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Endurance Athlete Consulting covers a broad range of topics regarding human performance in sport, sport related injuries, and rehabilitation. If there is something specific you would like to inquire about, please feel free to email me at: bradsenska@yahoo.com.

I am available for speaking engagements and in services regarding aspects about injury, injury prevention, training for specific competitive events, injury treatment protocols, and workplace ergonomic assessments for a healthier work environment.

Sunday, April 28, 2013

Running Minimalist Style Part II

My intent with this post is for you to be able to visually compare the two different types of running.  As I've said before, running is a skill that takes practice, concentration, and frequent self analysis by paying attention to purposeful movement.

I FIRST NEED TO MAKE SOMETHING VERY CLEAR:

Running "minimalist/naturalstyle and running "shod" style can and should be done regardless of shoe!

It is not the shoe that determines the way you run!  The shoes do not control you and the way you run!  But, they can "influence" the way you run! 

Here is how this works.  The shoes provide a stimulus on the feet that can produce a mild or very profound change our in running mechanics.  This change is purely a reflexive adaptation to the way the shoe is designed and how it feels on our feet.  I have mentioned in prior posts and publications that orthotics act as a "contact cue" on our feet.  Just as orthotics act as a contact cue in order to change the way we walk and run in order to help resolve injury or pain, running shoes are designed to do the very same thing!!  The idea behind the vast amounts of varying shoes is on purpose.  The shoes are designed to accommodate an individuals style of running vs. an individual adapting a more efficient running style.  

To help explain this just a bit more, let's say a person goes into a running store, tells the people in the store that when he/she runs I feel this here, I feel that there, and I get sore here.  The shoe guy then directs the person to the shoe that was specifically designed to prevent the symptoms that the runner is talking about.  So, how does the shoe store person know which shoe is for what?  Cause the manufacturer designed it this way and the shoe guy knows this.

  


*Comparing Running Shoes*




The shoe on the left is a New Balance 1080v3 "Neutral" running shoe.  Neutral meaning it has no extra components on the sole or in the shoe box itself to manipulate (by contact cue) the way you are running.  The design of a neutral running shoe is made upon the following assumptions:

1.  The arch of your foot is consider of normal height and maintained well.
2.  You do not excessively pronate or supinate when standing, walking, or running.
3.  That your foot does not have an excessive straight or curved shape.
4.  That for your style of running, you just need cushioning vs. support in the rear foot or midfoot.


New Balance 1080v3 Neutral Running Shoe

New Balance Minimus Road Shoe















The shoe on the right is the New Balance Minimus Zero Road Shoe.  This is considered a "Barefoot / Minimalist / Natural Style running shoe.  The design of a minimalist shoe is to simply give you a protective barrier between the surface you are running on and the sole of your feet.  Looking at the sole of this shoe, it maintains a more correct anatomical shape of a foot.  It is intended to fit like a glove.

When looking at the two types of shoes, it is obvious that the Neutral shoe will be much more forgiving and supportive than the Minimalist shoe.  This allows to a certain extent the ability to not pay attention to the way you are running when your heel strikes the ground and when pushing off from the ground.  Also know that when there is more prolonged contact on the ground over an isolated area, this equals more work to continue moving forward at the same speed.  But remember, this is not an absolute statement or rule!  Even in a Neutral, Posted, or Well Supported shoe, you can always change the mechanics of your running to a more natural or minimalist style.

Important issues to consider are:  

Heel to Toe Rise

In the "Shod Running" illustration, I tried to demonstrate this.  Heel to toe rise is the difference in height from the level of the plantar surface of your heel to the plantar surface of your toes.  This varies depending on the brand of shoe and the style of shoe, i.e. neutral shoe, stability shoe, racing flats, etc.  

This is a significant factor to think about when buying shoes and how you plan to run in shoes.  In a racing flat, the heel to toe rise is very small to no difference at all.  In a training shoe other than a minimalist shoe, this ratio can be significant and make minimalist style running quite hard to do.  This is because the heel is of sufficient height that it doesn't allow you to strike the ground minimalist style.  In addition, by running in a shoe with a significant heel to toe rise, the muscles in your legs, thighs, and hips are not performing an equal ratio of work.  Hmm, could this lead to a muscle imbalance?  When the heel to toe rise is large, the majority of the work falls on the quadriceps.

