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Methodology & Techniques Region Specific Uncategorized

Access Your Ankles – Reduce Pain and Enhance Performance

Do you wish you could squat like that?

Proper ankle mobility is important for most of our functional and higher level movements. Specifically, decreased dorsiflexion, or bending of the ankle (the foot getting closer to your shin), will likely add undue stress on joints up the chain including knees, hips, and the spine. If you cannot access your ankles well, you will have to borrow (compensate) extra movement from those other structures. From lesser to greater extents, dorsiflexion is utilized during walking, running, stair negotiation, and squatting. Here is a classic example of a test that illustrates the impact of decreased dorsiflexion on deep squatting. This is a test that you can do yourself. This “deep squat” is limited in depth:

 

 

The addition of a 2×4 under the heels decreases the need for dorsiflexion, allowing for greater depth. Although there may be more to this including hip and spinal mobility and control limitations, the ankles in these pictures are the limiting factor in a functional squat:

Another test you can try yourself requires only a wall and floor. Keeping your foot completely flat, bring it away from the wall as far as you can while still being able to touch the wall slightly with your knee. Measure the distance between your toes and the wall. Roughly speaking, this measure should be approximately 3 to 6 inches depending on your specific needs. Take note of what you feel when you do this test, either a stretch feeling behind the ankle and into the calf, or tightness and possibly pinching in the front of the ankle. The first picture illustrates limited dorsiflexion.

This is better:

How much should you have? That depends on what you need it for. If you squat (whether it’s for strength training or tying your shoes) or walk or run up hills or stairs, you will likely need more. Many of my high level and younger clients are lacking this range of motion, which is likely a reflection of how we move or don’t move in our society. It is also what prompted me to write this blog post.

If you noticed tightness or a stretch feeling behind your ankle and/or in your calf, then the muscles and tissues of your calf and Achilles are likely the limiting factor. You may try adding a typical runner’s wall calf stretch (not shown) to your routine. However, soft tissue mobility may be restricted. We find it helpful to gently loosen these tissues and calm the muscles down with some self mobility using either a rumble roller:

– Or a lacrosse or tennis ball:

There is no need to force anything. Keeping your calf relaxed, slowly roll your muscles over the points of the rumble roller or over the ball until you find a stiff or semi-tender spot. Let that spot “melt” over the point for 30 seconds or so. You can then get those tissues to move by slowly dorsiflexing your ankle back and forth.

If you had felt a pinch, stiffness or block in the front of the ankle during the test, then it’s possible the ankle joint (talocrural joint) is the restriction. One optional self-mobility technique I prescribe for this uses a pull-up assistance band. This is a great tool for mobilizing ankles and hips and can be purchased fairly cheap in stores or online. Just make sure you anchor it to something very stable (such as a squat rack):

In this position, keeping your foot and heel flat on the ground and keeping the band where the ankle meets the foot, gently lunge your knee forward thereby dorsiflexing. Perform 10-20 times.

This serves only as a basic guide to self-assessing your ankles and does not discuss other reasons you may have difficulty with your ankle mobility or functional movements such as a squat. The numerous bones and tissues of the ankle and foot, the knees, hips, pelvis, spine and trunk may all be factors. Only a thorough assessment can help identify these factors. Once found, manual and exercise therapy directed at these problem sites can help make your movements looser and more efficient.

 

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Methodology & Techniques Uncategorized

What is Visceral Manipulation?

Viscera – relates to the internal organs of the body, such as the liver, kidneys and intestines. Visceral manipulation (VM) is a gentle form of manual therapy that aids your body’s ability to release restrictions and unhealthy compensations that cause pain and dysfunction. VM does not focus solely on the site of pain or dysfunction, but evaluates the entire body to find the source of the problem. Skilled assessment with hands on manual therapy, the therapist can feel for the altered or decreased motion within the viscera as well as restrictive patterns throughout the body.

This treatment helps to re-establish the body’s own ability to adapt and restore itself to efficiency and health.

Physical Therapist performs manual therapy on the abdomen of a client

Emotions are stored in the organs as well. With the current stress all around the world due to COVID-19, emotional reactions can translate into simple spasms in the gallbladder or heartburn, vomiting, feeling faint, ulcers and even more serious diseases. When the brain receives negative emotions it sends tension to the related organ, the organ then sends tension back to the brain resulting in a vicious cycle. Conversely, a physically damaged or imbalanced organ can stimulate emotional upset. With the help of visceral manipulation we can break this cycle, enhance health of the organ, and restore emotional balance.

