What to Expect, How to Treat, and How to Prevent Runners knee, Achilles Tendonitis and Swimmer’s Shoulder
By Matt Fontaine, B.S., D.C.

Our body is composed of a series of structural kinetic chains, whereas dysfunction or imbalance in one area can quickly lead to dysfunctions in other parts of the body.

Pattern overload describes injury to soft tissues and joints resulting from repetitive motion in one pattern of movement, or restricted movement in one or more planes of motion. Pattern overload results primarily from faulty movement patterns and repetitive stress.

This is really a matter of load exceeding capacity. Unhealthy tissues have less capability to handle the load placed upon them. Repetitive motions cause tightening of the muscles, making them less able to handle loads during movement.

With the rigorous training volume of triathlon, the body often suffers from accumulation of load. This often results in a repetitive strain injury. The repetitive motion is the cause of chronic irritation to soft tissue. This can occur when swimming, biking, and or running. This irritation creates a friction and pressure, which eventually leads to small tears within the soft tissue. These in turn cause hypoxia (decreased circulation). This leads to decreased oxygen in the tissues which is a catalyst for biochemical changes that lead to fibrous scar tissue formation, called adhesions. These adhesions in turn create further restrictions in motion, muscle imbalances, inflammation and swelling. This cycle repeats itself, and escalates in pain, inflammation, and new injuries caused by the restrictive scar tissue.

Iliotibial Band Syndrome(ITBS) or Runner’s Knee
This condition frequently occurs in triathletes. It usually presents as sharp or burning pain on the outside part of the knee. It can also cause pain to radiate up the side of the hip or thigh. Correct and immediate rehabilitation is vital for this injury as, if ignored it becomes very difficult to treat.
There are a number of causes that can lead to abnormal stress of the IT Band including: overloading of hip and quadriceps muscles due to training, pronating or “flat” feet, and muscle imbalance. The quadriceps muscle group is responsible for the movement of the patella itself. If the lateral (outer) fibers are stronger or tighter than the medial fibers, or if the iliotibial band (ITB) is very tight this can lead to problematic patella tracking.
It is important to note that IT band tightness is caused by tightness (adhesions) in the outer hip muscles (gluteus maximus, medius, and TFL) which insert directly onto the IT band. Tight outer hip muscles result from repetitive overuse; usually secondary to muscle imbalance, weak core strength, pronated (flat arched/ hyper-flexible foot) or supinated (high arched/ rigid foot) feet and poor biomechanics.
Many people with weak core stability have weak gluteal muscles. These muscles are necessary for keeping the entire lower leg in normal alignment. When they are weak, they allow the knee to drift inward, thus resulting in tracking problems in the knee. Combined with faulty foot mechanics (either too flexible or too rigid) and the knee suffers repetitive stress and ultimate injury.
Addressing these core issues is crucial to permanent correction and recovery from injury. RICE treatments are effective only at alleviating acute inflammation. Correction of faulty biomechanics is the only way to prevent the repetitive stress from reoccurring.

What can the athlete do to resolve/ prevent IT Band syndrome:

The first thing is to deload the tissue. This means decreasing volume of offending activity (running, biking etc.)
A Selective Functional Movement Assessment by a sports medicine professional will help uncover faulty movement, usually due to soft tissue and joint dysfunction.
Then, adhesions must be released and joint dysfunction must be corrected. Active Release Techniques® is a fast and effective way to release adhesions and restore normal gliding of tissues. Manipulation of the hip, pelvis, lumbar spine, or foot and ankle may be needed to restore normal joint motion.
Apply RICE (Rest, ice compression and elevation) to the injured knee. This will help reduce swelling that occurs after training.
Active Rest until there is no pain (this is very important). This means decreasing volume which will decrease load through the tissues.
Use a knee support or patellar tendon strap (Use caution when using). Straps provide additional support to injured tendons. They may reduce pain and allow you to exercise more, but the overuse cycle continues and more serious injury may result.
Perform foam roller and stretching 3 times week focusing on gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles.

Achilles TendinosisTendonitis is an acute injury with inflammation of the paratendon- a sheath surrounding the tendon. Tendonitis is often caused by overuse or repetitive strain and is commonly occurs in triathletes and runners.
More common is tendinosis, which is a chronic degeneration of tissue. Circulation to the Achilles tendon is poor, which results in poor oxygen supply. This results in poor healing and formation of microtears, causing the tendon to thicken. Chronic Achilles tendonosis can lead to a complete rupture of the tendon if it is not treated and rehabilitated correctly.
Often times it is necessary to have an evaluation from a physical therapist or sports medicine physician. It is important to look past the point of pain and identify all other structures that are involved in the kinetic chain.

What to do

The first thing is to deload the tissue. This means decreasing volume of offending activity (running, biking etc.)
A Selective Functional Movement Assessment by a sports medicine professional will help uncover faulty movement, usually due to soft tissue and joint dysfunction.

For both the above conditions, as well as swimmers shoulder, soft tissue treatment such as Active Release Techniques® is an essential part of treatment. It is simply the best way to break down scar tissue in the muscles and tendons that affect the leg and knee function, particularly the gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles.

Perform foam roller and stretching 3 times week focusing on gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles, followed by stretching.

Instrument Assisted Release to tendon (patellar or Achilles) can help directly to break down scar tissue and aid healing, followed by ice massage for 5-10 minutes.

Swimmer’s Shoulder

Pain in the shoulder is common in swimmers. Shoulder function is highly dependent on the coordinated function of many muscle groups. These include the rotator cuff muscles, those that control the scapula or shoulder blade, pectorals and latissimus dorsi, muscles in the upper and lower back, as well as abdominal and pelvic muscles.