The Sagittal Plane Profile of the Sole of the Shoe

Um, I'm going to draw you another picture (I love this photo shop!  Just got it.)


Notice how the soles of the shoes are different.  The sole of the shoe on the left meets the tip of the shoe.  The sole of the shoe on the right terminates just prior to the tip of the shoe. Saucony has produced shoes like the one below.  Your toes would be hanging ever so slightly over the sole of the shoe inside the toe box.  This supposedly offered a mechanical advantage by not having to work as hard from 1st gear through 5th gear and past toe off.  In theory, you would just roll over the edge of the shoe without having to push off as hard.  The problem with this was that the muscles in the feet and calf were not being used as they should.  Subsequently, this caused a significant amount of plantar fasciitis, tibialis posterior tendonitis, achilles tendonitis, weakness in the hamstrings, and the onset of hamstring tendonitis.


The moral:  Do what you are built to do!  Enhance your performance with technology.  Do not make the mistake of using technology to substitute performance.  

*Comparing Running Styles*






The illustrations below compares the two styles of running.  The first illustration is Shod Running -obviously from the title, duh!.  I mentioned above that running shoes have a heel to toe rise ratio (toe to heel, either way).  Because of the heel protruding from the shoe, this inhibits proper positioning of the ankle and knee upon heel strike when trying to use a minimalist style of running.  In addition, the heel causes the mechanics of the lower extremity to put the majority of the workload on the quadriceps.  I don't want to generalize, but when a muscle imbalance begins or develops between the quadriceps and hamstrings, this sets you up for another extremely annoying and hard to resolve issue:  The dreaded ILIOTIBIAL BAND SYNDROME!

Shod Running 



Minimalist / Barefoot / Natural Style Running - All the same.

I believe this illustration speaks for itself.  Minimalist running takes practice.  I say this because running this way initially requires a conscious effort.  There are optimal stride lengths for each individual person, there is intent regarding the manner in which your foot strikes the ground, leaves the ground, and swings, and there is an excellent balance in opposing muscles, secondary, and tertiary (or synergistic) muscle groups.


This is a style of running in which we were meant to run!  It is efficient, it maintains an excellent muscle balance throughout our lower extremities, it fosters great self awareness, and most importantly, injuries caused by weak foot intrinsic muscles, calf muscles, thigh and hip muscles are absolutely minimized.





Until next time...

Happy Bipeding!

Brad Senska, PT, DPT, BS, ASTYM.
bradsenska@yahoo.com




    Saturday, April 20, 2013

    How Do I Run Minimalist Style?

    Please note that what you read in this post is absolutely not all encompassing!  These are solely the basics!

    It's been awhile since I've specifically talked about running in a "minimalist" shoes(or natural style)  and running in a standard or "by design" type of running shoe.  BTW:  the "by design" term is my own lingo.  I thought it appropriate due to the fact that the shoe was or is "by design" intended to serve a specific purpose.  It has been developed for a specific foot type, body type, and running style, etc.  

    I know that in many of my posts I have written about using a softer heel strike by adapting the mechanics of those used with minimalist shoe running but then realized I've never really explained with any detail how to do this.  Well, here it is...um, after a little prefacing first!

    To help with understanding certain elements such as the thinking behind shoe design and the mechanics of running, I think you will get more out of this with the following information:


    There is and continues to be an immense amount of research, trial & error, product testing, study of joint mechanics,  loading and impact forces, amount of time to complete the running stride from pre-loading to terminal stance and toe off.  Then there is muscle activity during specific phases of the running stride along with the breakdown of the amount of time spent in the different phases of running.  All of this is measured and documented with extreme precision.  
    It's amazing how much research has been performed and how much empirical data has been acquired through the study of running and walking.
    It's because of this information that we know "just running" is much more than just running!  This is the reason for the large amount of various running shoes besides the marketing angle by shoe companies.  The fact is, many people have no clue on how to run (I do not mean this in an insulting, condescending or offensive manner! Please know this!) in a manner that is efficient and long lived (meaning without acquiring an injury over time).  So, in an attempt to compensate for what many do so very poorly, an infinite amount of variously designed shoes are produced in an attempt to accommodate for where we fall short.

