The curse of the short leg

A fair while since my last blog post but I have been so busy it has fallen a little by the wayside!! A couple of recent highlights have been training one of my Pro boxers Phil Gill for his 11th pro fight on the 30th of April and Olympia, and also a great day with a bunch of Osteopaths going through the functional assessment process down in Brighton. I am also really looking forward to the upcoming functional assessment course in London on the 16/17th of April which has had a great response but require lots of prep!

The topic of this blog post is about a client I have been seeing recently who had lower back pain. When I assessed him I discovered a minor short leg (2-3mm) but was so small and short leg assessments so unreliable in terms of actual measurement that I payed less attention to it than I normally would a short leg. Short legs can be hugely destructive on the system and create a myriad of compensatory patterns.

The upshot was we created much better motion in the sessions but this reduced when he went off and did stuff on his own. Something else in the system was shutting it down. Very frustrating for me, but I think I may now know the reason why!

A usual compensation pattern that I see in the feet is that the long leg pronates to become shorter and short leg stays inverted or supinated to remain longer. With this individual however the long leg also had a large uncompensated Rearfoot Varus. This means that it cannot pronate and takes away this compensation mechanism and actually makes the short leg shorter in comparison (or the long leg longer!!) and therefore more significant and destructive on the system. The uncompensated rearfoot varus will create a lack of shock absorption in the chain and the inability to compensate for the short leg will create an obliquity in the system which can also cause it to shut down motion in favour of stability.

I have addressed this temporarily with a small heel riser, although a full length lift is always better because we do not create so much plantar flexion and shorten the calf. Watch this space for an update on the progress of this interesting case.

This definitely shows that when more than one structural deformity presents itself then things do not follow a set pattern. We must always remember the principle of individuality when helping our clients. A + B does not = C!!! We cannot simply have solutions without a thorough assessment process that takes many things into account.

This is something I will be teaching the guys on the upcoming functional assessment course!!!

 

 

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ITB Pain

Today's blog has come about from a conversation I had with a friend of mine who is running the marathon. Like many runners when they get beyond then 10 mile mark he has been struck down by IT band pain.

After consulting the physio he was given some classic stretches for this. General hip ADuction off weight bearing etc. This got me thinking about the predominant view of muscle function and how if we length or strengthen a muscle then it will do this by default.

First of all the ITB and muscles that attach to it maybe individually fine, but when they interact with the foot in a functional position such as stride stance this may change.

A flat or high arched foot may cause excessive lengthening or a lack of lengthening of the IT band and associated muscles. However much we lengthen or strengthen these muscles in isolation, when placed in a functional chain they will be limited or affected by other sections of the chain e.g. the foot. This means that in isolation and decompressed from gravity these muscles will appreciate the stretch but this may make little difference to their ability when back in a functional position during such as during running.

Many times I have treated people who have foam rolled and performed all manner of stretches in an isolated way but to no avail. Once we have found a cause rather than a symptom they have become much better.

The real point here is just because we spend time lengthening or shortening a muscle it may not choose or be able to use the motion or strength we have given it in a functional scenario. It maybe that another part of the system will not allow it to or the muscle or group of muscles have to perform another role because another part of the body has not done its job.

Another example of this would be kyphosis. People send hours retracting the scapulae to 'strengthen' the muscles of the upper back but their postures never change. This maybe because something further down the chain such as the hips and ankles are not able to effectively flex and attenuate the ground reaction and gravitational forces. This means the upper back will have to lengthen to decelerate the spine flexing forward so that the neck and head can remain in a relative upright position. In this scenario would these muscles choose to lengthen and decelerate motion to create relative upper thoracic and cervical extension or, shorten and force the superior distal segments at the cervical to lengthen disrupting head/eye function. I believe the latter regardless of the 'strength' we have given them. One thing we cannot 'beat' or get away from is gravity and ground reaction (unless you have a spaceship of course!!!)

This maybe a reason why people with limited thoracic motion get an anterior head position. The inability of the spine to relatively extend means the neck muscles have to decelerate the forces and end up at lengthened and at end range.

Just some thought out loud really!!!!

Ben

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Shin Splints

I had an interesting debate today with two guys I really respect for their knowledge and passion about the body and fitness. It centered around what we would describe as "shin splints". One opinion was shin splints were more on the medial border of the tibia while the other opinion was more central shin pain in the anterior tibialis.

