Great article on the relationship between chronic pain, low mood and catastrophising. Nothing that wasn't apparent, but good to see more research being doing in this area. Even better read if you're taken David Butler's courses!
Soft Tissue Restrictions
1) tenderness and restriction along the plantarfascia in a distal to proximal or proximal to distal direction.
This often feels like rice crispies and more so than other areas of the body (except thoracolumbar fascia and/or ITB)
2) along the bony contours of the superior medial and lateral calcaneal borders
this is often tender and restricted, limited calcaneal rocking and tilting
3) the proximal lateral posterior calf - pt's with lower quarter muscle imbalances often have a restriction here, and it can refer distally into the foot, plus limit dorsiflexion
Joint Restrictions
1) the talocrural joint is normally restricted in posterior glide, and more often than not, the medial portion of the talus is not moving posteriorly, but the lateral is. This causes toe out and compensatory overpronation, overstretching the plantarfascia during stance phase
2) the lack of dorsiflexion and the "too many toes sign" then lead to a decrease or complete lack of push off with the first ray, the longer this goes on, the more likely the restrictions in great toe extension, which should be up to 90 degrees passively
3) the subtalar joint may be restricted in medial/lateral tilt, upward rotation (dorsiflexion osteokinematically), or internal/external rotation (vertical axis)
Suggested Treatment
1) Functional Release and TASTM to the plantarfascia
3) some finishing touches of TASTM/functional release to the bony contours of the calcaneus to free up calcaneal rock
4) joint distraction and posterior glides to the talocrural joint, thrust as a progression for distraction
also remember to restore great toe extension with 1st MTP distractions and posterior glides if necessary, this will make #6 easier on the pt, thus increasing compliance.
5) home program of runners stretch with an emphasis on heel pushing into the ground and forward facing foot - no too many toes sign allowed!
6) the KEY to the home program is the The Strassburg Sock
If a patient wears this nightly, it will keep them in dorsiflexion and most importantly continue to activate the windlass effect which will keep their plantarfascia on stretch. They have to wear it at least 6 hours!
7) Progress on TASTM and joint mobilization - they should be better within 6 visits no matter how chronic their condition was!
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Here are a couple of instruction videos for the lumbar roll "kickstart" variation. After studies came out showing specificity wasn't needed, I started using first the SI gapping technique from the CPR for Lumbar Manipulation and then moved on to this technique, which I find easier and more comfortable for the patient. Hope you find the videos useful!
This is a variation for patient's with hip hypermobility. They can be difficult to get leverage on!
Hope you find these helpful! Please comment or question below!
This is a variation for patient's with hip hypermobility. They can be difficult to get leverage on!
Hope you find these helpful! Please comment or question below!
First in a series of courses at D'Youville College that will hopefully start up their certificate in Orthopaedic Manual Physical Therapy. Partnered with Learning Partners, a local con-ed company, both students from other schools, licensed PTs and DYC students may all take the courses! Here's one of my favorite videos. Blog and youtube channel will be updated later with more footage with better and longer examples and explanations for spinal manipulation. Thanks for reading!
If you haven't checked out any of NOI group's courses, you absolutely should. David Butler and his colleagues really put on a great course. They also have a good regular newsletter. Here is a good post by Adriaan Louw.
The Golden Click
The Golden Click
A patient's close friend was suffering from dizziness for years. She referred her to my practice. She was seeing a local specialist who was medicating her and giving her upper cervical injections (she wasn't sure what kind) monthly. This went on for years with no change. One scary aspect of her case was that she had difficulty driving and she was a bus driver in my local school district!
History
She presented as a pleasant female in her mid 50s, endomorphic with fair sitting posture, protracted shoulders, forward head (of course). Her main complaint was constant dizziness and feeling lightheaded. She also c/o HA and cervical pain L > R radiating to upper traps. Symptoms were worse in the morning, at night, with prolonged sitting and driving.
