Traditional vs Minimalist Shoes: When Science Meets the Road

January 26, 2012

Hotel Vancouver

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Panel Members:

• Jack Taunton, MD
• Blaise Dubois, BSc, PT, RCAMPT
• Adam Janke, BSc (Kin), C Ped (C)
• Curb Ivanic, MSc, CSCS
• Jim Bovard, MD (moderator)

For more information, click here.

Also, as of today (Monday, December 19, 2011) there are only 2 spots available for the “New Trends in the Prevention of Running Injuries” workshop with Blaise Dubois and Daniel Crumback. If you’re even remotely interested, I’d suggest you register real quick. Here’s the link.

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Interestingly, when therapists do consider exercise interventions, heel raises/lowers off stairs seem to be the “exercise of choice”. Often such presentations are acute or “hot” and based on Craig Purdam’s work on tendinopathies, such exercises may be too advanced for significant progress to be made.

Now before I introduce some alternative exercises, I’d like to address the “One Toe Syndrome”. Patients with plantar sided foot pain, especially women for some reason, often present with this “syndrome”. They may indeed have five toes, as most of us do, but if you look closely the toes actually function as one unit rather than five individual units.

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The "One Toe" Syndrome

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Dewey Nielson wrote a nice post (Barefoot Training by Dewey Nielson) a while back that included how our feet should actually look like. Next time you’re at the zoo, check out the monkeys’ and the orangutans’ feet. Others have written about the barefoot trend in recent times as well but often with relatively little suggestions. That said, Patrick Ward and Charlie Weingroff have made some suggestions themselves, so here’s how they recommend integrating foot work in training.

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• Short Foot Posture by Patrick Ward
• Where to Start Barefoot by Charlie Weingroff

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Tissue extensibility dysfunctions seem to be common in such presentations as well so prior to exercise, I’ll commonly get the patients to perform self myofascial release on their calves, feet and anything else that might need “freeing up”. Again, only if necessary but here’s an example.

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Aside from the above, two specific interventions that I commonly prescribe are the Vele Forward Lean and the Reverse Tandem Gait. The Vele lean is Michael Jackson-like, or for those of you who ride the subway, similar to facing backwards as the subway enters the next station.

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Michael likely never had foot problems

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The Reverse Tandem Gait, on the other hand, is a simple eccentric exercise that integrates the intrinsic foot musculature with less load than other commonly prescribed exercises. The key is to ensure that the feet are actively engaged, with the heads of the first and fifth metatarsals firmly planted into the ground to create the tripod with the calcaneus.

Here are both exercises in a recent patient. Note that for those that suffer from the “One Toe Syndrome”, I’ll often use toe separators to bring the 2nd, 3rd, 4th and 5th toes back into action.

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The one thing I want to make mention of, is what happens the other 23.5 hours of the day. To put it bluntly, high heels do your patients no favors. Neither do narrow toe boxes. Some will also argue that footwear is generally too supportive but personally, I (again) think it’s context dependent. And apparently so does Alex Hutchinson. He wrote a nice post not too long ago on Why Normal nor Minimalist Running Shoes Will Disappear.

I do think we can transition toward less support so here are some suggestions for your active patients based on my own daily experience.

Vibrams when performing kettlebell exercises…

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Just don't look down

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Vivos when deadlifting, squating and performing other lifts in the gym…

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Squats and Deadlifts

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New Balance Minimus when treating patients 12 hours a day.

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My work shoe

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Again, what I do on a daily basis may not apply specifically to yourself or those you work with, but it’s what works for me personally.

If you would like more information on any of the above, check out Barefoot in Boston by Art Horne and Craig Liebenson’s DVDs.

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Following this post, I was asked on facebook to describe the “prone heel squeeze” exercise. So for those of you wondering, here is a modified version (with a pilates ball) I found on youtube.

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*please note that in the original paper, the description states that the hips are slightly abducted, the knees are flexed to approximately 70 degrees and again, no ball is used. The individual is instructed to press the heels together and slightly lift the knees off the table. This position is held for 3 seconds and the individual is asked to slowly return to the starting position.

