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The “Leonardo Perspective “ 2 Jobs of the Foot Stabilization Principles

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The “Leonardo Perspective “ 2 Jobs of the Foot Stabilization Principles 3/30/2017 Russ Bartholomew PT ,DPT OCS 8:00-8:30 Overview of key principles from Day 1 8:30 -10:00 Gait assessment 10:00- 11:00 Plantar Fasciitis 11:00-12:30 Meeting 12:30-1:30 Lunch 1:30 -2:30Achilles Tendinopathy 2:30 – 4:00 Posterior Tibial Tendon Dysfunction , Bunionectomy , Hallux rigidus 4:00 – 5:00 Cuboid Syndrome and Sinus Tarsi Syndrome 5:00 to end ,Exercise Lab The “Leonardo Perspective “ 2 jobs of the foot Stabilization Principles Applied to the Foot ( intrinsics, near extrinsic , distant extrinsic) 1)Closed Chain Dorsiflexion Motor Learning 2)Knee Flexion at Loading Response Fryette’s Law of the Foot 3)Hip extension at terminal stance The torque converter concept of subtalar joint First ray stability STJN Magnetic North 1 3/30/2017 Gait Lab Foundation before roof Closed chain is the destination Facilitation versus strengthening Top down AND bottom up ( “The butt is the steering wheel of the foot “) Tri-Plane Stabilization principles / ( Not excessive pronation but lack of pronation control (Jam 2006 ) 2 3/30/2017 Pain as a guideline Is it really an “Itis “ ? ( If not why use anti- inflammatory treatment modalities ?) Add what is missing /create the environment. Self efficacy (The patient must understand and be educated in order to be expected to be compliant) 3 3/30/2017 TENSION (abnormal foot position or compensation for loss of flexibility . Surface of walking and running , shoe issues , weight gain. DOSAGE ( frequency , distance , speed or weight) Loss of lengthening of the Achilles complex/mechanical loss of dorsiflexion. (Tension) Eccentric weakness of the Achilles complex ( Tension) Excessive Prolonged Pronation (EPP). Think control versus motion . As we discussed in intrinsic stabilization . (Tension) Cavus foot type ( Tension ) Weight gain of obesity .( Tension and Dosage ) Change in running /walking volume (Dosage ) Change in walking /running surface (Dosage and tension ) 4 3/30/2017 Original description of this entity was Shoe gear (Tension /Shock ) “ Painful Heel “ Fatigue / prolonged standing ( Tension and Papers on this subject began to describe dosage ) inflammation being present , but there was no Proximal pronatory control weakness ( Hips as clinical .)histologic evidence that supports part of the Core ) inflammation as the underlying issue. Emerging evidence on intrinsic muscle “Itis” infers inflammation . Clinical signs of weakness / atrophy ( Chang 2012 ) inflammation: pain , heat , redness , swelling PLUS histologic findings( leukocyte accumulation macrophages ,lymphocytes , plasma and vessel proliferation ) Lemont H, Ammirati K, Usen N. Plantar fasciitis: a MRI evidence of lack of inflammation :Grasel et degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93(3):234-237. al: These authors ruled out inflammation as a ( Myxoid degeneration , fragmentation .) cause because of the linearity and low Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. prevalence of signal intensity within the fascia. Etiology, treatment, surgical results, and review of the literature. Clin Orthop. 1991;(266):185-196. They concluded that the changes noted are best (Fibrosis and thickening ) interpreted as perifascial edema due to Snider MP, Clancy WG, McBeath AA. Plantar fascia microtears in the plantar fascia in the area of its release for chronic plantar fasciitis in runners. Am J Sports Med. 1983;11(4):215-219. insertion into the calcaneus. (Collagen necrosis, angiofibroblastic hyperplasia and matrix calcification ) . 5 3/30/2017 NORMAL COLLAGEN DEGENERATED Acevedo and Beskin reported that in a group of 765 patients with a clinical diagnosis of plantar fasciitis, 51 were diagnosed as having a plantar fascia rupture. Of these 51 ruptures, 44 (86%) were associated with corticosteroid injection POST-STEROID NORMAL INJECTION 6 3/30/2017 Subjective /History : Examination ( Objective ) Pain located in the plantar heel ( not just pain Specific palpation of the calcaneal tubercle and somewhere in the foot ) along the plantar fascia middle/medial band . ( windlass will help locate) “Get up and go” pain. Active and passive dorsiflexion ROM . Increased after prolonged weight bearing . ( Tarsal tunnel clearing .( Phalen’s and Terrible in the morning , better after up a few Tinel/AND screening ) hours and then terrible in the evening ). Windlass Recent increase in weight bearing activity ( Navicular drop/FPI ( Planus or Cavus dosage) causation ) Subjective : Plantar fasciitis worse with first few steps , entrapment with prolonged activity . Manual= A (E*) Specific Palpation ( plantar or more proximal and medial. Parallel with Stretching= A (B) foot or oblique ) Tinel at Tunnel and Abductor Hallucis . Taping= A (C) Windlass. Orthotics = A (A) AND tests Symptoms don’t resolve when you address impairments . ( Stay out of Night splints = A (B) the rut …if not getting better reflect ) Modalities = D (B) * Often it is a mixed presentation as the stresses that lead to many foot diagnosis are the same . 