Since the shoulder is an inherently unstable, but highly mobile joint, muscle forces are critical for maintaining stability, proper motion, and painless function. The repetitive overhead activity of the swimming stroke can result in fatigue of these muscles. This in turn can lead to distinct changes in the function of the shoulder, resulting in the pain that is commonly known as “swimmer’s shoulder”.

One of the major factors causing shoulder pain is overuse and subsequent fatigue of the rotator cuff muscles, scapular muscles, and muscles of the upper and lower back. Consequently, this fatigue can lead to shoulder instability and predispose a swimmer to shoulder pain. The risk of injury and pain is especially true for swimmers who swim with poor technique.
Swimmers typically develop poor posture because of tight latissimus dorsi, pectorals, and internal shoulder rotators. These muscles are overused during swimming. Protracted shoulders disrupt the normal axis of rotation of the shoulder joint. The subscapularis (the rotator cuff muscle located in front of the shoulder blade) often becomes overworked, tightens, and then becomes weak. This muscle is needed to create a force couple that stabilizes the ball and socket joint during swimming and overhead movements. Losing this force couple results in shoulder impingement, commonly known in swimmers as “swimmers shoulder”.

It should be noted that several of these muscles are overloaded during the bike. Triathletes often think they are cross training but the reality is several muscle groups are worked in all three disciplines.

It is well-established that a comprehensive program to develop strength, endurance, balance, and flexibility of the muscles is the most important way to prevent “swimmer’s shoulder”. Releasing all the adhesions in the muscles of the shoulder prior to engaging in strengthening exercises is essential to ensure that they work properly.

The Big Picture

The common thread to all three of these injuries is overuse of muscles, accumulation of load from high volume training for triathlon, and repetitive strain injury. Repetition motion leads to adhesion formation in the muscles, leaving them unhealthy and with less capacity to handle load. Continued loading of unhealthy tissue leads to more injury and more soft tissue and joint dysfunction.
Of utmost importance is treating these soft tissue and joint dysfunctions. A Selective Functional Movement Assessment with help the sports medicine physician detect faulty movement and identify these dysfunctions. Once that is done, Active Release Techniques provides a means to effectively and rapidly resolve these stressful repetitive strain injuries without surgical intervention, and allows the patient to quickly return to training. Manipulation will correct joint dysfunctions and THEN corrective exercise can be added to help rehabilitate the injury and prevent recurrence.
Remember that once symptoms of injury have cleared, future prevention should begin by including regular foam roller self massage, stretching as well as strengthening exercises. Be sure to get proper fitting equipment and coaching or instructions if needed.

OK, I KNOW, I KNOW, I’ve been out of the loop for a little while. But in this issue of our Capitol Rehab Newsletter, I NEED YOUR HELP!! To show you how serious I am about this, please take down my direct email address;

Dr.Bill.Booker@gmail.com

Thanks for taking me seriously. Now what I need from all of you is ADVICE!! I’m going to describe a real life situation that recently presented itself in our practice and I WANT SUGGESTIONS ON HOW YOU THINK I SHOULD HANDLE IT.

A father recently brought his 14 year old daughter to the office. She is a successful cross country athlete who suffered a sudden knee injury during a race. The pain was intense enough for her to seek out the medical opinion from a reputable and highly qualified orthopedic surgeon. She was referred for an MRI which was taken and found to be negative and didn’t reveal any structural damage. She was then referred to physical therapy which provided some relief, but the pain was persistent and severe enough for her to return to the orthopedic surgeon for a followup. But on this subsequent visit, the original surgeon wasn’t available, so she was seen by another surgeon, also highly recommended.

This surgeon IMMEDIATELY recommended surgery!

Obviously, this news was disturbing for the entire family and they were understandably, reluctant to have a surgical procedure performed on their 14 year old girl, who had NO positive findings on MRI. So DAD brought his daughter to see us.

After an initial evaluation, we performed ART to the knee and the surrounding larger muscles. The young girl IMMEDIATELY reported SIGNIFICANT improvement in her condition. SO HERE IS MY PROBLEM.

What should I say to the orthopedic surgeon?

My parental side wants to jump up and yell, “What the (hey) are you doing? You were about to operate on an otherwise healthy 14 year old, without any positive findings and an MRI that didn’t reveal anything?”

My doctor side wants to use this to opportunity to educate and possibly improve the quality of care available in Northern Virginia.

To be clear, I am completely in favor of good surgery, assuming they are necessary and supported by the evidence. In fact, this particular orthopedic group is one of our PREFERRED groups when we require an orthopedic intervention.

Having never met this particular surgeon, the discussion will go one of two ways.
1. A wonderful relationship between structural experts (them) and functional experts (us) will be established.
2. My words fall on deaf ears.

I am aware that my newsletters are usually full of interesting anecdotes and well timed humor, but on this occasion, I sincerely would appreciate input from people I trust, which is why I ask.

I hope to see you in my inbox and as always, yours in health,

Dr. Booker
Dr.Bill.Booker@gmail.com

Get busy living or get busy dying.

by Dr Matt Fontaine

Using manual treatments like Active Release techniques provides the physical medicine provider with invaluuable tools for releasing scar tissue and tight muscles. However, when one identifies a tight restricted muscle, one should ask the question..Why is the muscle tight?

Ensuring the Proper Rehab Sequence:

Understanding Centration and the Body’s Support Structure

The above diagram is from Panjabi. It’s called “stabilizing system of the spine”. It is imperative that we look not only at the muscles and the joints, but also the coordination from the nervous system.
The kinematic chain can be likened to a domino effect. To properly execute movement, the body must execute movements at the right place at the right time, like dominos falling. Any disruption of the chain from a weak link in the chain can result in injury.
An example would be to discuss the change of view about the rectus abdominus . Once thought to create trunk flexion, which it does do, the role now is focused on anti-extension. Meaning it acts as a spine stabilizer. More accurately, the rectus should be seen as a muscle aiding in increasing intra abdominal pressure, which acts to buttress the spine.

