IASTM

Shoulder Rehab Part 2

In Part I, I discussed why physical therapy of the shoulder using traditional rotator cuff exercises does not always work .  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first. In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

There are many cases in which a certain movements may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back, stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

Previously I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using some IASTM soft tissue work to her upper trapezius, levator, and rhomboids.

Another soft tissue treatment modality we offer at  On Track Physical Therapy is   Dry Needling .

Another soft tissue treatment modality we offer at On Track Physical Therapy is Dry Needling.

Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Plantar Fasciitis Treatment – What are my options? Ann Arbor, Mi

Plantar Fasciitis (Ann Arbor, Mi) - Anybody who has ever experienced plantar fasciitis before knows that it can be a very frustrating process. Heel pain impacts just about every daily activity that involves standing or walking. Maybe your pain is not quite as bad, but it has prevented you from running or working out as you love to do so much. It is estimated that approximately 1 million patient visits per year are due to plantar fasciitis. It is also estimated that it may account for 8% of running injuries. 

(The point of this video was not to confuse you. This article is geared towards a more conventional approach to treating plantar fascia. However, I do hope this video opened your eyes a little that there are many more factors influencing plantar fasciitis that you may have never considered before.)

Plantar fasciitis refers to a strain in the muscle tissue on the bottom of the foot. Often times the area that becomes strained is on the inside portion of the heel. This is the area where most of the pain occurs and can often be very sensitive to pressure, touch, or weight-bearing. What causes this painful experience to occur?

Generally, it comes down to three things:

1) A sudden increase in activity that your body was not prepared to handle.

2) A lack of variability in movement.

3) An accumulation of repetitive physical stress without ample rest.

However, once you have reached the tipping point and pain has occurred, your body will start to heal itself naturally through a very normal process called inflammation.

Yes, you read that right! A very beneficial and normal process called inflammation. The inflammation process is needed for the body’s natural healing process to start.  Insulin growth factor is brought to the injured area for new collagen to lay down and build tensile strength back up.

If you never addressed the three causation factors described above, or never did anything to help influence the inflammation, repair, and remodel phases the body naturally goes through; then chances are the pain will linger on longer than normal.

Maybe you have experienced plantar fasciitis for quite some time now, and had an x-ray performed. Upon results of the x-ray, you may have been told that you have a “heel spur.” If you get one thing out of this article, please do not be intimidated or frightened by a “heel spur.” It’s not like what it sounds. I will use quotations around “spur” because you will not hear me say this word.

Understand that a “spur” most likely develops due to a failed healing response. The inflammatory response probably was triggered from one of the three causation factors listed previously. Again, inflammation is good because it will start the healing process. However, if then never allowed or influenced to both repair and remodel, the cycle may restart all over again as the body tries to autocorrect. Multiple restarts during this process can lead to an excessive buildup of osteophyte formation. This excessive buildup can start to form what would be considered a “spur”, but don’t get too anxious on me! Research has shown that this doesn’t necessarily always correlate with plantar fasciitis.  A study by Cornwall & McPoil, reviewed x-rays of 1,000 patients and found only 13.2% had heel “spurs”. Of these, only 39% reported heel pain. Yes, you read that right. Less than 50% of “spurs” caused pain.

So what can we do about all this?

The recovery process can be slow at times. Resolution for a case of true plantar fasciitis has been reported as long as 6-18 months in some cases.  This can become increasingly frustrating when each waking morning you take the first few painful steps. Chances are you have been told that you need better shoes and have to perform a series of stretches religiously throughout the day.

While both are great suggestions and often provide some, if not complete relief in the long term, the short-term results tend to be less than desirable.

High load strength training to the plantar fascia appears to be beneficial as well.

Self-myofascial release also gets a lot of publicity to treat plantar fasciitis. Maybe you have been told to roll a tennis ball or lacrosse ball on the arch of your foot.

This method can be effective, but not for the reasons you may have been told. Contrary to popular belief, you are not elongating the plantar fascia or breaking up scar tissue. Research has shown that it takes 460kg of force to increase the plantar fascia length by 1%6.

I doubt someone’s thumb or a lacrosse ball is going to create this amount of force. Rather, there is probably a neurological mechanism that occurs which temporarily reduces tone/guarding in the musculature.

While the research definitely supports these methods to reduce pain, it still can be a time consuming process. Furthermore, all these strategies can be implemented without a healthcare provider. This is where On Track PT and Performance is different. We know you can perform these methods in the convenience of your home, so we don’t expect you to come in 3x per week and watch you perform exercises that you are already doing at home. We treat patients 1x per week, every other week, or in some rare cases 2x per week.  For treatment, we focus on highly trained techniques with research that has shown to decrease recovery time.

Less therapy visits and a potentially faster recovery time! Sound interesting?

Instrumented Assisted Soft Tissue Mobilization (IASTM)

Again, the chances we are actually deforming fascia are slim here, as mentioned in the research above. If a clinician thinks they need to perform this technique aggressively and cause an excessive amount of discomfort to get results, they should reconsider why they have chosen this treatment modality. Rather, what is probably happening via mechanical stimulus is increasing blood flow, temporarily reducing tone, and influencing cellular mediators to start remodeling tissue in a more resilient way. With all these benefits, it is understandable why this, in conjunction with stretching/strengthening, has been shown through research to possibly speed recovery times.

Dry Needling to the Plantar Fascia

Admittedly, this treatment is not for everyone. Everyone always asks how painful it is? I will start by saying that anywhere I use dry needling; I have personally had it done on myself. So from personal and anecdotal experience, I can say that in some areas dry needling is actually very comfortable. However, the plantar fascia tends to be one of the areas where there are some sore points that elicit a “deep ache” or a “bee sting.”

Physiologically, it has a much greater physiological and neurological effect than IASTM. This is due to the increased stimulation that occurs when a needle penetrates the skin.  Even more stimulation occurs when therapeutic electrical stimulation is then hooked up. Dry needling in conjunction with electrical stimulation has been shown to have an inhibitory effect on pain through opioid release.  These effects can potentially lead to much better short term results.

Click the picture below to find 9 ways the pro's recover FAST from injuries!

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

References

Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study.J Bone Joint Surg Am. 2003 May. 85-A(5):872-7.

Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71

Cornwall, Mark W., and Thomas G. McPoil. "Plantar fasciitis: etiology and treatment." Journal of Orthopaedic & Sports Physical Therapy 29.12 (1999): 756-760.

Fasciitis, Plantar. "Plantar fasciitis: diagnosis and therapeutic considerations."Alternative Medicine Review 10.2 (2005): 83-93.

DiGiovanni, Benedict F., et al. "Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain." The Journal of Bone & Joint Surgery 85.7 (2003): 1270-1277.

Rathleff, M. S., et al. "High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up."Scandinavian journal of medicine & science in sports (2014).

Chaudhry, Hans, et al. "Three-dimensional mathematical model for deformation of human fasciae in manual therapy." The Journal of the American Osteopathic Association 108.8 (2008): 379-390.

Looney B et al. Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. JMPT. 2011;34(2):138-142.

Cagnie, Barbara, et al. "Physiologic effects of dry needling." Current pain and headache reports 17.8 (2013): 1-8.

Tillu, A., and S. Gupta. "Effect of acupuncture treatment on heel pain due to plantar fasciitis." Acupuncture in Medicine 16.2 (1998): 66-68.