7 3/30/2017 Manual Therapy= Strong ( from weak ) Cleland : Techniques to restore joint motions at the talocrural joint ( closed chain dorsiflexion), subtalar joint, and mid-tarsal joint as well as elongation of plantar fascia ) Soft tissue ( Renan-Ordine 2011) AND techniques ( Meyer 2002 and Young 2001) Randomized clinical 2 centers : NH and NZ Good external validity as The MPEX group it mimics typical manual experienced both trial . 2 study groups : therapy practice , but significant and clinically N= 60 Both : Gastroc/ soleus poor internal validity as meaningful Prior to this study no stretch ,plantar fascia there were a lot of improvements in LEFS randomized clinical stretch , strengthening variables in “impairment scores at 4 weeks and 6 trails of manual therapy of intrinsics . based “ treatment months that were interventions for EPAX= US, Ionto with techniques . significantly better than plantar heel pain Dexamethasone the EPAX. ( thus low level of MTEX= Soft tissue Authors noted that future evidence noted by mobilization, rearfoot studies should seek to McPoil ) identify which specific eversion mobilization, manual techniques and and impairment based exercises are most hip, knee , ankle and effective foot techniques. 8 3/30/2017 OTHER MANUAL TECHNIQUES MANUAL TECHNIQUES BASED ON IMPAIRMENT Knee flexion mob with Hip posterior glide Plantar fascia and FHL A/P talocrural stretch and tissue mobilization 1 and 2 ( valgus IR Figure 4 hip anterior glide mobilization . (plantar talocrural dorsiflexion Knee flexion mob with soft tissue restriction ) restriction) varus ER Prone internal rotation Distal Tibiofibular with extension mob Lateral glide/eversion Knee extension mob ( tibiofibular restriction ) mobilization .(ankle Patellofemoral mob Cuboid manipulation /rearfoot complex Proximal tib-fib restriction ) ( intertarsal restriction ) manipulation P/D tarsal mobilization Rearfoot distraction Hip caudal glide 90-90 manipulation ( ( intertarsal restriction ) belt talocrural joint motion Tibialis Posterior restriction ) stretch ADVERSE NEURAL Provides short term DYNAMICS ( AND ) clinical benefit of 2 weeks to 4 months ( TED Landorf 2006/ Sweeting SID 2011) PIP No difference between Slump sustained @ 3 min versus SLR intermittent 20 sec x 3 Pragmatic info : Technique Dynamic progression . 9 3/30/2017 WINDLASS STRETCH SELF MASSAGE MCCLURE ET. AL . This article is a great review of the effects of immobilization as well as the effects of excessive tension on peri- articular soft tissues ( PAT ) . Peri-articular tissues are designed to withstand tensile stress. If tissue is deprived of tensile stress or there is excessive stress ,morphologic, biomechanical and biochemical changes occur . Loss of GAGs ( key components of connective tissue ), and water cause intermolecular and intramolecular cross links to form . This limits extensibility of tissue which further leads to degeneration . 10 3/30/2017 There is a loss of degradation / synthesis balance . Frost proposes the theory of “ minimally effective strain”…not too much and not too little This is the theoretical basis for the treatment techniques to follow . CHOICES Reduces pain with patients Use or don’t use ? with “get up and go pain. “ Short term effect ( van de ( Hawke2008 , Lynch Water2010/Van Lunen 2011 ) 1998 ) K tape /Rock tap : effective but for less time (Tsia 2010) Designed to reduce tensioning stress overload by Custom vs. Prefabricated ? compressing tarsals ( as would (Pfeffer 1999, Martin 2014 ) occur with girding intrinsic muscles ) and by creating a tripod foot with first ray plantar flexion. Long term or short term ? Also created a girder under ( Landorf 2006) the bridge . 11 3/30/2017 Iontophoresis Short term relief ( 2-4 Progressive loading program for home weeks ) Moderate Evidence 1-3 month duration 2008 recommendation : Only recommend for those of 6 month or greater duration. THE QUESTION IS WHY ???? Itis or Night splinting ( “The Sock” Osis ???? )www.thesock.com Symptom not the problem 12 3/30/2017 The “ cut knuckle “ ; pain with tension on the release will result in altered gait with reduced pronation and eventual “lateral column strain “ Treat with motor relearning ,desensitization , and functional remodeling of the healing tissue . Restore dorsiflexion Tape /Orthosis Achilles focus Use for short term unloading Talocrural focus Motor Learning ( F evidence ) Both Pronatory control neuromotor re-education
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