Asking the question of why will often times lead to answering the question of How? How can we properly restore function to the structure. For more on proper rehab sequencing, read more here.

References:

Panjbai and White. Clinical Biomechanics of the Spine. Lippincott

by Dr Matt Fontaine

Every day in clinic I field questions like this? The conversation usually goes something like this…

Patient Joe Athlete: ” So doc, how does my injury feel? Is there less scar tissue? Are the muscles working better? Are my joints moving better?”

Doc: ” typically over the course of a few treatments (2-4) I will see changes in tissue extensibility. What this means is that some of the tissue adhesion has been released and some of the tissues have improved gliding. Manual muscle testing provides a window into the nervous system to show us if a muscle is engaging or not. We test these daily as indicators of joint dysfunction. We know joint function can dictates muscle function. Compressed or misaligned joints often cause a muscle or muscles to weaken.”

Patient: So, can I safely run, bike, swim , lift weights, etc. without causing more injury?

Doctor: ” That is the million dollar question. When dealing with soft tissue injuries, joint dyskinesis, and faulty movement, it takes time to make changes. A fracture can heal typically in 4-8 weeks provided there are no complications. Soft tissues are more dynamic and because the soft tissues we work on are rarely immobilized, they have to handle load and tension on a daily basis. During exercise, these not yet healthy tissues will have a decreased capacity to handle load under tension and further injury may result.”

Below are some guidelines and explainations on dealing withh these issues.

When will I be free to swim, bike, run without limitation?

Lets talk Math: basic mathematical equation I= NF/AR

Injury (I) = Number of repetitions (N) X Force of repetition (F)/ Amplitude (A) X Recovery time (R)

This means that all load into tissues is cumulative, meaning tissue damage occurs with repetitive movement.
Tissue load, over a certain threshold injury will occur. Going a little bit beyond threshold results in minor microtrauma the body can repair. Remember, the body repairs soft tissue with inelastic type III collagen and so some degree of adhesion will result. If the mild overuse is followed by proper rest, RICE, foam roller and stretching may in fact release the newly laid scar tissue and restore normal gliding.

Beyond the threshold over and over and over may result in more serious injury, despite the lack of pain.

How to Stay in the Game

During treatment with athletes, one of the goals is to keep the athlete in the game if at all possible. That may involve decreasing training volume to reduce the repetitive action below the threshold of further injury. In acute or severe chronic cases, complete rest from the activity or sport for a period of time may be necessary for complete recovery. After evaluation and initial first 2-4 treatments, the physician should be able to determine if the sport can be continued during treatment and rehabilitation.

It is important to note that with training while recovering from injury, there is a fine line between the volume and intensity that can safely be handled by one’s body and still make progress in rehab and recovery. Over that specific amount (training volume/intensity threshold) more injury can occur or at least create enough strain to prevent or slow recovery. Everyone has different genetics and abilities that will make each individuals’ training volume/intensity threshold different from the next person. It often requires trial and error to determine an athlete’s or individual’s particular threshold. Once that is determined, he or she must keep training below that threshold during the rehab and recovery phase to allow the injury to recover.

What signs & symptoms should I look for so I know the injury is coming back?

If the athlete can do his or her sport, like swim, bike, run etc. without pain during the activity or sport, that is a good sign the activity can be tolerated without very much if any further injury. It is especially important to watch for pain and swelling the day or two after doing a run or lifting weights or playing a sport. If the athlete has a lot of marked soreness and the injured area “feels raw and beat up” or has increased pain, this indicates the volume and or intensity of the sport or exercise was too much and overloaded the tissues creating further tissue damage.

During treatment and rehabilitation, it is imperative that we continue to monitor the athlete as they ramp up their activity for these signs of pain and swelling. As long as we can avoid the pain and swelling with a certain level of activity, say for instance a runner who can tolerate a 5K run without pain, then we can progress them to increase their running volume each week. Volume can be increased only as long as it is tolerated without pain and increased inflammation. If we reach a point of too much activity and overload, we can deload by decreasing the volume and or intensity of the activity or sport.

Pain: The Body’s Built In Fire Alarm. Usually the alarm sounds way after tissue damage has occurred.

As a physician, I often hear patients tell me that they have been playing a sport or doing an activity for years and never had a problem. the patiennt may say something like…

“Doc, I have been playing tennis for over 30 years and I never had any pain or injury until now. I don’t understand what happened.”

Here is my analogy to explaiin this: If you punched the wall over and over for 20 hours, what would happen? The first few punches may not hurt or cause injury. But the trauma to the soft tissues and joints is cumulative, eventually enough wear and tear causes breakdown to the point of pain. Likewise, if I drive my car over and over for years, I may not know there are problems lurking. Eventually enough wear and tear occurs and warning signs emerge (noise, black smoke etc.) For the body, it’s warning sign is pain, and although the presence of pain definitely indicates tissue damage, the absence of pain does not indicate the absence of injury, tissue damage or pathology.