    Quick diversion here:  For the seasoned runners reading this, I'm sure you can relate to being somewhat frustrated to find out that the shoe you have been running in over the past year to 18 months is no longer the same shoe when you return to the store and are told that your model of shoe is no longer in production.  This is in part because of so much research and theory from the vast amounts of data collected.  And it's not just biomechanical and physiological data.  It's also about the construction of a shoe with improved single and dual density soles along with material that "breaths" or retains it's impact absorbing properties.  Then there is the current trends to be considered in the aesthetic appearance of a shoe.  The absolute bottom line is of course is the cost to produce a shoe and increase the profit margin.  

    However, there is an unending combination of theory and technology to be combined.  So much so that every several months to a year the "Newer & Improved" version has debuted and taken the prior models place.  After all, if ever THE ONE SHOE TO BEAT ALL OTHERS was created, well...what fun would that be?!

    OK, back to topic:  There are four phases of running that will be mentioned and of which will be our main concern.  The quicker you get through each phase and with the greatest efficiency is after all something that is extremely important to the competitive runner or any runner that wants to improve their running performance.  

    Note however for the more experienced and researched runner, these 4 phases do not make up all of the phases of running.  The running stride is broken into many smaller phases.  To make things more technical and complicated, some of these phase have interchangeable designations.  

    Some examples of these phases are:  

    • Initial contact 
    • Loading response 
    • Mid-stance
    • Terminal stance
    • Toe off
    • Pre-Swing
    • Swing phase  
    • Forward swing 
    • Double swing 
    • Foot descend  
    Note:  These phases are not all necessarily in this specific order.  In addition to these phases, you have an opposite phase occurring in the opposite lower extremity.  To simplify things significantly but still maintain its' informative value, I'll be referring only to the following phases of running:

    1.  Heel Strike
    2.  Mid Stance
    3.  Gears 1 - 5 (Gears 1 - 5 is not an official tag for the phases of running.  Tagging it this way  makes it easier to make sense of.  Getting through these gears quickly and efficiently is crucial to maintaining speed). 
    4.  Toe Off

    In this post, I've used a shoe made by New Balance.  In the next post on this blog, I'll will give details of running in a by design shoe. 

    The Minimalist Foot Mechanics Explained  


    By looking at the picture, you can get a general idea of the differences in styles of foot mechanics and running.  New Balance has even indicated on the bottom of their shoe the optimal area of heel strike and ground contact.

    New Balance Minimus Zero:

    1.  The heel strike shoe as you can see is on the posterior and lateral aspect of the shoe.  To be able to land with this part of your heel and foot, the ankle and knee joints are in a more flexed position prior to making contact with the ground.  In this position, the landing is softer due to the braking action of the leg and thigh muscle vs. the force on the ankle or knee joint.  More forward speed and momentum are maintained, thus acquiring 1st gear more quickly (the red target).  

    2.  Mid Stance when running in minimalist shoes, the mid-stance is just slightly longer than in by design shoes.  This does not mean that you are on your foot longer though.  This just means that your foot is spending less time on the heel while maintaining better forward momentum and speed.  It's also at this time in which a significantly more amount of muscles within the foot (intrinsic muscles) are working.  This is one reason why minimalist shoes when used properly, are an excellent deterrent to plantar fasciitis and tibialis posterior tendonitis.  

    New Balance Minimus Zero Road Shoe

    3. Gears 1 - 5 is where peak muscle recruitment has occurred.  The energy built from muscle recruitment is now being transformed in to kinetic energy and is revving up to 1st gear.  As we continue to move forward, the kinetic energy is propelling us through 5th gear and to maximum speed.  While in my graduate program,  a professor of mine made an analogy regarding the gears.  He talked about why our feet are shaped the way they are.  The most logical and common sense answer to this is if our feet were straight across, then we would all walk like a duck!  But by having graduated toes, we are able to transition smoothly over the end of our feet in an efficient and smooth manner.  Just think if we all walked around like Ralph Macchio in the Karate Kid!

