laramie knee pain

Shin Splints

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The most common cause of shin splint pain is excessive (in magnitude or duration) of tension on the tibia by the Posterior Tibialis muscle.  The reason the pain is so extreme is that the Posterior Tibialis muscle fibers blend with the skin of the Tibia which is called the periosteum.  The periosteum has the majority of all sensory nerve endings in the entire bone…so if you are having shin splints, you are having “bone pain” as if the periosteum is tearing…that can be excruciating

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Once you understand the job of the Posterior Tibialis you will understand why it hurts and how to facilitate healing.  When you walk or run the arch on the inside of your foot lowers with shock absorption impact in a motion termed pronation

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The Posterior Tibialis resists this pronation motion much like a shock on a car. So, the more the foot and leg roll inward in both the magnitude and duration…the more “work” demands are placed on the Posterior Tibialis as it resists this collapse of the inside of your foot.  The more the Posterior Tibialis works, the more it pulls on the periosteum and the more likely you will have shin pain.

Treatment for Posterior Tibial Shin pain.

  1.   Ice will work as an analgesic…it treats the pain, but doesn’t address the pathology.
  2. Heat is also an analgesic…it treats the pain, but it may improve circulation to the injured tissue which can bring nutrients needed for healing.
  3. Anti-inflammatories. They also work as an analgesic and if taken as prescribed will in time reduce inflammation, so once again they do not address the actual pathology.
  4. Reducing the demand on Tibialis Posterior will lead to true healing of the pathology.  Rest can come in several magnitudes…
    1. Reduce pronation… limit wearing shoes that offer little or no support to the inside of your feet and time walking barefoot.
    2. Reduce pronation… limit walking on unstable surfaces like sand or gravel.
    3. Reduce pronation… you can purchase shoes that offer a higher level of motion control and any reputable running shoe store can help you select those.
    4. Reduce pronation… you can add an arch support to further limit pronation. Feel free to come to Bare Necessities for a free gait analysis to give you advice on both shoe and potential arch support prescription…if you don’t live near Laramie, WY…we are still happy to give you free advice if you can send us video of you walking barefoot on a treadmill.  Email to Tony@BarePT.com or send larger files to Anthony.Bare on facebook.
    5. Reduce Impact… decrease minutes of running or walking. Consider non-impact activities like biking and swimming.
    6. Reduce Impact… do your walking or running on a treadmill. A good treadmill provides a level and supportive surface.
    7. Reduce Impact… Reduce running downhill and consider increasing running uphill (once again made easier on a treadmill).
  5. There is no significant role for strengthening for this pathology… Tibialis Posterior is already over worked…more work is not the answer.
  6. There is no significant role for stretching for this pathology… the Tibialis Posterior is as tight as it “needs” to be to do it’s job.
  7. Manual therapy. There is a role for manual therapy to facilitate healing of the Tibialis Posterior and the Tibial periosteum, but if you haven’t addressed #4 above the manual therapy will be much less effective.

While Tibialis Posterior is the most common cause of shin pain, there are other causes and if your symptoms aren’t located on the lower inside of your shin or your pain doesn’t rapidly respond to the treatments suggested above, then it is time to seek medical evaluation.

The Fallacy of Plantar Fasciitis

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Plantar fasciitis is such a problem that you can hardly conduct an image search for plantar fascia without returning mostly images of the plantar fascia with a big angry red splotch on the plantar fascia near the heel.

I recently watched a video on Facebook posted by one of my Physical Therapy peers on the topic of plantar fasciitis. I privately messaged him to let him know that I thought his presentation had missed some key points and his reply cited the Clinical Practice Guidelines for plantar fasciitis. There are some issues with that response from my standpoint:
1. The Clinical Practice Guidelines for plantar fasciitis are fairly useless in regards to “what to do” to treat plantar fasciitis and of some limited value in “what not to do”. They very accurately reflect current available research which is of little clinical value in this instance.
2. I’m concerned that my profession is so entranced by Evidence Based Practice (EBP) that they have stopped seeking information or guidance outside of what research has generated, and as a result their patients often suffer through suboptimal care and (pun intended) limp down the clinical plank of failed conservative care, injection and ill-advised surgery. I know this not what the developers of EBP-theory intended, but I’ve seen it just about daily on social media.
3. The research available on this topic is doing very little to help clinicians truly heal their patients of their foot pain. I would dearly love to pitch research ideas for anyone who has faculty connections.
Now off the Soap Box and on to clinical guidance…
– Plantar fasciitis is a misnomer, most of these patients don’t use their plantar fascia at all. A more appropriate term would be “Mechanical Heel Pain”. Typically, the origin of Mechanical Heel Pain is a poor initial contact in stance phase in which the contact is too medial in magnitude and/or duration. The medial aspect of the midtarsal joint, subtalar joint and calcaneus are very neural dense and do not tolerate this increased pressure well and eventually leads to heel/foot pain.