By the time pain is evident, tissue damage has already occurred.

by Dr Matt Fontaine

Ensuring the Proper Rehab Sequence:

A major key to corrective rehabilitation of musculoskeletal pain syndromes is to retrain proper movement. Several factors can cause compensated movement in the body including overuse or repetitive stress injuries, stress, poor posture etc. All of these create stress on our structural frame causing the nervous system to adapt and change the body’s movement patterns. This is neurological adaptation to change. If tissues become tight due to overuse, the body will lose flexibility in those tissues and the joints those tissues cross. If a joint becomes immobile, then the body is forced to compensate and move from other joints above or below the fixated or dyskinetic joint. Then there is the issue of joint stability and mobility. Often times a joint or set of joints lacks proper mobility, and the muscles involved in a certain movement can’t properly stabilize the joints to handle the load and force of that movement. This forces the nervous system to find other ways to move to accomplish nearly the same gross motor patterns. The nervous system can adapt, but that adaptation comes with a price. And that price is often faulty movement, muscle imbalance, increased likelihood of injury, degenerative arthritis and pain.

It is important to note that the nervous system learns movement. It also has movement patterns that are “hard wired ” into the computer or CNS- Central Nervous System. Pavel Kolar, a pediatric PT has devised a system of rehabilitation he calls Dynamic Neuromuscular Stabilization (DNS). It is founded on the principle that the developmental stages from fetal posture of an infant progressing to an upright posture involves hard wired stored programming in the nervous system. Essentially humans have motor programs that are involuntarily controlled by the CNS that train the muscles to coordinate, facilitate, and stabilize upright posture. An infant rolling over in a crib is an involuntary movement directed by the CNS with the main function being to train and integrate the core with the extremities in the progression of supporting an upright posture. A detailed description of Dynamic Neuromuscular Stabilization is beyond the scope of this article. Suffice to say that as we develop from infants to toddlers and young children, our nervous system develops engraining us with movement patterns. When injury and other circumstances causes a disruption in these “engrained, involuntary” movements, we begin to move improperly. Move improperly long enough and injury and pain will ensue. The big key here is that after childhood, many of us sit too much and don’t move properly in our day to day activities. Subsequently these engrained neurological movement patterns become sluggish. Below is a simplified synopsis of how to best approach correcting faulty movement and not olnly resolving pain, but optimizing human movement and performance.

The following sequence ensures a complete treatment strategy for the musculoskeletal  patient.  Many times patients have had some of the treatments listed below, but rarely have they successfully completed all six stages, and in the proper order.  For example, consider the patient who sees and orthopedist or their primary care physician and receives a cortisone injection.  That works great for acute inflammation and pain.  But then what?  The patient needs follow up with the other five stages to completely recover from the injury and help to rehabilitate the injury with the goal of future injury prevention.  Or what about the patient who has been to physical therapy.  Most of these patient receive a good deal of exercise instruction, but are often lacking in adequate amounts of manual therapy to address the joints and overactive soft tissues.

When only acute care is given or when manipulation in combination with ART is missing, the patient fails to make a complete recovery.  What the patient needs is proper manual therapy to address joint fixation, compression or misalignment AND soft tissue release, such as Active Release Techniques(ART), to address overactive muscles.  During a proper sequence, once these issues are addressed in stages 2 and 3, then the patient can safely and effectively be progressed through corrective exercise.

Which leads us to stages 4,5, and 6.  First and foremost, the patient must be given exercises that will ensure they can activate muscles that have become weak.  Mostly these muscles are critical for proper joint stabilization during movement. Once this is accomplished, the patient can then safely progress to stage 5, focusing on increasing the speed of muscle contraction.  As coordination of movement improves, they patient can then progress to the final stage.
In stage 6, the patient can focus on improving mass movements.  This is where the athlete or active individual will retrain proper squatting and deadlifting patterns, or learn to do overhead press movements, throwing movements etc. while they have already gained the ability to stabilize and support the joints through a loaded movement, or through a movement with high velocity.

Proper sequencing ensures that all key issues are addressed.  Missing any of these stages will result in inadequate and incomplete recovery.  This is often one of the major causes that lead to chronic muscle and joint pain.  But this doesn’t have to be the case.

At Capitol Rehab of Arlington, our doctors and staff understand the importance of this proper sequence.

1.  Treat acute symptoms:  pain and inflammation.  The medical model works great.  Anti-inflammatories can be helpful.  Passive modalities like electrical muscle stimulation can help ease tightness from overactive muscles, ultrasound can help speed healing, Rest, ICE, Compression and Elevation(RICE), active rest are all essential in an acute stage.

2.  Manipulate/mobilize fixated/ compressed and misaligned joints.  This is often essential to reduce nerve irritation which may be causing muscle weakness and or pain.

3.  Release overactive muscles with Active Release Techniques. Learn more about overactive muscles here.

4.  Improve motor control:  rehab tracks( a series of exercise progressions) are prescribed which focus on retraining the ability to activate muscles for joint stability.

5.  Increase speed of contraction:  Moving from stabile to labile surfaces(BOSU, stability balls, Airex foam pads, balance work) further challenges the patient/athlete to optimize proper body movement.

6.  Improve mass movements for a full return to sport.

For more information on the importance of addressing muscle imbalance, read the article on The Janda Approach to Musculoskeletal Pain and A Comprehensive Approach to Resolving Muscle and Joint Pain Syndromes.

HOW TO STAY HEALTHY TIPS FOR ATHLETES AND WEEKEND WARRIORS
by Dr Matt Fontaine

We must get adequate Rest so that our body can Recover and Regenerate from all the wear and tear we put it through.

As an athlete you must be aware of the dangers of overtraining. You have to remember that no matter how many training hours you put in, if you get hurt, you can’t train. When you can’t train, you can not get better. So, resting and recovering is a crucial aspect of the sport that needs attention. You must have scheduled rest days during the week. The body is not meant to train 24 hours, 7 days a week. You need time to get off your feet, rest your mind, and rest your body. If you do not schedule rest and recovery time, you will quickly burn out and will lose the motivation to train and ultimately get hurt. Regeneration is also significant. Foam rolling and massage, consistent stretching, Active Release Techniques®, and ice baths are just a few recovery techniques you must implement into your training regimen on a daily basis. The body can be a fined tuned machine, but if it breaks down you will not be able to get to the level you set out for. So pay attention and listen to your body.