    4.  Toe Off is the beginning of the "double leg swing" phase.  Toe off may not seem very important at first.  However, after the toe off, you are in the double leg swing phase.  In other words, you are in the air.  During toe off, you can either propel yourself forward, or you can propel yourself upward.  The relevance of toe off to minimalist shoes is that to avoid firmer heel strike and greater deceleration,  as happens with by design shoes, there is a much stronger tendency to propel yourself forward to avoid meeting the ground more forcefully.  This then improves your running efficiency and speed.

    In Summary, running minimalist:

    • Decreases force of heel impact and deceleration with heel strike
    • Decreases total time of contact with the ground
    • Decreases time to toe off
    • Increases the amount of muscle recruitment in the feet, legs, thighs, and hips
    • Decreases the amount of time spent during the "double leg swing" phase which is the equivalent to decreased vertical motion and increased forward motion, and this = SPEED BABY!!
    • Movement and use of the longitudinal and transverse axis of the foot are 100% engaged.  Trust me, this is good.  Movement of these axis' seriously deter plantar fasciitis and tibialis posterior tendonitis.  Like I said, many many topics were left out. 

    Whew!!  I have to tell you, it's taken me a few days to write this post.  Minimalist shoe running though is not for everyone!  Running in this manner does take skill and concentration.  But once you've experienced the benefits and challenge, you'll never want to go back to a by design shoe!


    Up next is the "by design" shoe running mechanics!


    Happy Bipeding!

    Brad Senska, PT, DPT, BS, ASTYM.
    bradsenska@yahoo.com

    Sunday, April 14, 2013

    Treadmill Running vs. Road or Trail Running

    Ever wonder why switching from running on a treadmill (TM) to running outdoors on the road, track, or trail seems so much harder?  Well, there are a few reasons for this!  When running on a TM, the work coming from your muscles are being more or less minimized due to less work being performed on a TM when running (unless...we'll get to this).  There is also less energy being absorbed through your body when running on a TM.  This factors in to overall body fatigue and fatigue in the primary running muscles.  The amount of force absorbed through your foot, leg, thigh, and trunk are less when on a TM.  These are the two main reasons why of running on a TM is less vigorous or exhausting compared to outdoors.

    The following details these 2 specific reasons:

    Reason Number One:
    When running on a TM, less muscle recruitment in your lower extremities are occurring.  Therefore, if there's less muscle recruitment, then there is less demand for oxygen to the working muscles.  The reduced muscle recruitment comes from when your foot lands in front of you on the TM belt.  At this time your foot and leg are being "carried" backwards by the speed of the belt and TM motor.  You are not fully propelling yourself forward.  The amount of force coming through your lower extremity is equal to the amount necessary for you to remain running in place on the belt (I think this is along the lines of Newton's Second Law - The acceleration of a body is parallel and directly proportional to the net force acting on the body...I've probably skewed that some :))  Simply stated, you are not actively propelling yourself forward!  
      Here's an example, if you are running outside on a track, you are required to push the mass and weight of your body forward to traverse distance.  The force required to do this is much greater than on a TM. If you are running in an all out sprint, then the amount of muscle recruitment increases significantly as does the oxygen demand if this sprint is maintained for a long enough period of time that your immediate supply of blood/muscle/ATP (many of you may remember the days of suffering through having to memorize the Kreb's Cycle in biology) glucose is depleted.
      When running on a TM, there is just enough work being done to advance your foot quickly enough forward so as to maintain your position on the TM and avoid being carried off the TM backwards (you ever watch The Biggest Loser?  Happens all the time!).  On a TM, you are not pushing your body weight and mass forward, you are just maintaining it in place.
      But now we have to get into a little more physics.  When running on a TM it's like running in a vacuum.  No wind friction co-efficient or drag on your body has not been taken into consideration.  If you think this doesn't make a difference, then go back to the Olympics held in Mexico City.  Or consider how much farther a football can be kicked or thrown at high altitude such as Denver, CO at the Denver Broncos stadium.  We can take examples from drafting in cycling and drafting off of other runners.  It's a common practice in open water swimming competitions to draft off of another swimmer to conserve energy.  Yeap!  Even with swimming you gain substantial energy savings by swimming at the feet and in the wake of another swimmer.  The drag co-efficient is the one variable that can not be duplicated when running on a TM unless there is a fluctuating change in TM elevation to mimic a tailwind, headwind, downhill, and/or uphill running.  It would still be difficult to mimic an oblique tailwind or headwind.
      So, here's what you can do to equalize TM running with running outdoors.  If you are used to running outdoors but for some reason you have to change up your run and move indoors, you can assimilate outdoor running by increasing the grade/elevation of the TM between 2.5% - 3%.  By doing this, you now have made TM running equivalent to running outdoors but on level terrain and without the body drag co-efficient.  Anything above 3% elevation puts you into the "running up a hill" category or "running into a headwind" category.

