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

Homestead Bound!

Homestead Bound…
Many of you have known that Amy and I have always had the ultimate goal of moving to the country in Wyoming or Nebraska to get closer to my parents and out of the “city”.  Well, we found a home that met our extensive criteria and we are under contract with a closing date (God Willing) of 7 July 2017 in Laramie, WY.  There are still some deal-breaking type issues that the seller needs to address, but we are moving forward under the assumption that the first week of July will be the last week before we move…that’s the bad news.  There IS good news!!

1.       I do plan on coming back to Colorado Springs 1 week every month for several months and we’ve opened the July and August weeks up for scheduling already.  I will be working a solid 40 hours those weeks at the home I’m renting to my daughter:  4230 Great Place, 80917.

2.      I am actively working to find a manual therapist to turn my practice over to and we think we have found her, but we would appreciate prayer and direction for this search.  Ideally she will begin attending appointments with me next week and you will all have a chance to meet her and she will have the opportunity to “feel” exactly what I’m working to heal and even practice my particular techniques.

3.      We plan to set up a “cabin” for patients to come visit us in Laramie along the lines of a BnB.  You would receive an afternoon/evening treatment, enjoy a home cooked breakfast with free range chicken eggs and another treatment that morning.

4.      Lastly, I can still make your orthotics and shoe modifications and even gait analysis from Laramie.  If you think you might be close to needing new orthotics, you might want to get an order in before we move and you’ll save on shipping.

I’ve been very honored to have had the privilege to care for you and your families and I know God already has patients for us waiting in Wyoming!!

Follow our homesteading adventures at

thehighplainshomesteaders.com

 

My Orthotic History and Experience

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In 1996 I had been a physical therapist for 2 years and I left my assignment at Ft. Campbell, KY to attend a 2 week continuing education course at Ft Sam Houston, TX. During the course a man named Michael Cane taught 8 hours on gait, biomechanics and orthotics. It was completely over my head. I was so angry that Physical Therapy school had completely failed to teach anything useful on the subject, that I was on a mission to remedy the situation. I took a Michael Cane’s 3 day course, another 3 day course taught by a Podiatrist and another by an Orthotist. I took another 3 courses and dove into the research…in 1998 I re-wrote the curriculum of lower extremity biomechanics, gait and orthotic treatment for Baylor University. By 2001 I had become the Military’s gait and biomechanics expert (across all services) and was a guest instructor in 2 different Graduate PT programs and 2 different clinical residencies. I developed my own 3 day continuing education course and I have taught it all over the country.

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                                               Bosnia, Camp Eagle, 2000

God provided a perfect environment for me to become the expert described above… I grew up working for my dad as a machinist, so I had a comfort level with building and machine work. The Army provided me with an endless supply of Soldiers not biomechanically designed to run or march. I had access to some of the best orthotic labs in the nation, mentoring by orthotists with decades of experience and plenty of supplies. My skills were honed and I still learn from every patient I evaluate and treat. Every patient is so very unique. I’ve made over 5000 pair of orthotics. I’ve made orthotics for patients as young as 6 and as old as 96, patients who are Olympic track and field athletes, recreational and high school athletes and patients just struggling to walk without a cane or crutches.

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Do you have pain in your back, hips, knees, shins, ankles or feet? Have you a bag full of orthotics that didn’t help your pain in the past? If I evaluate you, you will see my evaluation will be comprehensive, I will explain to you what is working and not working throughout your stride and if an orthotic can help you. I will provide a comfortable and affordable device and you will have the chance to finally turn that page in the chapter of your life.

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Want more information?
See my Fallacy of Arch Supports article

LTC Tony Bare (ret) DPT, ATC, OCS
Physical Therapist
Colorado Springs, CO

Custom Orthotics By Providing Video Gait Analysis

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