The following are common therapies used in sports medicine:

RICE REST, ICE, COMPRESSION, ELEVATION

Elastic bandage wrapping helps reduce swelling and provides support. Elevation helps reduce swelling.

ICE Ice should also help reduce swelling and pain. Place damp paper towel between skin and ice pack. Apply ice 20 minutes on then 30 minutes off. Repeat several times per day.

HEAT Use a moist heating pad over affected area to help ease muscle spasm and tension, and increase circulation. Avoid heat in acute injuries as it can aggravate swelling.

CONTRAST Apply ice for 5 minutes/ then heat for 5 minutes. This is a great way to improve blood flow to recovering tissues. Repeat this 3-4 times. END with ICE.

TENDON TREATMENT: Apply heat to injured area for 10 minutes. Cross friction massage the tendon/ ligament for 2-5 minutes. Do 3 sets of 10 of loaded eccentric contractions, finish with cryo massage for 5 minutes. Do this 3-5 times/week.

RECOMMENDATIONS ON ACTIVITIES WILL LIKELY BE MADE FROM YOUR SPORTS MEDICINE PROFESSIONAL. THESE MAY INCLUDE:

REST / ACTIVITY AS TOLERATED W/O PAIN / FULL ACTIVITY

NOTE: For training/ practice days or for rehab/corrective exercise days, the following is recommended: 1. ) Apply heat for 10-15 minutes to injured area as warm up. 2.) Then use foam roller and dynamic stretching to prep for practice. 3.) practice. 4. ) End session or practice with ice and compression for 20-25 minutes.

NOTE: If redness, swelling, pain persists, or if you have any questions regarding these instructions, consult your doctor.

by Dr Matt Fontaine

Dr Vladimir Janda was a physician in Czechoslavakia who himself had suffered and recovered from Polio as a child.  As a physician he spent his early years with a focus on Polio patients. Dr Janda was one of the first physicians to combine his medical training with physical therapy and rehabilitation for a very unique hands on approach to physical medicine and rehabilitation.  He is considered by many the physical medicine world to be one of the founding fathers of physical medicine.  He has published over 16 books and 200 articles on muscle function and the locomotor system.

Traditional approaches to pain are to reduce pain and inflammation and dysfunction of the musculoskeletal system through  modalities such as ice, heat, taping, bracing, joint and soft tissue manipulation.  The Janda approach includes all of these, especially in the acute stages, but also includes analysis of muscle imbalance and its role in the perpetuation of chronic muscle and joint pain cycles.

There is a huge difference between traditional strength training and functional corrective rehab

Traditional approaches to strengthening a muscle entails progressive loading of the muscle during exercise in order to increase strength, power, hypertrophy, and endurance.  However, when muscle imbalance is present, there are weak muscles and tight muscles across the joints involved.  Attempting to strengthen a weak muscle in the presence of a tight antagonistic muscle is much less effective because of the fact that the tight muscle will be recruited first due to it being hyperactive.  This is a neurological issue and it is wired into the nervous system due to the fact that compensated movement has been “engrained” in the brain.

Sherrington’s Law of reciprocal inhibition states that a weak muscle may be inhibited by its overactive and tight antagonist.  Restoring normal muscle length of a tightened muscle often spontaneously improves the strength of the weak antagonist.

These muscle imbalances must be addressed early on in the rehabilitation sequence in order to ensure proper movement patterns with adequate muscle stability throughout the movement.

Read more in the article titled Proper Rehab Sequencing and Comprehensive Approach to Resolving Muscle and Joint Pain.

by Dr. Matt Fontaine

All Athletes and Weekend Warriors Have One Thing In Common… Soft Tissue Injuries

Sports and training have the potential to wear us down over time and lead to soft tissue injuries that result in muscle and joint pain syndromes. Soft tissue injuries that limit optimal sports performance are frustrating and can limit or shorten athletic careers or recreational sporting activities. Young athletes tend to ignore their minor injuries, aches and pains thinking that they recover quickly from their pain. Over time the wear down from these injuries catches up with us, usually manifesting with more severe muscle and joint pain syndromes, limitations of activities, and especially sub-optimal sports performance.

How Do Overuse Injuries Occur?

The following is taken from Dr. Michael Leahy, founder of Active Release Techniques ®
Leahy PM. Active Release Techniques Soft Tissue Management System, Manual®.

The following formula can explain how repetitive injuries occur, resulting in the cumulative injury cycle:
I= NF/AR Where I = insult to injury, N= number of repetitions, F= force or tension applied, A= amplitude of force, R= relaxation time between repetitions. This easily expresses how low load forces applied over thousands of repetitions with little relaxation time can break down tissue. We know this occurs to prime mover muscles that are adaptively placed under constant work load to try to stabilize joints for movement because of weak or inhibited deep small stabilizer muscles.

The nervous system will learn movements and tasks as we teach them, whether those tasks are functionally correct or incorrect. Faulty movement occurs due to poor motor control which often occurs following overuse and may be initiated in the presence of pain and/or tissue injury. These faulty patterns become learned by the central nervous system and are often sustained beyond the acute pain phase and contribute to the chronicity of muscle and joint pain syndromes.
Many athletes try to base a normal and regular workout session on top of this faulty system. This is very frequently why injuries occur while working out. Over time the body exhausts its capacity to compensate and prevent the tissue injury or inflammation and the symptoms finally surface on a more dramatic note.