      Reason Number Two:
      If you have ever shopped for a TM and have seen in the description referencing a "cushion flex suspension system" running surface or a "low impact springboard running platform", well it's because the running surfaces on a TM do provide a very forgiving surface.  If you have a running technique in which you land directly and with significant force through your heel, the fatigue factor that this will have on your body, muscles, and joints will be significantly less.  The running surface on a TM will absorb the energy from a hard direct heel strike.  Now, let's say that an individual is transitioning to running outdoors on a path, pavement, up and down hills, or just a much harder surface.  The amount of overall body fatigue will manifest itself quickly, but last only a short period of time as long as the transition is done properly.  The signs of this manifestation will be sore muscles, knee, hip, ankle joint soreness, and possibly mild joint swelling in the lower extremities.  No need to worry though!  These symptoms are simply from attenuating new workloads, increased muscle recruitment, and end waste product from the body's increased muscular activity and joint force attenuation that comes with the territory of a "less forgiving" surface.
      Just as our muscles become sore following the start of a weight training program or an increase in a current training program, our body needs to adapt to running on terrain that it is not accustomed to running on.  Just as muscles adapt to increasing workloads, the lining of our joints (joint articulating cartilage) will need to adapt to the increase in force.  This force affects multiple tissues and structures such as our muscles, nervous tissue, and joints.  The articular cartilage becomes dense up to the point that it is able to withstand the new forces.  It is no longer "soft and pudgy" from TM running.  The articular cartilage will become more dense, stable, and less prone to injury.  The joint effusion or swelling that may occur is increased synovial fluid within the joint and its' capsule.  The swelling in a joint relative to what is being discussed here is not blood!.  Your body is operating under its' design.  It is adjusting to your activities.  Just as we build calluses on our hands through the friction of gripping, the articular cartilage will toughen up to accommodate our activities.
      Here's an editorial for the running cynics that swear on their lives that running can severely damage the knee and hip joints.
      For the cynics out there, if blood were present, bruising would also be very apparent.  Pain, and not just a small amount of pain as would be present from mild joint swelling, a large amount of pain would be present!  If blood is present in a joint, it usually doesn't go unnoticed and the person would out of necessity seek medical attention.  Once the physician made his diagnoses, it's typical that the joint would be drained via a needle.
      You see, blood is toxic to articulate cartilage.  Blood can quickly deteriorate the cartilage in a joint.  Each joint in our body has a capsule around them.  This includes not just the larger joints in our body but the small joints in our hands, toes, and the facet joints in our spine.  The fluid inside a joint is the lubricating synovial fluid.  The synovial fluid in a healthy joint is clear and is the most slippery substance you'll ever experience (seriously though, don't cut yourself open just to check this out!).  Synovial fluid in a joint of which blood is present has a milky red to dark red appearance depending on the severity of bleeding in to the joint.  A grade II or III ankle sprain is a good example of a torn joint capsule that is  accompanied by marked swelling and bruising (not just joint effusion).  The synovial fluid in a joint with moderate to severe osteoarthritis has a milky yellowish appearance.
      Back to our original topic...
      So, in summary, the underlying message is: 
      • Running on a TM can be assimilated only so much to mimic running outdoors.  You can get close, but duplication of some variables are not possible.   
      • When transitioning to running outside, it's recommended that you assess your running mechanics and see if you could benefit from running with a less forceful heel strike.  Because of the forgiving surface of a TM, it's easy to develop an inefficient stride.  By landing hard with your heel, mechanically this means that your knee close to full extension and your body is absorbing an unnecessary amount of force.  
      • Remember, when using a strong heel strike, you lose a significant amount of your forward momentum, more time is spent on that leg during the single leg stance phase, and more energy is required to maintain forward momentum and speed.