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Authors: MJ. Philippon, MJ. Decker, E. Giphart, MR. Tory, MS. Wahoff & RF. LaPrade

Journal: American Journal of Sports Medicine

Date: 2011

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Summary:

• This paper is a MUST READ for rehabilitation and training professionals working in ice hockey, especially those of you in the “show”. As you know, Dr. Marc Philippon is one of the world’s leading hip surgeons and like the physician you refer your athletes with problematic hip injuries to. Published in AJSM, this paper looked identified the most appropriate EARLY postoperative hip exercises following hip surgery. With consideration of the fact that the Iliopsoas tendon occasionally becomes irritated or inflamed with early rehabilitation, the Dr. Philippon and friends utilized EMG to determine which of 13 exercises were most appropriate and when. To sum up the results, the exercises that demonstrated the highest peak gluteus medius muscle activation were the single-leg bridge, the prone heel squeeze, and the side-lying hip abduction (either performed with internal hip rotation, against a wall, or with external hip rotation). In comparison, the supine hip flexion, side-lying hip abduction with external rotation, and hip clam exercises  demonstrated moderate iliopsoas muscle activation. As a result, the exercises with the best ratios (high gluteus medius activity vs low iliopsoas activity) were the prone heel squeeze, single-leg bridge, and the side-lying hip abduction with internal rotation. Please note that all exercises were then classified into their most appropriate phase of rehabilitation: I, II, or III.
• What really caught my attention with this study was the lack of discussion pertaining to optimal and controlled muscle activation of the core musculature in general. It is my assumption that proper progression of early rehabilitation will respect optimal core control and integrity and subsequently optimal iliopsoas activity. It is difficult for me to swallow that those professionals adhering to proper progressions and appropriate rehabilitation principles actually elicit unwanted and increased iliopsoas activity. That said, this study must have been warranted and therefore must speak volumes of the rehabilitation protocols currently prescribed.
• Overall, I really enjoyed this paper and certainly walked away with a better understanding of EARLY postoperative gluteus medius and hip rehabilitation.

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Philippon, M. et al. (2011). Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis. American Journal of Sports Medicine, Vol. 39(8); 1777-1785
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Lindsay is now a chiropractic student and by the end of this weekend, will be an ART practitioner.

Anyway. She introduced me to a tool originating from Italy that I, myself, need to look into further. It may fit in and it may not. But I need to research it.

Because we first have Movement.

Functional Movement Screen

Y Balance Test

Got it? Good.

Now what about Performance?

Well she introduced me to the Optogait and the Optojump. And I think it might fit in. It might not. But then again it might. I just need to look into it further.

What do you think?

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If you're not a member, you're missing out!

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For those of you unfamiliar with FAI, make sure you read Kevin’s post before reading any further. But for those of you who are, you’ll know that there are a million orthopaedic tests that all look the same.

So what do you do when these tests are positive? We already know that many professionals who suffer from FAI also have labral tears, but what about those young athletes who have no labral pathology? And what about those who do have labral pathology but for some reason or other, may not be candidates for surgery?

Well some of you soft tissue the heck out of it on a weekly basis but do you truly get the results you’re after? Maybe, maybe not. And if not, why not?

To answer that question, we have to ask ourselves what, from a non-osteological perspective, may be contributing to this presentation in the first place? Well Shirley Sahrmann may have the answer to this one. And her likely answer will probably fall somewhere along the lines of the anterofemoral glide syndrome (check out Eric Cressey’s post for some info on this presentation).

But back to my question, as a manual and rehabilitation therapist what can you do about it?

We know that the deep posterior hip structures are often stiff and shortened, so the first thing I would do is mobilize these structures.

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We also may notice that the adductor musculature likely need some soft tissue work as well, so I would pistol (perhaps a simultaneous and combined ART / contract relax strategy – using the elbow as resistance) my way through these structures as well.

Personally, I prefer a more gentler and slow approach than his technique.

I’d also probably use a foam roller as well to save my hands.

I would likely then do some trigger point work in the anterior portion of the gluteus medius region at this point. Sorry I don’t have a video recorded for this one but only because its my secret weapon . Actually, you can do some needling here (and the TFL) as well, if you want even faster results.

Hit 'em RIGHT behind the ASIS.

But next I’d get them to do some self mobilizations, again for the deep posterior hip structures:

Then I’d throw down some “Sister Kenny” action (but more for the glute max rather than the glute med). Take a gander through Craig Liebenson’s ROS to see what I’m talking about (just click on the image).

And finally, I’d lock it down with the most appropriate, glute-dominant hip extension pattern that their exercise progression continuum calls for. This can be the lumbar-locked glute bridge:

It can be the hip extension portion (12:00 direction) of the Valslide Quadruped Hip Stability Clock Slide:

Or it can be the hip airplane:

As always, you’re free to choose whatever exercise you wish, just make sure its appropriate!

Happy treating!

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Um, not really!