A close look at Thomas Myers book Anatomy Trains reveals that “muscles are only separate in photos in anatomy books. In real life they are connected spiraling fascial tissue. Movement becomes habit, which becomes posture, which becomes structure”.
Adhesions and scar tissue can be described as fibrous (inelastic) tissue that is formed over damaged tissue in the natural process of the body’s attempt to heal or fix damaged areas from injury.

This results in the Cumulative Injury Cycle and the body produces tough, dense scar tissue in the affected area as part of the healing process. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up muscles become shorter and weaker, tension on tendons causes tendonitis/ tendinosis, and nerves can become entrapped.

This can result in reduced ranges of motion, loss of strength, pain, and often numbness and tingling.

Overused muscles (and other traumatized soft tissues) can cause changes to your body in three important ways. They cause acute injuries (pulls, tears, collisions, etc.), they accumulate small tears (micro-trauma), and they become tight which reduces blood flow to cells (hypoxia).

The result is the Cumulative Injury Cycle which occurs when the soft tissues of the body change or adapt with time. These changes cause your body to produce tough, dense scar tissue in the affected area as part of the healing process. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up:

• Muscles become shorter and weaker.
• Tension on tendons causes tendonitis.
• Nerves can become entrapped.

This can result in reduced ranges of motion, loss of strength, pain, and often numbness and tingling.

The Phases of Healing and Scar Tissue Formation

After injury, whether from microtrauma, compressions, strain/sprain, or an acute tear the body will :

1. Develop new capillaries around the injury to establish blood flow.
2. Migration and formation of fibroblasts
3. Lay down extracellular matrix ground substance which acts like scaffolding to support newly formed tissue repair.
4. Finally, the maturation and reorganization of the scar tissue. Scar tissue gets laid down in a criss-cross latticed pattern, while normal healthy soft tissue has it’s fibers running in parallel. Thus, the scar tissue must be realigned for it to become truly mature and function like normal pre-injured state soft tissue.

Immature scar tissue cannot be loaded in a normal manner without further injury.

Non Invasive Treatment for Soft Tissue InjuriesActive Release Techniques® is a proven highly effective treatment that locates and breaks down scar tissue caused by soft tissue injuries. ART® is done using a hands-on method of locating and correcting problem areas in and between soft tissues such as muscles, nerves and tendons. The primary principles are; active patient motion, specific contact method and internal gliding of tissues. Simply put, the tissue is placed in a shortened position; the contact is taken with emphasis on tension of the tissue rather than compression. The tissue is placed in motion to lengthen it while the lesion is palpated, held and allowed to release.

The main concept is to reestablish proper motion between fascial structures thus reducing fibrous adhesions and reestablishing neural and myofascial glide between tissues.

ART® should be a major concurrent component in the treatment of conditions resultant from muscle imbalance , resulting in joint dysfunction, and muscle and joint pain syndromes. It specifically locates and treats the problem areas in the soft tissues. There are some 500 protocols for ART® and they are unique and the technique is patented. They allow providers to identify and correct the specific problems that are affecting each area.

Specific Diagnosis and Specific Treatment Allow For Effective Treatment

It is often said “ the right tool for the job makes all the difference”. All too often athletes with chronic pain continue to suffer even after having physical therapy, joint injections, or surgery all because the soft tissue adhesions in the muscles were not detected and treated.

A comprehensive approach should include a functional movement screen, followed by appropriate treatment if needed to address soft tissue adhesions and joint dysfunction. These treatments should be accompanied by foam roller exercises, stretches, and movement prep. Properly prescribed exercises to address both mobility and stability and retraining to correct for movement patterns as described by Gray Cook are essential to optimizing sports performance.

Utilizing Gray Cook’s Functional Movement Screen as Coach Boyle recommends is a great way to find faulty movement patterns that give you tremendous insight as to which soft tissue may be involved. Once soft tissue restrictions are identified, they must be addressed and properly treated to allow for corrective mobility/ stability exercises to be optimally effective.

In cases where soft tissue adhesions are present you must free up tissue gliding between muscle planes to allow stretching to be effective. ART® releases the scar tissue and restores normal internal gliding of muscle layers, making the foam roller and stretching exercises much more effective at improving mobility and preventing future injury.

A comprehensive sports medicine approach should include 1.) A team coach for the sport 2.) A strength coach and/or Athletic Trainer 3.) A medical doctor who specializes in sports medicine and 4.) A Chiropractor/ Physical Therapist who is a certified ART® provider. Get the best care you can by incorporating all these people into your team of Human Performance specialists.

A Quick Note on Surgery

There are times when surgery is necessary. ART® is essential to the overall success of the surgical procedure. Pre-surgical treatments can begin to clear up soft tissue areas that are not functioning properly and may have contributed to the injury in the first place. Post surgically ART® is vital to aiding release of scar tissue and quick recovery of normal muscle function. This aids in the rehabilitation process.
If an athlete has had surgery, physical therapy and has not made a complete recovery, it may be time to try Active Release Techniques®.

References
1. Kumar V & Ramzi Cotran. Robbins Basic Pathology 7th ed. Elsevier; pp 69-77.
2. Falanga V, & Kirsner RS. Low oxygen stimulates proliferation of fibroblasts seeded as single cells. J of Cellular Physiology. 1993 Mar; 154(3):506-10.
3. Leahy PM, Active Release Techniques: Soft Tissue Management System. 2nd Ed. 2008; pp 8-16.
4. www.activerelease.com
5. Hinz, B. The myofibroblast: paradigm for a mechanically active cell. J of Biomechanics 2010 Jan 5;43(1):146-55.
6. 6. The First International Fascia Research Congress. 2007 Harvard Medical School www.fascia2007.com
7. 3. The Second International Fascia Research Congress. 2009 Vrije Universiteit http://www.fasciacongress.org/2009/
8. Brady, W. Hypoxic Fibrous Adhesion Production: Chemical Pathway and Clinical Importance. http://www.integrativediagnosis.com/

by Dr Matt Fontaine

In part I of this two part article, I discuss some key points on the rage of the minimalist shoe and barefoot running.