I think the key to shin splints muscle pain can be mid tarsal joint. The anterior tib inserts onto the medial cuneiform and first ray, much like the peroneus longus which runs down the lateral malleolus rather than the medial molleolus that the anterior tib inhabits. When the fore foot smashes into the ground it will invert and lengthen these muscles. If the supination process does not happen effectively the forefoot will not evert and lock up and these muscles will stay loaded throughout the propulsion phase leading to pain. This would be a similar scenario to why plantar fascia pain can occur.

One thing to check is the big toe. By lifting the toe up when weight bearing we can check to see if the arch will rise giving an indication of if the foot will become a rigid structure ready for propulsion. A manual inversion of the rear foot and eversion of the forefoot will also give an indication of the foots ability to lock up for propulsion.

Foot type and the individual flexibility in the foot can affect the propulsion process. If we had a valgus forefoot for example, as the forefoot hits the ground it will be unstable due to the lateral border being unsupported by the ground. An approach by the foot maybe to supinate early during midstance, however the foot will then be unstable on the lateral border leading to a pronatory compensation from the STJ at toe off or propulsion. This disruption in the foot sequence leads to an unlocked foot meaning an added lengthening load to the anterior tib and subsequent shin pain. An osseous restriction of the forefoot such as a valgus will also affect big toe function reducing the dorsi flexion of the first ray and the locking up of the foot.

Another topic of conversation was transverse plane motion at the STJ during the front foot phase of gait (I know, what geeks right!!!). Some people describe motion at the calcaneus as adduction. My opinion is however that most motion in the transverse and sagittal plane is blocked by the ground and therefore the plantar flexion and adduction of the talus will create relative abduction and dorsi flexion at the joint. This would be a case of the proximal segment moving faster than distal!! This talar motion now means the navicular portion of the talonavicular or mid tarsal joint will be abducting!! What fun we had!! Really a pointless piece of knowledge but a good reasoning process.

I have had a great response to my AFS/functional assessment process weekend in April so places are limited. Email me at [email protected] if you are interested. We will be looking at how to understand the assessment process better and applying knowledge as discussed in these blogs. After the success of the sports specific course in January I am planning another one in June. Please let me know if you are interested!!

Have fun.

Ben

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Golf, the performance zone and meccano!!

I am no golfer but understand a bit about the biomechanics. I have been involved with a golfer recently trying to improve his swing. Obviously when we look at the swing we see two ends or transformational zones (TZ) for those who have GIFTed or seen a video digest. The third zone or ball strike could be called the performance zone.

Now, many times we look at the load and strike of the ball and don't pay much attention to the other end or deceleration of the swing. This for me maybe the most important part. With this golfer the load was perfect but the ball strike not. The question to be asked is does the second TZ affect the performance zone. For me the answer would be a resounding yes!!! If the body does not feel it can decelerate the motion then this will affect the down swing right from the top of the backswing. It has to work out a way to decelerate the motion and this will change the swing dynamics and result in inconsistent and erratic shots.

This was certainly happening in this case. The gentleman in questions left hip did not like to internally rotate. The huge rotation of the left foot gave that away when swinging!!! The internal rotation demand on the left hip is pretty large in the down swing especially with the larger clubs. Working on the follow through has produced pretty amazing results in this case. Little time has been spent looking at the loading on the backswing apart from working on the left calcaneal eversion. This probably has an impact on his left hip in gait as well as golf which showed up pretty quick in testing.  Pretty happy with this one!!!!!

I also saw a lady this week who had had her ankle put back together with medical meccano after an accident. Sometimes AFS can give us accelerated results, other times we have to settle in the for he long haul. I think this is one of the latter scenarios.

Her Dorsi flexion was hugely limited and it is hard to know what can be got out of it with the mechanical restrictions. The dorsi flexion was worse when coupled with inversion and limiting hip extension, creating a little limp onto the right leg. She was also suffering from some left shoulder pain. Her spinal motion was limited into left rotation so it maybe the hip also has some capsular problems both anterior and posterior ligaments affecting the front foot TZ in gait when the T spine is left rotating.

I used the BAPS for driving inversion through the external rotation of the leg in a load bearing single leg stance and it really seemed to help. The mechanical energy always seems to get stuff going!!

Watch this space for info on the progress.

Catch you soon!! Ben

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Course and new patient Paul update!!

Its been a little longer than I would have liked since my last post. I have been flat-out however!! I ran my first course last weekend and had a great turn out of over 20 including 8 GIFT fellows both past and current!!

Always great to be around passionate and intelligent people who were there to learn and not just to make themselves look cleverer than everybody else. I myself selfishly probably learned the most from those guys and I was the one taking the course!!! Hopefully I imparted some of my experiences on those guys too. The mark of a good teacher not being how much you know but how much of your knowledge your students know.