A high ankle sprain can be an injury to any or all of the following:

• The distal anterior tibiofibular ligament (ATIFL)
• The distal posterior tibiofibular ligament (PTIFL)
• The transverse ligament
• The interosseus ligament
• The syndesmotic recess
• The synovium
• The plica
• The intermalleolar ligament
• and may include a fracture to any of the osseous structures

There are certainly no shortage of structures in this area and therefore, assumption that the injury is sustained solely by the ATIFL is simply a dart thrown with a blindfold.

For example, upon suspicion of a syndesmotic injury, it is important that specific clinical tests are utilized to determine in fact whether or not such injury was sustained. Dr. Pajaczkowski does a nice job in this case report of summarizing four orthopaedic tests including the squeeze test, the external rotation stress test, ligament palpation, and passive dorsiflexion. It is also important to assess the proximal tibiofibular joint to determine the possible presence of a fracture or ligamentous injury.

Following this, should imaging be required, an x-ray is commonly the first line of defense to determine the presence of osseous damage. Among the studies required, the entire tibia and fibula must be examined to identify whether or not a fracture of the proximal fibula is present. Additionally, stress views are commonly performed since traditional anterior-posterior and oblique views may not fully demonstrate an increased tibiofibular clear space. One specific injury commonly missed is a fracture of the posterior malleolus.

While access to MRI may be limited for some, its clinical utility is generally of extreme importance for optimal management since specificity of diagnosis = specificity of treatment. This imaging modality will likely provide the medical team with direction of care through the identification of the specific tissue(s) involved (as per above). Since there are too many structures to discuss, more information on diagnostic imaging of these injuries can be obtained from the articles by Molinari et al, Williams et al, and Hermans et al.

From a rehabilitation perspective, treatment is typically a product of the specific grade of injury sustained. Naturally, the P.R.I.C.E principle, medication, and modalities may take precedence although it is not uncommon for early active range of motion to be employed. Certainly, addressing dysfunctional and non-painful patterns will prove valuable yet the focus must not be taken away from basic tissue healing principles. To my knowledge, a randomized control trial for the rehabilitation of such injury has yet to be performed although several papers have identified successful rehabilitation protocols in the management of this injury. For a detailed outline of rehabilitation protocols for this and other orthopaedic injuries, you may be interested in obtaining Clinical Orthopaedic Rehabilitation by Brotzman and Manske.

A must have for rehabilitation clinicians

Unfortunately, the recovery time line for high ankle sprains are longer than that of “traditional” ankle sprains but hopefully the above information will facilitate a more optimal approach to the management of this injury. Certainly, T.D. Forss and Chris Davie have their work cut out for them but I have no doubt they are more than familiar with such injuries (they are very common in ice hockey) and will have Taylor ready to go for the 2011-2012 season.

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You walk into a specialty store dedicated to running. For the Canadians, you know which one I’m talking about. You’re a relatively fit individual looking to run your first half marathon or are someone new to the fitness industry and would like to run to get into shape. A store employee asks how he or she can help you and you inform them of your intentions. “Great” he or she says and proceeds to ask you to remove your shoes and socks so that he or she can take a look at your feet.

“Since we all have different types of feet and walk/run uniquely, then it’s important that you wear sneakers best suited to your running style,” he or she says.

You’re excited.

You quickly remove your footwear and the employee then checks your shoe wear-pattern, looks at your arches, and watches you walk.

“Great. You need a stability shoe!”

Does this sound familiar? Good. Because for some reason, everyone and their mother seems to require a “stability” shoe.

It really amazes me that some retailers go through all the trouble of looking at your arch and asking you to walk when all they will do is recommend the exact same sneaker to 95% of individuals every time.

Selling tactic? Maybe.

Time waster? Probably.

Something important? You be the judge. Have a look at this paper, published in the American Journal of Sports Medicine last year and ask yourself that question again.

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Now if they suggest a motion control shoe, run away. Far far away. Even if you’re running barefoot, just keep running. You’ll likely suffer from less pain running barefoot than you will with a “motion control” shoe. In reality, you’ll probably be fine with a neutral or stability shoe but this randomized controlled trial by Ryan et al, demonstrated that motion control shoes are NOT the way to go!

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Now what about my arches?

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The Solution

Below you will find several links to posts throughout this site to help facilitate “stability” and “motion control“. There are certainly no shortage of options so rather than giving you a generic solution, I have decided to provide you with a list of links that may assist in adding to the strategies that you may already employ.

• The Short Foot
• Ankle Dorsiflexion
• Frontal Plane Instability
• The Glutes
• Low Level Stretch Shortening
• The Glutes…again
• The Hip
• and finally, the core
• And the core some more!