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– Unfortunately, a bad initial contact (as described above), has consequences throughout the foot and lower extremity that further perpetuate an inefficient gait cycle. Here are some examples: hallux abductovalgus (painful bunion), metatarsalgia, achilles tendinitis, medial knee pain (pes anserine, plica, etc), lateral hip pain (trochanteric bursitis, piriformis syndrome, etc) and SI dysfunction.
– The good news is that when you treat the cause (improve foot mechanics) and treat the tissue (manual therapy), the patients’ symptoms resolve very quickly…1-4 visits.
If you are a clinician reading this blog and you didn’t delete it from your feed after reading #2 above,  you have practiced long enough to be frustrated at heel and foot pain patients’ poor prognoses. Please consider attending a lower extremity biomechanical course, it will completely change your practice. I teach a 2 day course called Thinking on Your Feet. Of course, I’m biased and think mine is best, but there are some other good courses out there. Give one of them a chance and it will elevate your practice above the limitations of the current Clinical Practice Guidelines.
If you are a patient reading this blog, you may have had “mainstream” care for your foot pain which probably included: activity modification, exercises (strengthening/stretching), modalities (heat, ice, ultrasound), massage, shoe inserts, dry needling, injections or surgery. You have probably been nodding your head the whole time, because you know your foot pain isn’t completely (or any) better. Find a clinician with biomechanical training in this topic or contact me directly for advice at Tony@BarePT.com or find out more about my unique practice and skill set at Barephysicaltherapy.com

LTC Tony Bare (ret) DPT, ATC, OCS

Laramie, WY

The Fallacy of Leg Length Correction

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For many years I was honored to be the Military’s expert in lower extremity biomechanics and I’ve made tens of thousands of orthotics in my career and yet I’ve only added a leg length correction in maybe 10-20 instances.  The reason this came to mind is that I recently assessed a patient s/p TKA who became one of the very rare patients to add her name to that list.  I thought I would share my thoughts on the subject because I certainly have run into no shortage of patients (and providers) who strongly believe in correcting for leg length difference.

  1.  Since Jesus ascended to heaven there hasn’t been another person on the planet whose legs are symmetrical and really how could we be symmetrical?  The obvious is the actual length of the femur and tibia, but functional leg length difference is more often due to asymmetry of Coxa, femoral, genu, and tibial varus/valgus alignment

        2. Leg length asymmetry is just one part of the picture of frontal plane function…the real culprit is often what’s happening below the ankle and understanding those biomechanics will help you go a long way to deciphering the potential effect of leg length difference on functional biomechanics.

       3. The body has numerous mechanisms to cope or compensate for frontal plane deviations and typically it’s been coping well for years or decades.

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How do I decide whether or not to correct for a leg length asymmetry?  

  1. Has something changed in the bone?  Most of my leg length corrections followed a TKA, THA, or Femur/Tibial fracture.  Some change in bone length that the patient’s body hasn’t lived with for decades.
  2. Is there an observable frontal plane gait deviation?  Look for a drop in the pelvis on one side that would indicate an uncompensated leg length difference that might need intervention.
  3. Does the patient present with chronic or recurrent frontal plane pathology?   Unilateral sacroiliac/trochanteric symptoms (bursitis, piriformis, etc), lateral thigh/knee pain (ITB, Vastus Lateralis, and patellofemoral pain).
  4. You’ve balanced the frontal plane issues below the ankle (typically: rearfoot varus, forefoot varus, and/or unstable midtarsal joint) and the patient’s symptoms have not improved.  The foot has so much more leverage to impact the pelvis, you will be amazed how quickly your posterior and lateral hip pain patients recover when you address frontal plane issues below the ankle.

So you might be asking, why not correct for the apparent leg length asymmetry? What’s to lose?

  1. As noted above, of all the things that could lend to the appearance of a leg length difference, most of them are more variations of angulation (varus or valgus) than a true difference in length of either the femur or tibia (unless something has changed in the bone, see #1 above).
  2. You might actually be creating a leg length asymmetry. (Whatever the patient has going on, they may have been coping well with it for decades and changing that may cause more problems than it improves).
  3. Correcting for a leg length difference inside the shoe can significantly change the fit of a shoe far more than treating the frontal plane issues in angulation below the ankle…and if the patient doesn’t like how his/her shoe is fitting, she won’t wear the correction.   Typically the most correction you can fit inside a shoe before shoe fit becomes an issue is ¼”, so the picture below is for your entertainment purposes.  I was stationed at Brooke Army Medical Center in 1998 when I ordered a “custom shoe modification” for a 2” leg length difference secondary to femur fracture and instead of doing the hard work of adding the correction to the sole of my patient’s shoe, the Orthotist did the ridiculous work of constructing the biggest heel lift I’ve ever seen.  I’ve kept it as a souvenir.

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Custom Orthotics By Providing Video Gait Analysis

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I’ve had a lot of interest in my Bare Necessities  Custom Orthotics (arch supports or shoe inserts) from people across the country and I’ve had good success making them based off the information below. If you’ve read my post on the Fallacy of Arch Supports, you know that one of the components of my exam that makes the orthotic successful is the dynamic gait analysis, so if I’m provided the video footage I’ll have great insight into your biomechanics and if they need any help or correction.

The good news is that I’ll assess your videos FREE!! All I need is 10 second clips of you walking barefoot on the treadmill from behind and from each side.   Just do your best to walk on the treadmill at your comfortable walking pace.  Take video footage of the following angle/level  (including both sides/foot):

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I’ll need a tracing of your foot next to a ruler. See picture below (it doesn’t have a ruler but you’ll need a ruler next to your tracing).  The tracing will let me know what size of orthotic to make and I’ll have an idea what adaptations your biomechanics have forced your foot to make and that will be even more information helping to guide my orthotic prescription.

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IMG_2431The orthotics themselves are only an average cost of $85 plus $10 shipping and handling, so send me your videos and get on the road to pain free walking or running.

Now that we are relocating to Laramie, WY please refer your Colorado Springs friends to this post.

Please email me your video and foot tracing to tony@barept.com

LTC Tony Bare (ret), DPT, ATC, OCS
Physical Therapist
Laramie, WY