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Methodology & Techniques Uncategorized

Mobilizing Nerves: How Does That Work?

We strengthen, stretch and massage our muscles.  Dry skin is moisturized.  We load our bones and feed our organs.  Nerves are extremely important structures in our body.  What do we do for them?  Not much… at least not intentionally.  Nerves require clear paths to and from our brain and spinal cord to their many destinations including those previously mentioned muscles, skin, bones and organs.  Without nerves those structures can’t function.

If nerve paths are restricted then a little extra pinch or stretch may occur on the nerve itself.  Blood flow to the nerve may also be effected.  Nerves are blood thirsty as they have huge requirements for oxygen and nutrients.  Lack of steady flow will likely impact the nerve.  The result of all of this includes pain, burning, numbness, tingling, weakness and feelings of tightness.  Carpal Tunnel Syndrome is a typical example.

So how do you know if a nerve(s) is not as mobile as it should be and is contributing to your issue?  That requires a proper physical examination with a healthcare provider versed in Neurodynamics (otherwise know as neural tension).  Once mobility restrictions are found they can be addressed.  Basically, it comes down to clearing the tissue restriction followed by a movement to reinforce proper mobility of the nerve in its path.

Don’t worry.  Nerve mobility restrictions are common and not a permanent condition.  However, involvement is often missed and/or not understood.

 

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Methodology & Techniques Principles Uncategorized

Mobilization Over Stretching

Stretching is the most common and touted way to increase flexibility and it may be the least effective.  Immediate gains made during stretching are a result of stimulating nerves that are also on stretch.  Your nervous system will reach a point of over-stimulation and begin to relax.  Once relaxed, your muscles are calmed down and therefore more flexible.  This process does not change the properties of the muscle.  For muscles to become longer, it is argued, takes days, weeks, and maybe even months of devoted stretching.

Soft tissue mobilization (STM) leads to immediate gains in flexibility.  The focus of STM is to promote stagnant and temporarily stuck layers of tissue (skin, fascia, muscle, bone) to glide more easily over one another.  These structures move together yet are independent.  The more freedom between them the more flexible you are.  Will these immediate gains stick around for the long-term?  Sure!  As long as you keep them moving and occasionally get into those once-challenging positions.

A good manual therapist can determine if soft tissues are limiting your flexibility and treat accordingly.

 

PRO-TIP:

Still feel the need to stretch?  Do a warm up to get your blood flowing and stretch in a relaxed manner.  Studies show that gentle stretching with mild discomfort is as effective (if not more) than aggressive stretching.

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Methodology & Techniques Uncategorized

Instant Gratification – Pick Your Test!

In an industry where it is normal to only expect results after a month or two of seemingly mindless stretching and exercising, at Move Physio, we’re quite different.

We love instant gratification.

When someone comes to see me for the first time, at the consultation, it usually becomes pretty clear to them how very different our approach is. The most shocking aspect of our approach isn’t that I spent 90% of the session with my hands on them. It isn’t that they won’t see anyone other than me for their care. New clients are most shocked when I tell them my expectations for results. I expect results with every session…not after a month, not after a week…EVERY SESSION. If I do my job well and get to the root of the biggest problem with your system today, I expect that to have a profoundly positive effect over the functioning of your body – today.

To prepare for these changes, I give new clients a small piece of homework: pick a test, or several tests. I want every client to have a movement, position or activity that they find difficult, limited or that reproduces their symptoms or complaints. I don’t want something that really aggravates their system, just something that can be measured somehow: pain level, quantity of movement, weight lifted, etc.

For example, I can ask you to Squat as deep as you can without symptoms…or try to touch your toes. Here we can measure depth and level of symptoms. Then, we do a bunch of treatments on the table…and re-test. If my treatment was successful, not only will you feel the difference during the test, but you’ll be deeper into the movement… and with less symptoms. This process continues with every visit, until you have crushed your biggest Goals.

 

PRO TIP:

Test – Treat – Retest. This concept should be the standard of care for any type of treatment. If you aren’t getting measurable results that you can see and feel, you aren’t getting a great return on your investment!

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Methodology & Techniques Principles Uncategorized

All wound up?

What are you stretching?