Objective
Cervical flexion WNL, cervical extension showed moderate loss and pain during motion. Cervical rotation was limited severely bilaterally with hard end feels. Cervical SB was limited severely L > R. Passive intervertebral motion testing revealed severe restrictions in OA bilaterally, severe restrictions in C2-4 downglide L > R. Myofascia was L > R severely restricted along the occiput laterally to medially, and along paraspinals and upper traps proximally to distally. L > R 1st rib was grade 2 for inferior glide.
Discussion: I didn't perform special testing as I don't find it useful. She did not have any trauma and did not have enough restrictions in motion as to appear unstable. Vertebral artery testing is not reliable. I could have tested for BPPV, inner ear dysfunction, etc, but I thought it was cervicogenic based on her very limited cervical ROM and passive accessory motion.
Treatment: Tool Assisted STM to cervical paraspinals and upper traps
In one treatment, her dizziness, which was constant had decreased by 75%. Her active ROM in rotation improved by at least 20 degrees in both directions. She was completely symptom free by the 3rd treatment. We kept treating her using TASTM to her cervical paraspinals, upper traps, added first rib non-thrust manipulations. HEP was not changed as she was still symptom free for her last visits. She was treated in all 6 visits, the last of which was two weeks after the 5th. She had near full ROM in all planes, including extension with no reproduction of any dizziness, HA, or cervical pain. She was very pleased, and we were both relieved that school kids were no longer in danger of the dizzy bus driver!
Just wanted to repost this great article by of the practitioners that got me into looking more at Fascia. Dr. Leon Chaitow. Please check out his blog and website, very informative!
Chaitow's Chat
Chaitow's Chat
A few years before that, when I was studying at the University of St. Augustine, I wrote in a case study that I was doing an upper limb tension test. Dr. Patla asked if it was only for provocation testing, because "you should never stretch a nerve." I replied yes, only because I was doing it for testing, and as it was a current patient, I stopped doing it as treatment. A little white lie.
Over the years, I have definitely found uses for neurodynamic tensioners (current term for nerve loading or stretching). For example, chronic medial and lateral epicondylagia that didn't respond to the traditional treatments, and persistent leg pain/paraesthesia that didn't centralize with MDT. They are also useful to show someone for home exercises.
Conversely, as I got into more tissue work, both functional and tool assisted, I found myself using them only during evaluation. For example, on a patient with chronic lateral epicondylagia, I would test radial nerve, find a limitation, maybe at the elbow, forearm, wrist, or all of the above. I would take a functional measure next, possibly grasping with or without elbow movement. I would then perform some TASTM on the bony contours of the radius, both posteriorly where the symptoms are, AND anteriorly. Maybe some radial head lateral glide (MWM) and/or thrust like Mill's manipulation would also help. Function and radial nerve neurodynamics were then retested. More often than not, it would be better. The neurodynamic tensioner was instructed as a home stretch to be performed 5-7 times/day, for 2-3 sets of thirty second oscillations.
As treatment your choices are this...
Use neurodynamics as tensioners to those who can tolerate them (stretching)
- oscillate at different joints, shoulder depression, shoulder ER, elbow extension, forearm supination, wrist extension for median
- hip flexion, IR, adduction, knee extension, ankle dorsiflexion for sciati
- median: head bent toward, then shoulder abduction to 60
- full shoulder ER, elbow extension, FULL supination, wrist extension
- sciatic: head extension in supine or slump (may also sit upright)
- hip flexion, IR, adduction, knee extension, ankle dorsiflexion
use neurodynamics as pre-test and post-test, treat the neural container
- screen all adjacent joints along the path of the nerve
- perform STM/TASTM along areas of dysfunction
- retest after treatment
as a progression for step 3
- combine and "get jazzy" as Butler would say
- put someone in neural load, i.e. median stretch
- perform wrist mobilization P/A for extension in load
- perform TASTM to anterior forearm or medial upper arm in load
If you choose steps 1-2 and be a "nerve head" or 3-4 and only use it as testing, you will find many patients that you can help with chronic conditions. Questions? Comments? I'll be posting some videos of examples this week. Be sure to check out the OMPT Channel and subscribe for notifications!
Median Neurodynamics
Radial Neurodynamics
Ulnar Neurodynamics
Sciatic Neurodynamics
Femoral Neurodynamics