I think I may run the next one on the assessment process and strategies. The feedback was that this could be a popular and useful course for the AFS community. Let me know if you are interested!

It's great to have started off the year so well. A wonderful course. An audio symposium upcoming on PTonthenNET and being asked to talk at some international conferences. All exciting stuff but pretty tiring organising it all and having lots of clients to deal with.

An update on my last post: My client Paul was displaying some right foot problems and also definite capsular tightness on the right hip. My strategy for the foot was although it was pretty flat I wanted to see if I could get some load and explode out of it through FMR before I decided to go down and orthosis route.

Although it was at endish range I think sometimes the talus can get stuck in a position and needs to move to drive proprioceptive info in the system. This really needs to be hands on I find motion does not tend to free them as effectively (although follow up with motion)

Although in this scenario success in eversion maybe driving the dysfunction, a small load to explode strategy can create some positive reactions in supinating the foot. I created a load on and off weight bearing and also unload mechanics to the foot tissue. This had a positive impact instantly and also seemed to have some carryover to the next time I saw Paul.

I hit the hip capsule in a non weight bearing positions to minimise the elastic mechanisms of the hip muscles. Then created 3d motion and finally got some movement going to create strength and stability. It all worked pretty well and Paul's stiff spinal motion was noticeably altered by a change in hip motion. I finished by driving hands on FMR of type 2 spinal motion to the right that Paul noticeably lacked and also a little upper cervical type one with left rotation where Paul was also limited and again gave some lightly loaded motion after.

I find that when presented with an excessive arm swing during gait analysis sometimes driving spinal and scapula motion (both hands on and off) is not enough. A little cervical driver possibly at the same time really creates proprioceptively authentic information to the scapula and can have some great results. The neck can really lock down when presented with a spine fixed in a position and can need a little help to free up!!
Paul was a little surprised at how quickly he could notice a significant difference after seeking more traditional help previously. This is the power of AFS people!!!

Until next time.

Ben C

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First blog post-New patient paul!!!

I am usually a technophobe but I am trying to conquer this. I know what I like and I like what I know and it aint usually computer stuff!!!

I wanted to start off my new blog by talking about a client/patient I was referred this week by a lovely Osteopath Andrea. Andrea called me (we had never previously met or talked!!) and asked me to take a look at her patient Paul.

Paul had some right hip and knee pain. The hip pain like nearly all mystery pains decided that it wanted to move around to confuse the people trying to sort it. Paul definitely was a little thrown by my methods! I first wanted to look at Paul move. Instantly it became obvious that he was pronating when he should be supinating, when his right leg was the back leg. This set the alarm bells ringing and I wanted to check this out further.

I first had Paul just stand on weight-bearing and it was obvious that his right foot was much flatter than the left. He also had the classic pump bump (Haglunds deformity) on the rear of the right foot. I thought I would get him off weight-bearing and have a better look!!

Off weight-bearing I was able to check Paul's callous pattern. It was pretty obvious he was spending a lot of time on the medial side of the foot. He displayed large callouses under the 5th and 1st met heads. I went back to the rear foot and confirmed my suspicion he had a small rear foot varus. This was compounded by the smallish forefoot varus he also displayed. Individually small but together have a much more significant impact on flattening the foot.

During some gait tweaks Paul struggled on the right when we internally rotated the leg. I followed up with a balance reach that confirmed this. Right rotation was only 30-35 degrees versus almost 50 degrees on the left.

Hypothesis time. I think what was happening was as the foot supinates it should come onto the lateral side. Paul's foot was already structurally on the outside due to the pair of varuses and is inherantely unstable. This means it wants to get the medial side back to the ground for stability. Paul's foot was able to compensate through the STJ to do this, the STJ pronates instead of or late in supination. This was having a profound impact on Paul's knee. The tibia and femur want to rotate together, helping supinate the foot. Now the femur is rotating externally and the tibia is being pulled back in by the pronation of the foot. The patella is now stuck in the middle with no place to go and complains about it!!!!

The hip will sense this and close down motion. This is because it maybe sensing the opposite motions from both the proximal and distal ends. Together they create a much larger ROM than can be tolerated. The capsule playing a big part in this. The internal rotation on the back leg being a major victim.

Many of the muscles of the hip will be irritated if they cannot go through the IR they need. Hence the moving pain from the medial and lateral sides. This may also be an indication of a capsular pain pattern from the tight capsule.

I will follow up on this blog later in the week with some treatment strategies that I used. Thankfully both Paul and Andrea were happy with the resolution. You are always under pressure when being referred people.

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