Attention Overhead Lifters!

Lifting overhead, whether for training, for sport or for work-related activities, is a movement that regularly leads to shoulder injury and dysfunction if not performed correctly.   I was directed to this interesting demonstration of lifting overhead under fluoroscopy through Dr. Jeff Cubos who has a great blog on evidence based training and rehabilitation.

The Right Shoulder Joint

This demonstration of the mechanics of the shoulder joint was posted by David Whitley.  Watch the videos and then consider the effects of repeatedly performing that overhead lift without correctly packing the shoulder.

Check out the videos HERE.

 

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Plantar “Fasciitis”: Not always one cause, not always one cure

One of the problems we have when someone comes to the clinic saying that they have, or were told they have Plantar Fasciitis is that they probably don’t.  The “itis” refers to inflammation and in most cases, there is very little inflammation going on.  Instead, the tissues show more signs of collagen degradation resulting from repetitive, chronic irritation without inflammation.  This is much the same as the majority of cases of “Tendonitis” that we see.  They should predominantly be called a tendonosis and this plantar fascia condition should be called a fasciosis.

Plantar Surface of Foot Showing Muscles that Lie Under the Plantar FasciaOne of the reasons for the lack of inflammation, chronicity and slow-healing of plantar fasciosis is that it does not have a very good blood supply, like most thick collagenous structures.  This is significant because it limits the amount and speed of transport of the nutrients and building blocks required for healing.

A second problem that occurs frequently when people come in with this complaint is that they are sure of what they need in terms of treatment.  They either have a friend who’s had the problem before or a requisition for orthotics from their GP.  The trouble is that finding the cause and appropriate treatment for any given case of plantar fasciosis is a tricky business and can typically only be achieved on a case by case basis.  There is no “1” cause.  There are many scenarios that can create an irritation in the area. 

A few of the potential culprits include:  Heel spurs, high arches, low arches, hyper pronation, sudden weight gain, increased activity levels or a combination of any of the above.  None of those is a guaranteed risk factor however.  Take the example of heel spurs.  If some one has had a plantar fasciosis for a while, it might be recommended that x-rays be taken.  On occassion a person will be found to have a heel spur, which is a bony spur at the medial calcaneous caused by a tugging reaction of the tissues that attach there.  When that is seen on an x-ray, it’s tempting to blame the pain on the heel spur.  The flaw is that not everyone with heel spurs gets plantar fasciitis, not everyone with plantar fasciitis has heel spurs.  The spur can be surgically removed and the patient can still have pain and even when the spur is removed, it will often come back over time.

In general there is some excessive stress being placed on the plantar fascia, causing degradation over time. The fascia spans the peaks of the arch of the foot.  (Imagine the fascia as the string on a bow.)

Site of pain in plantar fascia

Plantar Fascia

As that arch collapses under load it stretches and strains the plantar fascia.  Too much of that stretch and strain leads to micro-tearing and cumulative degeneration.

The good news is that although it can be a painful condition and not always easy to determine the cause, it does get better with treatment.  Appropriate conservative treatment can include rest, taping, soft tissue treatment for the plantar fascia and calf muscles, ice and in some cases othotics.  Other options include surgery (which can be quite successful, but can have a long recovery period) or cortisone injections (which do show improvement at 1 month follow-ups, but no lasting improvement at 6 months…with the added “bonus” of increasing the chance of rupture in the plantar fascia).

The bottom line with this (and any other condition), is to make sure you have a proper examination to determine the cause so that you are directed towards the most effective and appropriate treatment.

Illiotibial Band Syndrome: The Runner’s Nemesis

Iliotibial Band Syndrome (ITBS) is one of the leading causes of knee pain in runners and cyclists. It is often referred to as a Friction Syndrome because of one theory that it is caused by the repetitive friction of the iliotibial band (ITB) sliding over the lateral femoral condyle. During flexion-extension ranges of motion at the knee, the ITB moves anteriorly as the knee extends and posteriorly as the knee flexes, which impinges the posterior edge of the ITB. This repetitive friction can lead to irritation and inflammation of the ITB and the bFriction Syndrome ITBursa.  Another theory has compression playing more of a role than friction and through that compression, structures around the knee become irritated.  In many cases, ITBS is associated with tight musculature at the hip, which can increase pressure or tension on the ITB.

The ITB is a thickening of the fascia that is formed by the confluence of fascia of the hip flexors, extensors and abductors. It extends from the muscles of the hip down to the knee and attaches at 3 sites: the lateral border of the patella, the lateral retinaculum and the Gerdy’s tuberlce of the tibia.   The ITB functions with the hip musculature and plays an important role in stabilizing the pelvis and knee during the support phase of the gait cycle.

The initial goal of treatment should be to alleviate inflammation at the site of irritation by using ice massage, ultrasound, or NSAIDS.  An application of a kinesiotape such as Spider Tech can also be useful at this stage.  Patient education and activity modification are crucial to successful treatment. Exacerbating activities must be avoided and the athlete’s training schedule must be modified.  Stretching exercises can be started once the acute inflammation subsides. This is also when we want to address the myofascial restrictions in the tissues.

Active Release Technique can be an effective treatment for Iliotibial Band Syndrome. ART restores optimal texture, motion, and function to the soft tissues by removing adhesions between adjacent structures. Treatment often focuses on restoring normal muscle motion between the ITB, quads and lateral knee structures. Treatment also focuses on the lateral hip musculature; TFL, gluteus muscles and rectus femoris.

Once the myofascial restrictions have been addressed and range of motion is restored, strengthening muscle weaknesses becomes a very important part of the recovery process. Exercises should emphasize eccentric muscle control, multi-planar movements and functional integrated movement patterns. A return to running program needs to be carried out gradually, with small increases in running mileage and frequency and can be initiated once patients can perform strengthening exercises without pain.

Predisposing factors for ITBS can include training errors, such as increased mileage or intensity too quickly, road camber (always running on same side of road) and excessive down hill running.  Other contributing factors include altered biomechanics such as low/high arches, over pronation, genu varum, tibial torsion, pre-existing ITB tightness and muscle imbalances. Research studies have demonstrated that many people with ITBS have significant weakness in the hip abductors of the affected limb and increased adductor adduction moments because the hip abductors are unable to eccentrically control that movement.

The primary initial complaint in patients with ITBS is diffuse pain over the lateral aspect of the knee. With time and continued activity, the achiness caClinical Presentationn progress into sharp, localized pain above or below the lateral knee joint. It can also cause pain along the length of the ITB, or at the lateral hip. Pain worsens with continued activity and can be especially aggravated by running downhill, climbing stairs, or after sitting for long periods of time.  Typically the pain begins after the completion of a run or after several minutes of exercise. As the ITB becomes more irritated the symptoms begin earlier and can even occur at rest. In some cases, patients will present with swelling at the lateral knee or report a snapping/popping sensation at the lateral knee or hip.

Physical examination will often reveal tenderness on palpation of the lateral knee approximately 2cm above the joint line. Tenderness is often worse when the knee is flexed at 30, which is the angle that the ITB is at maximal stress. Palpation of the hip musculature (TFL, gluteus medius, vastus lateralis) may reveal trigger points that cause referred pain to the lateral aspect of the knee.