      As usual, please feel free to contact me with any inquiries at:  bsenska@therightfeet.com

      Happy Bipeding!

      Brad Senska, PT, DPT, BS, ASTYM.
      bradsenska@yahoo.com

      Tuesday, April 2, 2013

      Tibialis Posterior Tendonitis Case Study With Pics!

      The material that I'm going to present here is an actual case study in which this patient was initially diagnosed with plantar fasciitis.

      Patient demographics:
      • Female
      • 38 years old
      • Height = 5' 5"
      • Weight = 148 lbs
      Abbreviated patient history:

      With out too much formality, I'll summarize her limitations and significant clinical findings upon her evaluation and assessment.

      This patient was a professional.  She managed a very upscale dining facility.  She was required to be on her feet for over 8 hours at a time.  The dress code required her to wear high heel shoes.  When not at work, she did go for hikes on hilly terrain that lasted up to an hour or more.  She had a mesomorphic body type with poor joint mobility and a low Beighton Index score.  Her overall general fitness level was good.  Given this information, she was found to have poor motion either actively or passively with right dorsiflexion.  Active and passive calcaneal inversion and eversion were also moderately restricted.  Her overall foot structure was semi-rigid.  Midfoot and forefoot joint mobility was also moderately restricted.  The arch of her foot was appropriately maintained in standing and in a non-weightbearing position.  She did not present with pain in the arch of her foot nor at the MTP joints with firm palpation.  Initial stepping in the morning was intermittent with pain.  As you'll see in the below images, she did have swelling present in her medial calf, her medial ankle, and slight swelling near the medial malleolus.  She also did not present with any leg length discrepancy.  Her pelvis was well aligned in the frontal and sagittal planes.  When observing her walking gait, she showed more midfoot pronation on her right during mid stance than with her left foot midstance.  With regards to her gastrocnemius/soleus strength, she demonstrated a 5/5 on the left and a 4-/5 on the right.  Right hip abduction and right hip external rotation strength were also showing weakness.  Right hip external rotation active and passive range of motion were increased compared to the left.  Single leg standing was > 45 seconds on the left. Single leg standing on the right = < 20 seconds due to onset of symptoms combined with weakness.

      Other findings were present, but let's move forward from this.  Here are key findings that I immediately identified as suspect:

      1.  Prolonged habitual posturing.  During the subjective part of the evaluation, she was asked to show me how she stands at her station or which posturing habits she favors.  She immediately went to posting on her right lower extremity while letting her left hip drop.  This explains the increased movement with hip external rotation and the weakness.  The weakness here was identified as a stretch weakness from overuse during habitual posturing.
      2.  Pt. presented with a deficit in right ankle dorsiflexion.  This is indicating either a capsular restriction at the ankle or shortening of one or more contractile tissues in one of the posterior compartments in her right leg.
      3.  Weakness was present with plantar flexion, midfoot inversion, and heel raises.  Pain symptoms also presented when performing these motions and activity.  Pain also presented with prolonged single leg standing.
      4.  During weight bearing and walking, her right arch showed a moderate collapse in mid stance.  Her left foot did not show this same collapse.
      5.  Her description of her pain was not consistent with plantar fasciitis in spite of the fact that she was feeling pain in the same area that plantar fasciitis would also present.

      So, with the above findings, I would say that this would be plenty to move on with.  I begin with palpation of the suspected tissue.  In the first image, I'm identifying the insertion of the tibialis posterior tendon and the origin of the plantar fascia on the calcaneus.

      In this series of pictures, I'm isolating the tibialis posterior tendon, muscle belly, and origin in order to help confirm what my suspected diagnosis.

      Notice the space shared by the origin of the plantar fascia and the insertion of the tibialis posterior tendon.  The way to rule out that the plantar fascia is not inflamed is by examining the arch of the foot up to the MTP joints.  If indeed plantar fasciitis is present, pain will be present at the heel, through the arch, and to the MTP joints.  In Image 1, the patient was extremely tender with moderately firm palpation. 


