Posterior Tibialis Tendon Dysfunction

The posterior tibialis tendon crosses the inside of the ankle joint, and works to control foot position during stance and walking.  Posterior tibialis dysfunction is the major cause of acquired flat foot deformity.^1,2

Nearly 60% of patients with a rupture of the posterior tibialis tendon had 1 or more of the following symptoms: hypertension, obesity, diabetes mellitus, previous surgery or trauma in the medial aspect of the foot, or exposure to steroids.¹

 

There are two main classifications within this disorder process:

Stage I: The tendon is of normal length, pain and swelling at medial foot
Stage II: Elongation of tendon, patient is unable to stand on toes of affected limb

What is the rehab role?

A study by Kulig et al examined the effectiveness of a 12 week program with custom -made orthotics in addition to stretching with or without an exercise program in adults with Stage I or II PTTD.  The study found that all interventions were effective in reducing pain; however the custom made orthotics along with eccentric exercises group had the most improvement in all subscales of foot functional index scores.³

A study by Alvarez et al found treating patients with Stage II PTTD with short articulating orthotics in combination with a high repetition ankle strengthening program showed significant improvements in VAS, single-support heel rise, ambulation distance, and strength.⁴

While being more expensive, custom articulating orthotics have been shown to provide best foot kinematics in gait, when compared to OTC or solid custom AFOs.⁶

Rehabilitation guidelines:^3,4

• Early stage (up to two weeks): Unload the tendon using orthotics, gastroc/soleus stretching, and build ambulation tolerance.

• Middle stage (2-8 weeks): Recruit tibialis posterior, eccentric strengthening

• Late stage (8-12 weeks): Progress toe walking to 150ft, progress ambulation distance to 2 miles, increase reps in HEP.

References:
Geideman WM, Johnson JE. Posterior Tibial Tendond Dysfunction. J Orthop Sports Phys Ther. 2000;30(2):68-77.
Trnka HJ. Dysfunction of the tendon of tibialis posterior.  J Bone Joint Surg [BR]. 2004;86-B:939-46.
Neville C et al. Choosing among 3 ankle-foot orthoses for a patient with Stage II posterior tibial tendon dysfunction. Journal of Ortho and Sports Phy Ther. 2009;39(11):816-824.

Alvarez RG et al. Stage I and II posterior tendon dysfunction treated by a structured nonoperative management protocol: an orthoses and exercises program. Foot & Ankle Internationional. 2006;27(1):2-8.

Kulig K et al. Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot & Ankle International. 2009;30(9):877-855.

Franettovich M et al. A physiological and psychological basis for anti-pronation taping from a critical review of the literature. Sports Med 2008;38(8):617-631.

ASTYM

The ASTYM system is an evidence-based rehabilitation process designed to effectively treat chronic tendon disorders, scar tissue and fibrosis.


The goal of the ASTYM treatment is to stimulate the body’s healing response, resulting in the resorption and remodeling of scar tissue and the regeneration of degenerative tendons. This effective therapy incorporates a customized program of stretching and exercise, which positively influences the alignment of the new collagen.

For some of you who may have heard of this technique, through personal experience or observation, there are some common misconceptions that we would like to clarify.  Please read-on as we unravel the myths surrounding this effective rehab process:

Myth:  All soft tissue injuries are treated equally regardless of the underlying cause.

Fact:  Chronic, long-standing repetitive injuries must be treated differently than acute injuries.  The absence of cardinal signs of inflammation should necessitate that an alternate approach should be taken.  Interventions used for a tendinosis that attempt to address inflammation where inflammation is absent will be unsuccessful.

Myth:  ASTYM is just “scrapping” people with tools.

Fact:  ASTYM tools are designed and used to promote controlled capillary leakage promoting phagocytosis of inappropriate tissue and stimulation of fibroblasts.  Although to the lay person treatments appear to be scrapping tissue, provider training and testing ensure the  proper tool pressure, direction, and angulation give the sought after effect.

 

Myth:  ASTYM is most effective when done without exercise.

Fact:  Exercise, including strength and flexibility,  in conjunction with ASTYM treatment is necessary to promote proper collagen fiber alignment and alleviate impairments caused by chronic dysfunction.

 

 

References:

Kannus P and Jozsa L. Histopathologic changes preceding spontaneous rupture of a tendon. Journal of Bone and Joint Surgery. 1991; 73-A(10):1507-1525.

Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998; 14(8):840-843.

Gehlsen GM, Ganion L, Helfst RH. Fibroblast Response to Variation in Soft Tissue Mobilization Pressure. Med Sci Sports Ex 1998; 31(4):531-535.