With all the hype of late on barefoot running due largely from the popularity of the book Born To Run by Christopher McDougall, I thought it appropriate to weigh in on this issue. The concept of barefoot running has been around for many years in many cultures all over the world, as McDougall describes in his book. The key concepts to recognize for the modern day runner is that most of us have been raised to walk on man-made surfaces(roads and sidewalks) that have been evenly paved and smoothed out. Adding to which, we have spent our entire lives in built up shoes with cushioned soles and even arch supports. Contrast this with tribes like the Tarahumara that McDougall highlights in his book, who have spent their entire lives walking and running barefoot on natural, uneven terrain, and do so injury free well into the later years of their lives. How can they do that? Why do we suffer so many running injuries despite expensive running shoes and years of engineering making these shoes better?

A lifetime of barefoot running and walking has led the Tarahumara people to develop a wider foot structure, with much stronger foot intrinsic muscles and much better balance and coordination of the foot, ankle and lower leg muscles. As such, we cannot expect someone who has spent their life walking and running on smooth surfaces and in shoes to just go cold turkey and hang up their running shoes.

The problem for modern day runners is that they do not possess enough strength, balance and coordination of the lower leg and foot intrinsic muscles that control the foot and ankle. From age 6-12 are the most critical developmental years for structure and development of the arch. Therefore minimalist activity may be best done at these times.

A lifetime of wearing shoes can result in dysafferentation (a fancy neurological term which simply means that nerve receptors in the joints, tendons, muscles etc. are not properly stimulated and do not send proper impulses to the brain). Dysafferentation can weaken reflex muscle activity, affect joint and muscle function, and result in pain. A lifetime of wearing shoes can also impair the proper balance and coordination required for us to adjust to the ground as the foot strikes the ground during running. Therefore, if barefoot running is a goal, you must approach it in a way that slowly trains these muscles to adapt gradually to be able to run barefoot.

Before we detail some guidelines for safe and proper usage of minimalist shoes, lets look at a few key points:

1. The theory behind the minimalist shoe is that by allowing the bottom of the foot to sense suface irregularities, cutaneous receptors in the sole of the foot will initiate a reflex that causes the flexors of the foot to engage, distributing pressure over a larger surface area. This is known as “positive support reaction”.
2. During the positive support reaction, a stimulus is applied via the ground to pressure receptors in the sole of the foot, the longitudinal arch, and the intrinsic foot muscles. This triggers the extensor thrust mechanism, and facilitates posture by engaging the lower extremity extensor muscles and spinal erector muscles. This reflex often becomes dysfunctional in cases of flat feet (pes planus) or high arched feet (pes cavus).
3. With regular use of minimalist shoes, such as the Vibram Fiver Finger, Vibrum Komodo Sport or New Balance Minimus Zero, the arch of the foot can strengthen. Minimalist shoes also lesson vertical forces traveling through the lower extremity because of the shift to a more forefoot or midfoot strike during gait. This allows the gastrocnemius/ soleus muscles to dampen ground impact forces.
4. Several studies have shown minimalist shoes/barefoot running can reduce retropatellar pressure by up to 50%. 1,2
5. The reduced impact of barefoot or minimalist shoe running can cause other compensatory issues such as increased ankle dorsiflexion and rearfoot eversion (turning outward) which can greatly increase tension in the Achilles tendon and the medial posterior compartment of the lower leg. This can lead to overuse injury.
6. If the flexor digitorum muscle (on the bottom of the foot) is not strong enough to decelerate digital dorsiflexion of the toes, too much tensile strain may be transferred to the plantar fascia resulting in plantar fasciitis.
7. Longterm use of minimalist running has been shown to deform the calcaneal heel pad, leaving the heel vulnerable to injury. Therfore, it is recommended minimialist shoes or barefoot running be done on grass, trails, or sand and avoid asphallt or concrete.
8. Remember, early hominids had different foot architecture than that of the average shod wearing human of today. The noteworthy differences are wider forefoot, and higher arch.
9. People with lower arches may be predisposed to abductor hallicus(plantar fasciitis) and posterior tibialis(shin splints) muscular injuries. This is because use of minimalist shoes and barefoot running place more stress on the medial musculature structures of the foot and lower extremity.

In Part II of this article will detail proper break in guidelines for minimalist shoes.

A special thanks to Dr. Thomas Michaud for all his efforts in his latest book, Human Locomotion. Dr, Michaud has provided a very comprehensive look in detail at not only foot and ankle biomechanics, but in overall movement and how the foot and ankle affects the entire kinematic chain. He has provided the practitioner of manual medicine invaluable information and into many troubling chronic and complex pathologies and offered us biomechanical explanations as to their etiology as well as conservative management treatment protocols.

References

1. Cavanagh PR. Ground reaction forces in distance running. J Biomech. 1980;13:397-406
2. McClay I. “Lower Extremity Kinematiic Comparisons between Forefoot and Rearfoot Strikers,” in Proceedings of the American Society of Biomechanics, p. 211, 213, Stanford, CA, 1995.
3. Michaud, T. Human Locomotion: The Conservative Management of Gait Related Disorders. 2011

By Dr. Matt Fontaine

In part two of this two part article I will detail some recommended guidelines for implementing a safe progression from running in sneakers to minimalist shoe or barefoot running. Keep in mind, there are different foot types, some of which may be better suited for barefoot running.