      Image 1

      To help determine the severity or acuteness of her symptoms, I'm going to palpate the tibialis posterior tendon and muscle up to its' origin.  Typically, if pain already presents in the foot at the insertion site, then this is an indicator that her injury or the process of acquiring the tendonitis has been in progress for some time.  In this case, she stated that her foot had been bothering her for over 6 months.



      In Image 2, I'm still over the tibialis posterior tendon just below the musculo-tendon junction.  Again, this area was extremely painful with just light to moderately firm palpation.  Fluid or swelling was also palpable in the area with a crepitus or gas exchange type of sensation and sound.

      Image 2

      Also, to better isolate palpation over the tibialis posterior tendon, I maintain the ankle at 90 degrees dorsiflexion.  This was enough dorsiflexion in this case to bring the tibialis posterior tendon more pronounced without exacerbating her symptoms.



      Image 3

      Notice in Image 3 the swelling present above the medial malleolus, posterior of the medial malleolus, and anterior of the achilles tendon.  This swelling was obvious and palpable the entire length of her medial calf along the path of the tibialis posterior tendon.  My right index and middle finger are over the musculo-tendon junction at this point.  Because of the amount of stretch receptors and nocioceptors present here, this area was again extremely painful to just light palpation.  This area felt as if it had a collagenous callus over the area.  This developed most likely from the same principle as Wolff's Law.  The body recognized a weakness and attempted to strengthen it through laying down scar tissue.



      Image 4
      I've now palpated the entire length of the tibialis posterior tendon and muscle.  My right index and middle finger in Image 4 are over the origin of this muscle.  Again, because of the more dense group of various nerves and blood supply here, her pain was quite elevated with light palpation.  There was also the same palpable swelling and collagenous tissue build up here.

      Assessment:  Stated simply, I am positive that she has tibialis posterior tendonitis and it has been present for quite some time.  The combination of her already inherit tight connective tissue and joint capsule (as indicated by the Beighton Index), prolonged habitual posturing, and then aggressive hiking on steep and rolling terrain were all contributors to acquiring this diagnoses.  

      I believe that because of her requirement to wear high heeled shoes for such long durations at work and then habitually posting on her right lower extremity caused a shortening of this muscle and tendon.  When she went hiking in much flatter shoes (she would hike in Merrell shoes which had a very close heel box and toe box height ratio), this caused a stretch weakness in the muscle and it's subsequent breakdown.  

      Just to editorialize some here, when climbing a steep grade, this is going to put a very significant strain on this muscle and tendon at the origin, musculo-tendon junction, and insertion site.  This can easily explain the build up of scarring or collagenous tissue at the origin and the musculo-tendon junction.  With the lengthened position of the tibialis posterior muscle while hiking steep grades, this tendon and muscle were under a heavy and vigorous tensile load.  It was substantial enough and lasted for a long enough period of time, this muscle was not able to adapt to the loads being placed on it.  This in turn invited the onset of this injury.

      Treatment:  I'll give you two components of her treatment:

      1.  ASTYM or Augmented Soft Tissue Mobilization
      2.  Contrast Baths
      3.  You'll have to buy my book! :)

      Treatment Duration & Outcome:  Patient had complete resolution of symptoms, full return of strength, normalized ankle joint active and passive range of motion, and was pain free with firm palpation the length of her tibialis posterior muscle and tendon.  Her treatment duration was 8 weeks.  

      This patients symptoms were quite engrained and it took aggressive and dedicated commitment and compliancy with her treatment protocol in the clinic and outside of the clinic with her usual work and recreational activities.  She did not undergo any injections or invasive treatment.  She also did not require the use of orthotics or any kind of splinting with her treatment protocol.  Changes in body mechanics, body awareness, specific strengthening, and a change in habitual posturing made all the difference.

      As usual, if you have any questions, inquires, intrigues, or other concerns regarding PT, please feel free to email me. 

      Happy Bipeding!!

      Brad Senska, PT, DPT, BS, ASTYM.
      bradsenska@yahoo.com