laramie orthotics

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

Bare Physical Therapy bunion, Cortizone Injections, foot pain, Manual Physical Therapy, metatarsalgia, Orthotics, plantar fasciitis, Podiatrist , , , , , , , , , , , ,

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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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Visceral Therapy for stomach problems

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How many people do you know who take medications for their abdomen on a regular basis? Stomach medications for heart burn, reflux or indigestion, intestinal medications for ulcers, constipation, diarrhea, or general digestive problems. How many have had their gall bladders removed?? What if there were fibrotic adhesions from illness or injury that may have occurred years earlier? Adhesions that were impacting the performance of the abdominal organs and causing them to be symptomatic?

These tissue adhesions can be treated with physical therapy, specifically visceral therapy in which tissue mobility and motility can be restored and stomach or intestinal symptoms can be resolved which may eliminate the need for medications.

Come to Bare Necessities PT…There is Hope…True Healing Exists!!

Testimonial from my patient Tyler:

I had severe stomach problems from the age of 12 to 17. Severe pain, nausea, constipation, and diarrhea were all symptoms that I lived with on a daily basis. I missed so much school that I was unable to graduate on time.  I had seen several doctors and specialists and was diagnosed with IBS, possible Crones disease and even parasites.  I was prescribed several different medications and supplements, as well as changed my diet, all with little to no relief.  I was told I would have to live with this for the rest of my life. I then was introduced to Tony.  Just three visits cured my problem and I no longer suffer or have to worry about how I’m going to feel each day. It has changed my life. THANK YOU TONY!

 

The Therapeutic Value of Visceral Manipulation

Visceral Manipulation (VM) was developed by world-renowned French Osteopath and Physical Therapist Jean-Pierre Barral. Comparative studies found Visceral Manipulation beneficial for various disorders

Digestive Disorders
Bloating and Constipation
Nausea and Acid Reflux
GERD
Swallowing Dysfunctions 

Emotional Issues
Anxiety and Depression
Post-Traumatic Stress Disorder

 Pain Related to
Post-operative Scar Tissue
Post-infection Scar Tissue
Autonomic MechanismsPediatric Issues
Constipation and Gastritis
Persistent Vomiting
Vesicoureteral Reflux
Infant Colic

VM assists functional and structural imbalances throughout the body including musculoskeletal, vascular, nervous, urogenital, respiratory, digestive and lymphatic dysfunction. It evaluates and treats the dynamics of motion and suspension in relation to organs, membranes, fascia and ligaments. VM increases proprioceptive communication within the body, thereby revitalizing a person and relieving symptoms of pain, dysfunction, and poor posture.

An integrative approach to evaluation and treatment of a patient requires assessment of the structural relationships between the viscera, and their fascial or ligamentous attachments to the musculoskeletal system. Strains in the connective tissue of the viscera can result from surgical scars, adhesions, illness, posture or injury. Tension patterns form through the fascial network deep within the body, creating a cascade of effects far from their sources for which the body will have to compensate. This creates fixed, abnormal points of tension that the body must move around, and this chronic irritation gives way to functional and structural problems.

Imagine an adhesion around the lungs. It would create a modified axis that demands abnormal accommodations from nearby body structures. For example, the adhesion could alter rib motion, which could then create imbalanced forces on the vertebral column and, with time, possibly develop a dysfunctional relationship with other structures. This scenario highlights just one of hundreds of possible ramifications of a small dysfunction – magnified by thousands of repetitions each day.

There are definite links between somatic structures, such as the muscles and joints, the sympathetic nervous system, the visceral organs, the spinal cord and the brain. For example, the sinuvertebral nerves innervate the intervertebral disks and have direct connections with the sympathetic nervous system, which innervates the visceral organs. The sinuvertebral nerves and sympathetic nervous system are linked to the spinal cord, which has connections with the brain. In this way someone with chronic pain can have irritations and facilitated areas not only in the musculoskeletal system (including joints, muscles, fascia, and disks) but also the visceral organs and their connective tissues (including the liver, stomach, gallbladder, intestines and adrenal glands), the peripheral nervous system, the sympathetic nervous system and even the spinal cord and brain.

Thanks to the dedicated work of Jean-Pierre Barral, a Physiotherapist (RPT) and Osteopath (DO), healthcare practitioners today can use the rhythmic motions of the visceral system as important therapeutic tools.

Barral’s clinical work with the viscera led to his development of a form of manual therapy that focuses on the internal organs, their environment and the potential influence on many structural and physiological dysfunctions. The term he coined for this therapy was Visceral Manipulation.

