People have asked "if you were given only one area of the body to treat, what would it be?"

Answers by renowned therapists, have included the psoas and coccyx.

For me it would be the feet.

A bonus for me in teaching my Balance Enhancement and Fall Prevention Class has been the knowledge and importance this anatomical structure is any standing individual.

• It is our Base of Support in standing and therefore an integral component of Balance and Fall Prevention. 

• In my clinical experience 95% of falls are contributed to from foot and ankle dysfunction.

• 84 % of 65 year olds have structural dysfunction in their feet.

• Individuals increase their chances of sustaining and injury due to a fall by 2 times if they are unable to perform 1 legged stance for 5 seconds.

• A person must have 8 degrees of ankle dorsiflexion with the knee extended and 10 degrees of motion with the flexed to be at a decreased risk for falls.

• The Hallux and toes must have 90 degrees of extension is necessary for normal push off.

• It is the foundation of our body. Misalignment at the foot will cause compensations and dysfunction up the kinetic chain.

• By improving alignment at the foot we can correct dysfunctions up the kinetic chain; knee, hip, pelvis, etc...

• Proper functioning of the foot is vital for efficient walking and any ADL's that is performed in standing. 

• Research shows that there is a significant decrease in proprioception of the feet after 80 years of age. 

• We can halt the progression of painful bunions, callouses and hammer toes as well as diminish the need for orthotics.

If you don't know about NPH, please read this

NPH stands for Normal Pressure Hydrocephalus.

Diagnosis of NPH is often difficult due to the symptoms being similar to other disorders.  In many cases the NPH is thought to be mild dementia, Alzheimer's, Parkinson's or simply old age therefore, it often goes completely unrecognized.

It is estimated that 400,000 persons in Nursing Homes have this disorder and are improperly diagnosed. 

NPH patients usually exhibit:

• Gait disturbance (difficulty walking)
• Dementia or forgetfulness
• Urinary incontinence (bladder control)

*Note that not all symptoms are always apparent or present at the same time.

Here is a link to a video of a person's gait with NPH.

NPH is treatable with the implant of a surgical shunt.  These patients do not improve with Physical Therapy intervention.  

In my over 15 years of practice, I can recall 3 patients who presented with these symptoms and were not diagnosed.  Two have passed and the other is my Grandfather.  Currently, I am in the process of learning more about this disease and getting him to the correct doctor. 

The following website has information and a link to doctor's who specialize in this area:

www.lifenph.com

Modifying Lunging exercises

Lunging is a functional exercise as it is a vital action for properly retrieving items off of the floor and for people themselves, being able to get up off of the floor after a fall.

I confess that I do not prescribe this exercise to patient's and I didn't know why until I visited a hotel gym the other day and was watching someone perform lunging exercises.

The way a traditional lunge is taught places excessive pressure on their lower back.

This occurs due to the relationship between the hips, pelvis, sacrum and lumbar spine.

When a human extends their hip past 30 degrees of extension, they should begin to have movement into extension at their lumbar spine. The majority of people, however begin to extend their lumbar spine well before (I have tested people who begin to extend their spines at as little as 2 degrees of hip extension).

A traditional lunge requires about 60 degrees of hip extension thus mandating the lumbar spine to move into extension.

The goal of patients with lower back pathology and those who are at risk for lower back pathology (everyone) is to stabilize their spine's and increase motion in the lower quadrant rather than feed into a pathological motion of premature extension of the lumbar spine.

In my experience Lumbar extension is the most common overused compensation for a lack of hip extension and pelvic motion in younger people.

I would suggest rather that keeping the shoulders back and trunk upright during a lunge, that a person hinge at their their hips forward at least 30 degrees and keep the spine in neutral alignment during both the forward and backward lunge. (As shown in the picture above)

Additionally I suggest that a person bring their opposite arm (with respect to the leg) forward and backward. (Not shown in the picture above)

Why Novak Djokovic is Falling All Over the Court

If you follow Men's tennis you are aware that Novak Djokovic falls more than any other player on tour.


At this year's Wimbledon he tried to overcome this by adding treads to the sides of his sneakers. As a result, the All England Club asked Djokovic to change his Adidas shoes after his quarterfinal win over Tomas Berdych because the nubs on his shoes gave him an unfair advantage. The Grand Slam Handbook states that grass court shoes “with pimples or studs around the outside of the toes shall not be permitted.”

From that point forward he was slipping and sliding and hitting the turf with more frequency than his previous matches and this may have cost him the title.

When you look at Djokovic's impressive record you will note that he has far greater success on hard court (4 Grand Slams) versus Grass or Clay (1 Grand Slam against an injured Rafa Nadal) where there is less traction. 