Wilson JK, Sevier TL, Helfst RH, Honing EW, Thomann A. Comparison of rehabilitation methods in the treatment of patellar tendinitis. J Sports Rehab, 2000;9:304-14.

Walking Speed

There is significant evidence to suggest that people with decreased walking tolerance, strength, and balance are actually dying sooner.  There is also significant evidence that sitting time, alone, increases risk of death.  Walking speed is a powerful indicator of functional status for patients with varying diagnoses; however, it is not routinely assessed by the medical community.

The functional requirements for community-living, aging adults are identified as follows:

·         1203 feet (366.7 meters) to complete an errand in the community

·         Gait speed of 1.2 m/s or 2.68 mph to cross a street safely

·         Need to carry an average of 6.7  lb. package

How do we measure walking speed?

We can time how long it takes a person to travel a 20-meter distance, by using only the middle 10-meters of this area, to allow for acceleration and deceleration.

 

What does the research have to say?

A significant increase in mortality existed among subjects with increased time to perform the 400 meter walk test.  (948 men and women; this was further adjusted for depression, education, smoking, BMI, sedentary, chronic disease.)^2,3  For each additional minute of longer performance time, risk of death increased 35%.⁴

Walking speed, walking less than 400 meters, and decreased lower extremity strength are strong predictors for nursing home placement.  Loss of leg strength is the strongest single predictor for subsequent institutionalization, stronger than disease diagnosis. ^5,6

A change in gait speed by .10 m/s (.22 mph) has been shown to be a meaningful change in community dwelling older adults, hospitalized male veterans, and patients with a hip fracture. A 2011 study in the Journal of American Medical Association found that a change of .10 m/s (.33 mph) increased survival over a 10 year period.⁷

How can we help?

The staff at Rock Valley Physical Therapy can help to identify a decline in function, using this measure along with other special testing.  We will then work with you to establish a program that is consistent with your pace of life & desired activity level, restoring your mobility and independence.

References:

Shumway-Cook A, et al.  Environmental demands associated with community mobility in older adults with and without disabilities.  Phys Ther.  2002;82:670-681.

Chang M, et al.  Incidence of loss of ability to walk 400 meters in a functionally limited older population.  J Am Geriatr Soc.  2004;52:2094-8.

Vestergaard S, et al.  Characteristis of 400-meter walk test performance and subsequent mortality in older adults.  Rejunenation  Res.  2009;12:177-84.

Newman AB, et al.  Association of long-distance corridor walking performance with mortality, cardiovascular disease, mobility limitation, and disability.  JAMA.  2006;295:2018-2026.

Guralnik JM, et al.  Validation and use of performance measures of functioning in a non-disabled older population: MacArthur studies of successful aging.  Aging.  1994;6:410-419.

Judge JO, et al.  Step length reductions in advanced age: the role of ankle and hip kinetics.  J Geritol A Biol Sci Med Sci.  1996;51:M303-M312.

Studenski S, Perera S, Patel K, et al.  Gait speed and survival in older adults.  JAMA.  2011;305(1):50-58.

Fritz S, Lusardi M.  White paper: “Walking speed: the sixth vital sign.”  J Geriatr Phys Ther.  2009;32(2):2-5.

 

Welcome Alicia!

We would like to welcome Alicia Kuhns to the Rock Valley family.  She will be assisting Cheryl at the front desk, by serving as our front line on Fridays. 

Alcia is from Decatur, IL and currently resides in West Peoria.  She enjoys spending time with family and friends, as well as coaching middle school volleyball.

Headache

Headaches originating from the cervical spine are believed to account for approximately 15-20% of all chronic and recurrent headaches.¹  The International Headache Society (IHS) defines cervicogenic headache as “pain referred from a source in the neck and perceived in one or more regions of the head and/or face².”

 
 

Individuals with cervicogenic headache have been shown to exhibit restricted neck motion, palpable upper cervical joint dysfunction, and impaired muscle performance of the deep neck flexors.³
 

Limited upper cervical spine rotation with the neck flexed has been shown to differentiate individuals suffering from cervicogenic headache from those suffering from migraine headache.⁴

 

 

How can we help?

Based on the available current best evidence, the combination of exercise and manual physical therapy has been shown to be beneficial in reducing symptoms of headaches.  Jull et al.⁵ showed that a physical therapy program that combined manipulative interventions with endurance training for deep neck flexor endurance resulted in significantly reduced frequency, intensity, and duration of headaches.  These improvements were maintained at twelve month follow-up.  Hall et al. ⁶ showed that regular performance of a patient self-mobilization exercise resulted in significant improvements in headache symptoms.  These benefits were also maintained at twelve months.

