  Are you falling victim to cyclical arguments that ENABLE being a ‘passenger’ along for the ride? “I can’t walk it hurts my back…” how about exercising your arms?  “I have a shoulder problem”  well how about working your ankles a bit “well I’ll try but I have a busy schedule”.

Be careful of the often caring but toxic enabling partner.  “I wouldn’t do that if I were you…” they’ll say.  “Oh, let me get that for you…” will be the response.  I have even heard the divine enabling partner, “God doesn’t give me more than I can handle”.  Continuing the cycle of being a ‘passenger’ in the chronic pain journey.

Checks for introspection…  Is this me?

  1. I am waiting for someone to ‘fix me’
  2. Cyclical arguments  that enable no change in behavior
  3. Enabling relationships

Western medicine essentially offers 3 options of intervention.  Needles, knives, and pills all utilized in the hopes of facilitating the body to HEAL ITSELF.  Your body by adulthood has been estimated by some accounts to have up to 100 trillion cells, which make up specialized tissues, which make up specialized organs, which make up organ systems, which combined create us as an organism.  This wonderfully complex system is awaiting the orders of one ‘owner’ namely you to get in the ‘drivers seat’ and direct the outcome of your current challenge.

You are in control.  You have the power to make change.  Empower yourself with knowledge and action.

Why Exercise for Chronic Pain?

Here is a hard science reason for utilizing exercise to address pain.

Beta-Endorphin.  Beta-Endorphin is produced within the body and plays a powerful role in controlling pain.  In fact it’s power to control pain is several times that of morphine.  Of the endogenous opioids, Beta-Endorphin also produces the greatest sensation of euphoria.

So how can I get prescribed Beta-Endorphin?  Through sustained exercise.

The body produces Beta-Endorphins in large amounts through SUSTAINED EXERCISE which in turn binds to receptors to produce euphoria and modulate pain.

The initial research connecting exercise to production of ‘endorphins’ involved runners participating in running for two hours.  Through imaging, there was observed a positive correlation between sensation of euphoria and distribution of ‘endorphins’ in the brain.

So how long do I need to exercise to receive the benefit?

The relationship between endorphin release and exercise seems to be related to the intensity of the exercise.  A recent study entitled ‘Opioid Release after High-Intensity Interval Training in Healthy Human Subjects’ observed a higher production of endorphin release with Anaerobic interval training.  Positive mood was noted after 60 minutes of moderate aerobic treadmill training suggesting endorphin production but not at the observed concentration that HIIT produced.  It was hypothesized that the increase in endorphin production was in proportion to the discomfort of the exercise.  ‘Feel the burn’.

Therefore as a guideline, endorphin facilitation workouts are more efficient when producing uncomfortable but safe muscular fatigue.  This fatigue occurs most efficiently during a workout facilitating an anaerobic environment.

What does this mean?  It means if you can sustain the exercise such that you do not require a rest secondary to muscular fatigue, or ‘burn’, then you  may not be producing the stimulus required to most efficiently produce endorphins through exercise.   So this begs the question.

Endorphin facilitation in the body is a natural process stimulated by many things besides exercise.  Concerning movement and exercise this post attempts to empower you though new ideas and research.  So, concerning exercises and endorphins, are you working out the ‘right way’ to achieve the goals you are after?