Falling occurs when a person's center of gravity (located at sacral level 2) moves beyond their base of support (the feet). This occurs in In Djokovic's case when his looses base of support a portion of his foot comes off of the ground. 

From what I could see in pictures, it looks like Djokovic's left foot is the one with greater dysfunction and will present with a premature loss in base of support.

To test this on Djokovic's foot I would perform an evaluation that I call foot clocks.

Foot Clocks can be tested in multiple directions, in Novak's case I would test the 6 o'clock motion as he often falls when he is in a anterior/posterior position of the feet. The 6 o'clock position tests plantar flexion in the closed chain. People who lack range in this direction will often fall when they slip.

Click the following link for a video demonstration of this evaluation showing dysfunction.

This is easily treated with mobilization once it is determined where in the range of motion base of support is lost. It would behoove Djokovic's team to evaluate and likely treat the mechanical dysfunctions of his foot so he won't have to compensate with illegal footwear and can spend more time hitting the ball and less time hitting the ground.

In any sport including tennis, a fraction more balance and speed on one movement could be enough to make the difference between victory and defeat.

If anyone out there has the opportunity to evaluate Mr. Djokovic, throw me an email and let me know if I was right, physicaltherapy@hotmail.com

Why I think Pilates is effective

I had mentioned in my last entry about my lower back patient finding benefit with Pilates exercise (please note that this patient was performing supervised exercise using Pilates equipment).

 As a result a question was raised:

"What is it about the Pilates method that makes it beneficial for some Orthopedic patients?"

My theory is that the springs and the command/manual contact provided by the instructor provide both traction and approximation. Traction and approximation are theorized to provide irradiation into the core.

Traction decreases pain and elicits proximal stability

Approximation increases muscle recruitment and proprioception into the joint.

Many of the Pilates exercise incorporate rotation, particularly of hips. When you look at the kinesiology of muscles that are know to be core muscles, their action is rotation.

Lastly Plilates classes are one hour in length and in my experience the number of patient's that spend a dedicated hour on stability exercises are few.

Similar to any other profession there are excellent instructors and not so excellent instructors, it is vital that any person particularly a patient find a qualified instructor.








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Difference between Stability and Muscle Guarding

 

A colleague recently stated that when people are in pain there is muscle guarding and hypertonicity of muscles and would this not make a patient stable? I do not feel that this guarding stabilizes an individual's joint effectively as the muscles that are guarding are not the muscle that are designed for stabilization.

I believe that this guarding is a result of a compensation for a lack of stabilization.

It is from the principle of Stability/Mobility that I developed the ARMS (Active Release with Manual Stability) release technique. The success that I have achieved using this technique in my practice, reinforces my belief that hypertonic, guarding muscles are compensating for a lack of stability elsewhere.

I was trying to mobilize the connective tissue around a sacrum so that it could move in the direction of nutation. I had tried all of the techniques that I had learned for release without success.

The words of my Orthopedics teacher in PT school "you need to have stability in order to have mobility" entered in my mind. I then provided a prolonged hold type of stabilization to the patient's abdomen and the hypertonic tissue immediately released.

Yesterday I attended a private Pilates session with a patient who I referred there. He expressed that when he was performing a certain exercise, he felt that the spasms an tightness in his back release.

To answer my colleagues question, I think that a person with muscle guarding does not gain adequate stabilization from this guarding, and teaching them stabilization exercises and techniques may in fact help to decrease their painful muscle guarding.

Can your patient's feet even articulate with the floor?

Of course.

You don't often see anyone standing or walking with their foot off of the floor, but how many people can achieve this task without compensation?

The other day in clinic I decided to passively evaluate my patient's feet and ankles moving them into a neutral position to see if their foot could articulate with the floor without compensation.

None of my patient's, age range 18-84 could achieve this motion without mobilization.

Restoring it helped to elicit an improvement in posture as well as function.

Compensations up the kinetic chain for a lack of neutral dorsiflexion in standing include the following:

• Genu recurvatum
• Anterior innominate rotation
• Knee flexion in standing (think of your elderly patients)
• Elevation of the rib cage a sternum
• Forward head rounded shoulders posture
• Thoracic kyphosis
• Rotation of the tib/fib
• Rotation of the femur

To evaluate place the patient in prone or supine and passively move the toes, metatarsals (where most the structural restrictions are), mid tarsals and ankle joint to see if the patient can achieve a neutral position in all.

As you do this look up the kinetic chain as you do this to see if there is movement including, rotation of the lower leg or femur and/or hyperextension or flexion of the knee.

In my classes I always say that I could make the world a better place, physically if I could restore dorsiflexion in my patients.

 See what happens to yours when you take a close look.