Visceral Manipulation relies on the palpation of normal and abnormal forces within the body. By using specific techniques, therapists can evaluate how abnormal forces interplay, overlap and affect the normal body forces at work. The goal is to help the body’s normal forces remove abnormal effects, whatever their sources. Those effects can be global, encompassing many areas of bodily function.

How Does Visceral Manipulation Help You?

Visceral Manipulation is used to locate and solve problems throughout the body. It encourages your own natural mechanisms to improve the functioning of your organs, dissipate the negative effects of stress, enhance mobility of the musculoskeletal system through the connective tissue attachments, and influence general metabolism. Today, a wide variety of healthcare professionals perform Visceral Manipulation. Practitioners include osteopathic physicians, allopathic physicians, doctors of chiropractic, doctors of Oriental medicine, naturopathic physicians, physical therapists, occupational therapists, massage therapists and other licensed body workers.

How is Visceral Manipulation Performed?

Visceral Manipulation is based on the specific placement of soft manual forces to encourage the normal mobility, tone and motion of the viscera and their connective tissues. These gentle manipulations can potentially improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body.

Harmony and health exist when motion is free and excursion is full – when motion is not labored, overexcited, depressed, or conflicting with neighboring structures and their mobility. Therapists using Visceral Manipulation assess the dynamic functional actions as well as the somatic structures that perform individual activities. They also evaluate the quality of the somatic structures and their functions in relation to an overall harmonious pattern, with motion serving as the gauge for determining quality.

Due to the delicate and often highly reactive nature of the visceral tissues, gentle force precisely directed reaps the greatest results. As with other methods of manipulation that affect the body deeply, Visceral Manipulation works only to assist the forces already at work. Because of that, trained therapists can be sure of benefiting the body rather than adding further injury or disorganization.

*from the Barral Institute

hip and back pain during and after pregnancy

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Marnie – hip and back pain during and after pregnancy:

When I was four months pregnant, I started getting severe hip and back pain. I was as stiff as a board, no matter how much stretching I did, and I did a lot. I would get a pinched nerve near my tailbone so bad that I couldn’t lift my feet off the ground to walk. My hips felt like they were burning on fire. The mornings were the worse, when it felt like the wind got knocked out of me, my back and hips hurt so bad. I felt like I was 90 years old and there was nothing I could do about it.

I was in PT from four months pregnant until 10 months postpartum. I would feel better sometimes but it was only temporary, sometimes only half an hour, sometimes a couple of days. But nothing ever got better. Finally, a friend referred me to Tony.

Not only was Tony a kind and gentle person, he figured out what was structurally wrong with me and “fixed” it in one visit! It turns out, that during pregnancy, the hormones that let your hips open up also caused my sacrum to sort of drop down and get wedged underneath my hips and pelvis. There was no way for it to get out, until Tony and his wife teamed up and literally pulled it back out into the right place! It didn’t even hurt. I am still in shock every day that I was able to walk out of Tony’s office and not feel any pain! I will never be able to thank Tony enough for what he did for me. My life as a “90-yr old” in chronic, 24/7 pain is no longer a reality for me. I believe he works miracles!

To all the mamas out there who think that hip and back pain are just a normal part of pregnancy and giving birth, please believe me when I say, it is not normal. You can get help. You deserve to not be in so much pain!!

 

Emily: 34 Weeks Pregnant

I first came to Tony last Spring after visiting my chiropractor numerous times for my cramped neck and not feeling any relief. He was able to give me some tips and excercises that improved my neck pain in just a few visits. Because of my experience last spring I decided to go back a few weeks ago and have Tony work on my hip/ lower back area. I was 34 weeks pregnant and would cramp up so bad that I could hardly walk after laying down for a while. Again, it took just one visit to feel relief. I was amazed and slightly disappointed that I didn’t see Tony earlier in my pregnancy!! I had a chiropractor appointment scheduled for the following day. I knew I needed to explain that my hip felt much better after Tony’s adjustment. I asked that she wouldn’t adjust my hips so that it would stay in place. Unfortunately, she went right on and popped them like usual and undid the work that Tony and Amy had done. Thankfully I knew it could be fixed, so I came back to the Bare’s with the regret of seeing my chiropractor, and they were able to work their magic again. I love how they work together as a team and really truly want you to experience a pain free life. Thank you for all that you’ve done for me! I can’t express how greatful I am for your practice!

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

Bare Physical Therapy achilles tendonitis, Arch Support, bunion, foot pain, knee pain, metatarsalgia, Orthotics , , , , , , , , , , , , , , , , , , , , , , , , ,

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