I have written previously about short versus tight muscles, using an example of short or tight hamstrings limiting the ability to bend and touch your toes.  Think about the stretch feeling you get in the back of your thighs when attempting to bend and reach for your toes.  That stretch feeling is coming from the elongation of your hamstrings as muscle fibers are being pulled to their limits, right?  Maybe.  We don’t exactly know what structure is generating that feeling.  It may be muscle fibers, the tendons that attach the muscles to bones, or nerves under tension.     

Unlike skin, fascia, muscle, tendons and ligaments, nerves do not have elastic properties.  In other words, nerves don’t stretch well.  Nerves like to glide.  They run inside sleeve-like structures that allow them to slither and slide to accommodate movement.  The sciatic nerve and its branches, receiving connections from the brain and spinal cord, reach from your low back all the way to your feet.  This nerve moves and winds intricately through and around bones, muscles, tendons, and ligaments to allow for someone to bend.  So, what happens when a movement such as bending tugs on a nerve?  It is difficult to be precise, and symptoms are often vague, but any of the following are theoretically possible: feeling a stretch, numbness, tingling, pins and needles, burning, stiffness, or even pain.  This has been labeled ‘adverse neural tension,’ although ‘adverse neurodynamics’ has been used most recently and is more indicative of the mechanism behind the symptoms written above.1

Any of the symptoms noted above (stretch, numbness, tingling, burning, stiffness, or even pain) can be NORMAL. These symptoms do NOT mean that something is wrong.  I am confident I can put almost anyone in a position that tenses a nerve.  Tension on a nerve can be a normal limitation.  We can all feel these symptoms with specific movements and positions.  However, it is only when normal, functional, every-day movements are limited AND reproduce neural tension symptoms that suggest adverse neurodynamics may be at play.  How do we know?  It is not always clear, but physical therapists have specific tests that can help determine if adverse neurodynamics are contributing to your pain or dysfunction.  Tests involving the lower and upper extremities, including the sciatic, median, radial and ulnar nerves, are the most standard. 

In my experience, when adverse neurodynamics are involved they are only part of the picture of what brings someone to physical therapy.  There are typically other things that we need also need to work on.  As far as why a person experiences adverse neurodynamics is usually unclear.  I see it sometimes following surgeries, injuries, immobilization, and for reasons totally unknown.  It is important to differentiate certain musculoskeletal diagnoses, as adverse neurodynamic involvement may mimic common diagnoses like carpal tunnel syndrome and tennis elbow.2  A physical therapist examination can help determine this involvement and provide interventions to improve nerve excursion, symptoms and restore function.

Dr. John De Noyelles, PT, DPT, OCS, CSCS

References:

1 Ellis RF, Hing WA. Neural Mobilization: A systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008: 16(1):8-22.

2 Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008; 13:213-221.

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Methodology & Techniques Principles Uncategorized

The ‘Magic Wand’ of Therapy

Those in pain want an easy fix. Who can blame them? But relying only on pills or magical passive techniques typically won’t do if longstanding pain relief is the goal. To a fault, many healthcare practitioners tend to over-rely on passive techniques. Physical therapists are no exception. A passive treatment is one that is done to you with little to no participation on your part. Massage, manipulation, and therapeutic ultrasound are a few examples. Active treatments are those that you participate in such as exercise and certain types of manual therapy. Many passive treatments are effective in relieving pain. However, this relief is typically short-term when not followed by an active approach.

We happen to use a good amount of manual therapy at Move Physio primarily because we see positive outcomes from its use. However, we ALWAYS follow-up with active treatments to complement the manual therapy. For instance, manual therapy may help to reduce pain, increase range of motion, or improve functional movements. The next step is key. Once the threat of pain is decreased, reinforcement with movement and exercise will help maintain the improvement. Simply, the brain says to itself, “Hey… this isn’t so bad. I can do this and not have to report pain.” If mobility is gained through manual therapy, it is crucial to safely move in that new range so that the body adapts and learns how to control within its new expanded boundaries.

Physical therapy should not ONLY consist of ultrasound, heat, and stim. Unfortunately, this still occurs within the industry. Therapeutic ultrasound (the “magic wand”) is fortunately on the decline but some practitioners still use it. Most do it for 8 minutes for billing purposes. Nonetheless, research for therapeutic ultrasound demonstrates little to no effectiveness even with longer durations of 20-25 minutes of application.

It’s important that you evaluate the true effectiveness if you’re a patient of a clinic that performs purely passive treatments. You have every right to be an active participant in your healthcare. Need more information? Contact us and we will be happy to help.

John De Noyelles, PT, DPT, OCS, CSCS