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Authors: N Malliaropolous, T Isinkaye, K Tsitas & N Maffulli

Journal: American Journal of Sports Medicine

Date: February 2011

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Summary:

• Through one simple omission, this article provides little value. As you may be aware, the biarticular nature of the hamstrings seems to put this muscle group at higher risk of strain than monoarticular musculature. Since previous research has demonstrated reinjury rates as high as 34%, the objective of this cohort study was to determine whether a specific clinical assessment may be able to provide indicative factors of possible reinjury following an acute hamstring strain. 165 elite track and field athletes with first-time strains were evaluated in this prospective study. The specific clinical assessment utilized was a 4-grade classification system of hamstring injury based on active range of motion (AROM) – the greater the AROM deficit, the greater the severity of injury. Interesting classification system if you ask me! All athletes followed the same standardized plan of management following their injuries although the rehabilitation protocol was not described. Based on this classification system, it was revealed that athletes who suffered a grade II hamstring strain demonstrated a significantly higher risk of reinjury than those who suffered a grade I, III, and IV injury.

• Unfortunately, the results from this study mean very little to me since the rehabilitation protocol administered was not provided. One of the highest risk factors for reinjury is previous injury so it is clear that in non-contact sports, many rehabilitation and sport conditioning professionals are missing the boat when it comes to return to play. Therefore, in my opinion, a grading system based on AROM has little value compared to a well designed return to play rehabilitation and conditioning strategy as it pertains to minimizing the risk of reinjury following acute hamstring strains in elite track and field athletes.

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Malliaropolous N et al. (2011). Reinjury after acute posterior thigh muscle injuries in elite track and field athletes. American Journal of Sports Medicine, 39(2); 304-310

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The following is a review of several of Craig Purdam’s presentations on tendinopathy at the recent 2011 Pan Pacific Conference for Medicine and Science in Sport, held in Honolulu.

Craig is the head of physical therapies for the Australian Institute of Sport and had a wealth of information to share during the weekend. I was very grateful to be in attendance.

Craig proposed that the pathology and the response to treatment are different in the various tendinopathy presentations and therefore interventions should be dictated by the specific pathology. More specifically, that there exists a continuum of tendon pathology. Namely:

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• Reactive tendinopathy
• Tendon Dysrepair (failed healing)
• Degenerative Tendinopathy

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Craig stressed that rather than looking at the above as three distinct phases, that a continuum should be kept in mind.

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Source: http://bjsm.bmj.com/content/43/6/409/F1.large.jpg

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Classification of Stages must be identified via:

• Clinical picture, and
• Diagnostic imaging

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Stage characteristics:

Reactive Tendinopathy

• Pathology: Non-inflammatory proliferative response secondary to acute tensile or compressive overload (i.e. too much too soon). Note that tensile forces cause also compression (think of an elastic band narrowing in width (compression) as it is being stretched (tension). Tendon thickening results, presumably as a protective mechanism. Upregulation of large proteoglycans, resulting in increased binding with water, accounts for the observed swelling
• Diagnostic Ultrasound: Cleaving of collagen (longitudinal separation) as exhibited by diffuse hypoechogenicity
• Demographic: Common in younger athletes (i.e. a lengthy basketball tournament) or in the young deconditioned athlete who is now exposed to moderate load exposure.

Tendon Dysrepair

• Pathology: Failed attempt at healing (greater tissue matrix breakdown) results in matrix disorganization and further collagen separation. Changes are more focal and increased thickening is certainly present
• Diagnostic Ultrasound & Doppler: collagen fascicle discontinuity and focal hyoechogenicity, as well as increased vascularity
• MRI: swelling and increased signal intensity
• Demographic: May be secondary, but not limited, to chronic overload in young athletes. In older athletes with less adaptive, stiffer tendons, this stage may develop with lower loading exposure

Degenerative Tendinopathy

• Pathology: Perhaps the most clearly described stage in the literature. Cell death is apparent, as well as matrix disorganization, vascularity, and little collagen. Reversibility of pathology is minimal
• Diagnostic Ultrasound & Doppler: Hypoechogenicity and vascularity
• MRI: Increased tendon size and intratendinous signal intensity
• Demographic: Primarily in older athletes but may present in chronically overloaded tendons of young elite athletes. Focal nodularity with or without general thickening. Typical history of repeat bouts of tendon pain with short-term relief. Injury often returns with changes in tendon load. Rupture may occur.