 

Effective Interventions: 

·         Deep neck flexor endurance training

·         Self-mobilization

·         Postural education

·         Manual physical therapy



References:

Nilsson N.  The prevalence of cervicogenic headaches in a random population sample of 20-59 year olds.  Spine 1995;20:1884-1888.

The International Classification of Headache Disorders:  2^nd Edition.  Cephalgia 2004.24:9-160.

Jull et al.  Cervical musculoskeletal impairment in frequent intermittent headache, Part 1:  subjects with single headaches.  Cephalgia  2007.27:793-802.

Zito G, Jull G.  Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy 2006;11:118-130.

Jull et al.  A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.  Spine 2002;27(12):1835-1843.

Hall et al.  Efficacy of a C1-C2 self-sustained natural apophyseal glide in the management of cervicogenic headache.  JOSPT  2007;37(3):100-107.

American Gastroenterological Association (2005, January 16). Study Shows Long-term Use Of NSAIDs Causes Severe Intestinal Damage.ScienceDaily. Retrieved January 31, 2011, from http://www.sciencedaily.com­/releases/2005/01/050111123706.htm

Hall  T, Briffa K.  Reliability of manual examination and frequency of symptomatic cervical motionsegment dysfunction in cervicogenic headache.  Man Ther 2010;15:542-546.

Gadotti I, Olivo S, Magee D.  Cervical musculoskeletal impairments in cervicogenic headache: a systematic review and a meta-analysis.  Physical Therapy Reviews  2008;13(3):149-166.

Injury Prevention and Management in the Soccer Athlete

It has been quite some time since we posted on our blog. That means it has been busy at the clinic. We wanted to share with everyone in the Peoria area athletic community that we are hosting a presentation on June 8th entitled, "Injury Prevention and Management in the Soccer Athlete." This will be a joint presentation between us and Joe Terry, PT, CSCS of the Human Performance Lab. Feel free to forward this information to coaches and parents who might be interested. As physical therapists and strength coaches, sports-specific rehabilitation and injury prevention have been a primary focus. We hope to educate the soccer community on injuries most commonly seen in the sport, functional testing, and preventative training.

Date: June 8th, 2011

Time: 7:00 - 8:30 PM

Location: Rock Valley Physical Therapy (9901 N. Knoxville)

Amy Johnson, PT, OCS/ Luke Acklie, PT, OCS, CSCS/ Joe Terry, PT, CSCS

Description: The presentation will consist of two lectures with the first lecture discussing the management of common injuries in the soccer athlete. The second lecture will focus on injury prevention in the soccer athlete from the sports enhancement perspective. There will be time devoted for a question/answer session after each presentation. For more information or questions, please contact the clinic at 309-243-1989.

Low Back Pain

 
 

There is no question that low back pain is a problem for many people.  Annually, low back pain accounts for approximately 40% of all lost workdays and has been estimated to cost $49 billion within the industrial sector.¹

So what do we do about it?
Attempts to identify effective interventions for patients with low back pain (LBP) have been largely unsuccessful.^2,3  One explanation offered for the lack of evidence is the inability to define subgroups of patients most likely to respond to a particular intervention.⁴  Recently, Flynn et al. validated a clinical prediction rule that identifies a subgroup of patients with nonspecific low back who are likely to respond to spinal manipulation.⁵

The predictor variables, based on the history and physical examination, were identified as follows:

• Pain of less than 16 days duration
• No symptoms distal to the knee
• One or both hips with internal rotation < 35°
• One or more hypomobile lumbar segments
• FABQ*-work subscale score of < 19

The presence of four out of five variables in the prediction rule increases the likelihood of success with manipulation from 45% to 95%.

According to a study by Childs et al.⁶, patients who were “positive on the rule” (met 4 or 5 of 5 predictor variables) and did not receive spinal manipulation were 8 times more likely to experience a worsening in disability as compared to those that did. 

*Fear-Avoidance Belief Questionnaire: measure of how beliefs of fear and avoidance are contributing to function.


References:

Leigh J et al.  Occupational injury and illness in the United States.  Arch Int Med 1997;157:1557-1568.

van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128–56.

van Tulder MW, Malmivaara A, Esmail R, et al. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25:2784–96.

Bouter LM, van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23:2014–20.

Flynn T, Fritz J, Whitman J, et al.  A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.  Spine 2002;27:2835-2843.

Childs J, Flynn T, Fritz J.  A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.  Man Ther 2006;11:316-320.

Ernst E, Canter P.  A systematic review of systematic reviews of spinal manipulation.  J R Soc Med 2006;99:192–196.

Flynn T, Fritz J, Whitman J, et al.  A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.  Spine 2002;27:2835-2843.

UK BEAM trial team.  United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.  BMJ 2004.10:1-8.