At Capitol Rehab of Arlington, we utilize the Functional Movement Screen™ that was developed by Physical Therapist Gray Cook.
• Cook states with looking into barefoot running it is important to clear up the Big 3 movements: Deep squat, In line lunge, and Hurdle step. These three movements look at mobility, stability and balance of the foot and ankle, knee, hip, lumbar spine and pelvis in relation to each other during the movement.
• We then must evaluate single leg balance. We can also evaluate the effect of an orthotic or running shoe on balance. If balance is better with an orthotic or sneaker, then we may need to use a corrective orthotic or specific sneaker type(neutral, motion control, or stability) for a few months to re-pattern the arch of the foot.
• After a few months in the orthotic, we have re-patterned the arch, but you do not possess the motor control to own that new arch, the orthotic does.
• Now we can progress to one day a week training in a minimalist shoe like the Vibram Fiver Finger, Vibrum Komodo Sport or New Balance Minimus Zero.
• Jumping rope will foster correct posture and gluteal activation and hip extension, as opposed to running on treadmill which is hip flexion dominant.
• Calf muscles and outer hip muscles (abductors) will hurt due to intrinsic activation from jumping rope and wearing a minimalist shoe. After one month, you can progress to twice a week barefoot training. That may consist of wearing the minimalist shooes during a strength training workout in the gym, or a 20 minute tempo run on soft surface.

Bottom line is barefoot running does result in a shorter stride and cause runners to land on the mid foot/ball of foot which is preferred to heel striking for more efficient running. The problem with making the change from running shoes to minimalist shoes like the Vibram or even barefoot entirely, is that most runners will need to progressively transition to less shoe over time and maybe eventually barefoot. There are many runners who have foot types that are too rigid and high arched, or even too flexible to be able to safely barefoot run. That being said, these individuals can benefit from wearing these shoes to walk around while strength training at the gym, or walking around in general. Overtime they may be able to build up to jogging.

The bottom line is recreational use of a minimalist shoe while walking or jogging does stimulate the digital flexors of the toes and can strengthen the arch of the foot and increase arch height.
Having your foot type and biomechanics evaluated by a sports medicine professional is recommended before attempting to go barefoot.

Here are some basic guidelines if you are interested in barefoot running or just want to get into wearing a minimalist shoe during exercise or walking:
• Start with walking 1-2 times per week for 30 minutes and then gradually progress to running(see the protocol above).
• Start with short tempo runs (15-20 minutes). Do not go out and run a 5K the first time you wear a minimalist shoe or go barefoot.
• Stop barefoot running or training at the first site of pain, and consult your physician.

Some Key Points Concerning the Minimalist Shoe or Barefoot Runner

• Foot biomechanics can vary among individuals causing a need for different shoes for different foot types. Runners need one of three basic shoe types-neutral, stability, or motion control.
• The human foot can be best described as a mobile adaptor. The foot is rigid at heel strike, then becomes flexible through midstance, and becomes rigid again at toe off. Running mechanics whereby the runner lands midfoot can slightly change biomechanics of pronation, supination, inversion and eversion, but the foot still must be a “mobile adaptor”, adapting to ground reaction forces.
• Our feet are designed to traverse the natural varying terrain of the earth, which places three dimensional forces into the foot, and subsequently into the body. The foot is designed to continually adapt to the ground surface.
• The earth gives natural shock absorption in a natural setting.
• Manmade surfaces like roads and sidewalks, boardwalks etc. are relatively flat and two dimensional. Thus the combination of two dimensional road surface and the enclosing shoe somewhat limits the mobility of the foot.
• Any covering on the foot will alter the foots natural biomechanics. Shoes like the MTB rocker restrict the biomechanics to a relatively sagittal plane (front to back) and eliminate a lot of the three dimensional forces the foot is designed to utilize.
• Much research has been done in the field of foot biomechanics and shoe design over the past decade.
• Newton’s Action/Reaction technology helps assist runners to utilize a mid foot or forefoot strike and the lugs on the sole of the shoe help to store potential energy at foot strike. These lugs spring back assisting in lift off during toe off.
• Most runners would be better suited to use the minimalist shoe on a limited or part time basis as part
of their training regimen.
• Despite many advances in sports medicine and performance, like corrective exercise, kinesiotape and
orthotics, runners and walkers continue to sustain injuries at an escalating rate.
• Injuries such as plantar fasciitis, runners knee, shin splints, stress fractures, neuromas etc. are often due to faulty biomechanics, overtraining/ overuse, and improper footwear.
• A strong core with good hip strength and mobility, along with proper foot biomechanics are essential to injury free optimal sports performance.
• Stretching is vital to maintain good flexibility of soft tissues to allow for proper joint motion, and
better contraction capability for force production.
• Yoga, frequent foam roller use, stretching, soft tissue release such as Active Release Techniques and chiropractic manipulation are essential elements to
staying healthy.

A special thanks to Dr. Thomas Michaud for all his efforts in his latest book, Human Locomotion. Dr, Michaud has provided a very comprehensive look in detail at not only foot and ankle biomechanics, but in overall movement and how the foot and ankle affects the entire kinematic chain. He has provided the practitioner of manual medicine invaluable information and into many troubling chronic and complex pathologies and offered us biomechanical explanations as to their etiology as well as conservative management treatment protocols.
References

1. Cavanagh PR. Ground reaction forces in distance running. J Biomech. 1980;13:397-406
2. McClay I. “Lower Extremity Kinematiic Comparisons between Forefoot and Rearfoot Strikers,” in Proceedings of the American Society of Biomechanics, p. 211, 213, Stanford, CA, 1995.
3. Michaud, T. Human Locomotion: The Conservative Management of Gait Related Disorders. 2011