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For ease of interpretation, the above continuum is divided into:

• Reactive/Early Tendon Dysrepair, and
• Late Tendon Dysrepair/Degenerative

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Cornerstones of Rehabilitation:

• Confirmation of actual tendon involvement
• Stage identification
• Symptom and function quantification via outcome measures
• Load modification via training alteration and biomechanical efficiency
• Load progression
• Pharmacological and Modality interventions

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Considerations:

• Mono-therapy is rarely successful
• Tendon unloading must only be reserved for significantly “hot tendons” and must be performed for only short periods of time. Otherwise may result in decreased tissue strength

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Rehabilitation Principles:

• Unloading interventions – i.e. biomechanical efficiency
• Priority given to muscle wasting – need hypertrophy
• Early rehab – static and slow
• Speed progression
• Volume progression of functional activities
• Late rehab – elasticity
• Load management

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Treatment Strategy:

Reactive Tendinopathy:

• Load management
• Slow tempo
• Moderately heavy loads with full recovery between sessions
• Inner range then outer range
• Isometric
• Downregulate sensitization – you do not want to push this stage and aggravate further

Tendon Dysrepair:

• Gradually increase length (outer range)
• Introduce Speed and Contractility
• Undulate loading in 3 day (High, Low, Moderate) cycles

Degenerative Tendinopathy:

• Introduce Contractility and Elasticity
• Load undulation
• Eccentric progression
• *Note that this is the only stage where eccentric exercise was suggested. Perhaps this may shed some light as to why eccentric exercise has demonstrated mixed-results in tendinopathy rehab. Are some of you utilizing rehabilitation modality at the wrong stage?

*Note modalities such as cross-friction, therapeutic ultrasound, and shockwave are only appropriate in the Late Tendon Dysrepair and Degenerative Tendinopathy Stages

*For (hopefully) obvious reasons, I have intentionally omitted recommendations pertaining to pharmacological treatment..

Purdam has authored and co-authored numerous articles on tendinopathy but perhaps three of the most significant ones you may be interested in are:

• Cook JL & Purdam CR. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43; 409-416
• Allison GT & Purdam C. (2009). Eccentric loading for achilles tendinopathy – strengthening or stretching? British Journal of Sports Medicine, 43; 276-279
• Malliaras P, Purdam C, Maffuli N & Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. British Journal of Sports Medicine, 44; 944-947

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The purpose behind these exercises are to facilitate corrections for those who may be demonstrating too much hip external rotation when performing said exercises. As you can see, he first demonstrates the faulty pattern, then follows this up with the corrective strategy.

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Commonly, we will also see individuals who may not be ready to perform the single leg straight leg deadlift and therefore, I will often regress them to the hip airplane exercise as suggested by Stuart McGill. The emphasis here is on the closed chain internal rotation / adduction portion of the exercise so a cue I normally use is to tell the individual to “close the book.”

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It is also not uncommon for individuals to have difficulties when performing this movement for the first time. Therefore, here are a few reactive neuromuscular training techniques to help facilitate proper hip control. Please remember that a restricted posterior hip capsule may limit the available range of internal rotation.

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Study Title: Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study.

Authors: A. Robb & J. Pajaczkowski

Journal: Journal of Bodywork & Movement Therapies

Date: January 2011

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Summary:

• Here is a nice little pilot study by two of my colleagues from Toronto on the effect of Active Release Techniques on immediate pain thresholds in elite ice hockey players. Using 9 players from AAA to the major junior level, they studied the influence of this popular manual therapy technique on its ability to modulate reported pain pressure thresholds (PPT) in acute adductor muscle strains. Up until now, the majority of the current literature on this technique had looked at the beneficial application of ART through case studies, however, few if any have looked deeper into the therapeutic effect of such protocols. PPT, “the minimal amount of pressure applied to the tissue to change the pressure sensation to discomfort or pain”,  was assessed both pre- and post-treatment via a hand-held mechanical pressure algometer. A significant improvement in PPT was demonstrated in this study. Since the painful experience involves both a bottom-up and top-down process, this study sheds some light into the potential positive effects manual therapy may have in acute pain patients. While the authors disclose that it is still difficult to conclude with certainty the exact pathophysiological and histological mechanisms responsible for these outcomes, they do provide some potential mechanisms for such reduction of pain. Certainly this study lacked a large sample size and randomization (hence a pilot study), however, the work of Drs. Robb and Pajaczkowski do pave the way for further research to validate a therapy that carries with it an extreme wealth of anecdotal evidence.

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Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork and Movement Therapies, 15, 57-62

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