Golf Without Pain

Well, today I wrapped up our series of golf injury prevention presentations at "Senior Days" with "Golf Without Pain." Overall, I'd like to thank everyone who came out to hear what we had to say, and would encourage everyone to run with our suggestions and prepare themselves to hit the links within the next month or two. Also, I would like to thank all of the equipment reps, Dr. Phillips, Dr. Driessnack, and everyone with the park district for putting together a great series for the senior golfer. Below, I have posted video for some of the components of our recommended warm-up. Please use these and all of the other videos/information that we presented when you need and have a great golf season!!!


Tight Twist

Wide Twist

Chops

Golf When Your Legs Hurt

It has only taken us three weeks of golf presentations to finally get our act together and post these exercises before the lecture. Thank you to all of those individuals attending these lectures, and we hope you are getting something out of them. If you have any questions, then do not hesitate to ask either Luke or me. You can grab us before or after the lectures or call us at the office at 243-1989. (A)

HAMSTRINGS STRETCH ON BACK

HAMSTRINGS STRETCH IN STANDING

QUADRICEPS STRETCH IN STANDING

CHAIR SQUAT

HIP FLEXOR STRETCH ON BACK

HIP ROTATION STRETCH

STANDING BALANCE 3 POSITION

STEP AND HOLD

Golf When Your Arms Hurt

Have you heard of Murphy's law? Well, the version that I know states: "What can go wrong will go wrong." In regards to the video for the "Golf When Your Arms Hurt" presentation that was the case.....and to make it worse, after the presentation and before I got back to the clinic I already realize my problem! Below are the videos that were supposed to be in the presentation. Enjoy!!! (L)

GENIE STRETCH
G


TUBING EXTERNAL/INTERNAL ROTATION

FOREARM/OUTER ARM STRETCH

FOREARM/INNER ARM STRETCH

WRIST EXTENSION/FLEXION STRENGTHENING

FOREARM PRONATION/SUPINATION STRENGTHENING

ASTYM DEMONSTRATION

Golf When Your Spine Hurts

Senior Days are back and in full swing (no pun intended!) The first lecture in the series "Golf When Your Spine Hurts" was held on January 31, 2011 at the Golf Learning Center. Luke and I wanted to pass along our thanks to those of you that attended. We also wanted to ensure that the participants had access to the videos depicting the exercises discussed in the lecture. As a result, you will find the video links below. If you were to have any further questions, then give us a call. If not, we look forward to seeing you next week when we cover shoulder, elbow, wrist, and hand injuries. - (A)

TRUNK ROTATION STRETCH SITTING IN CHAIR:

TRUNK EXTENSION STRETCH SITTING IN CHAIR:

TRUNK EXTENSION STRETCH ON YOUR BACK:

ABDOMINAL STRENGTHENING VIA TUBING:

CLUB BEHIND THE BACK DRILL:

GOLFER'S LIFT:

Senior Days are Back

As mentioned in earlier posts, our practice is focused on providing orthopaedic and sports physical therapy. From being on the clinical side of health care and working with numerous injured individuals over the years, it has been a shared goal of Luke and myself to focus more on the injury prevention side of the equation. As many of you already know, Luke and I had worked for one of the bigger physician-owned orthopaedic practices in town. Due to the large patient caseload of that practice, there was minimal time devoted to community awareness of injury prevention. With our career move to a smaller practice in the same community, this has allowed us the time and resources to focus on injury prevention spanning the decades from the junior high athlete to the senior recreational golfer. As a result, we are pleased to bring back "Senior Days."

"Senior Days" is a free special winter program for ages 50+ that will be hosted at the Golf Learning Center. This program is offered in partnership with the Peoria Park District. The format will be in lecture format and will consist of contributions from: PGA pros, Rock Valley physical therapist, equipment club reps, and Great Plains Orthopaedics surgeons. The dates and topics are as follows:

• January 31: "Golf When Your Spine Hurts" by Amy Johnson, PT, OCS/ Callaway Club Rep/ PGA Pro Clinic


• February 7: "Golf When Your Arms Hurt" by Luke Acklie, PT, OCS, CSCS/ "Upper Extremity Injuries & the Golfer" by Mark Phillips, MD/ Cleveland Club Rep/ PGA Pro Clinic


• February 14: "Golf When Your Legs Hurt" by Amy Johnson, PT, OCS/ "Arthritic Knee Pain in the Golfer" by Richard Driessnack, MD/ Mizuno Club Rep / PGA Pro Clinic


• February 21: "Golf Without Pain" by Luke Acklie, PT, OCS, CSCS/ Ping Club Rep/ PGA Pro Clinic

No RSVP is necessary. There will be $5.00 lunch special each day, bucket discounts, and the chance to preview 2011 golf clubs. We hope to see you there! (A)