Preventing plantar fasciitis

A friend of mine asked me about some strategies for preventing plantar fasciitis.

The specifics will depend on the patient, but I think the optimal approach is to think of plantar fasciitis as a kinetic chain issue.

Remembering my 3 rules of the kinetic chain:

1. Forces have to come from somewhere

2. Range of motion has to come from somewhere

3. If you cannot address your forces and range of motion anatomically, then you will do so pathologically

When you use this perspective, you realize that usually plantar fasciitis is not a problem with the plantar fascia itself, but in asking the plantar fascia to more than it was designed to do.

The big issue, in this case, is range of motion.  Most people with plantar fasciitis have tight heel cords (their Achilles tendon), and therefore put too much stress on the plantar fascia.

The solution, then, is to stretch the heel cords.

My personal favorite stretch is the "Downward Facing Dog" position from yoga.

http://www.yogajournal.com/poses/491

This is a great exercise in that it is a closed-kinetic chain exercise that uses your own body-weight to help load the Achilles tendon.   

I do make this caution, however- if you have back problems or are especially inflexible, this can place unhealthy loads across other joints, and you therefore should have someone (whether a PM&R physician or another clinician) evaluate your form, and perhaps make some modifications.

Health and Wellness Tip of the Day- Know the Goal for your Exercise

Failure to plan is planning to fail.

One simple tip that can improve the quality of your exercise program, whether it is a formal physical therapy program, or just a general workout, is to ask one simple question before you exercise- what is my goal with this exercise today?

This can make a huge difference in that quality of your experience, and doesn't require any more time.

Examples:
1. Taking a walk.  Many of us take a walk at lunch.  Before you do, ask yourself- "what is my goal?"  It may be to get in some movement in the middle of the day, it may be to clear your thoughts, it may be to get some much-needed sun exposure.  By asking the question, it let's you judge whether you met your goal.

I find this helps me quite a bit.  I am often super-busy in clinic, but will try to find time for a 20 minute walk outside.  At the end of the walk, I can look back and say "I was able to make some for myself, got in some exercise, listened to a podcast, and saw some sunshine.  That was awesome."

2. Physical Therapy.  When you are in a Physical Therapy program, ask the therapist what the goal is for each exercise you are performing.  This will help you set a goal for those exercises, and determine whether you are meeting those goals.

One of the most common reasons patients are referred to me is because they "failed" physical therapy.  Often times, they are performing the proper exercise, but they don't know why they are doing an exercise, and therefore don't pay attention to whether they are doing it properly.

One common example is exercises for a tendinopathy, like Achilles tendinitis or Tennis Elbow.  There are many exercises one might do, but the most important exercises are typically repetitive eccentric loading.  I'll ask the patient to show me what they are doing, and they may be doing 6 different exercises, and not realizing that not all of the exercises are of equal importance.

For this very reason, when I give my patients an exercise prescription, I try to emphasize 1, or at most 2, exercises at a time.  I think it's far more important to do one targeted exercise well and with purpose then to go through the motions with 10 exercises.
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Bottom line- you are all busy people, so if you are going to take the time to exercise every day (which you should), make those exercises count!

PM&R- Your Health and Wellness Physician!

I am a Sports & Spine PM&R physician.  One challenge for me is that most patients (or other physicians) have absolutely no idea what that means.

The way I like to think about what I do is that I figure out what a patient wants to do, look at the barriers that prevent them from doing it, and develop strategies so that they can overcome those barriers and continue without limits.

What makes this challenging is that it is a totally different way of approaching medicine.  Instead of asking what's wrong with you and getting rid of it, I like to look at what is already awesome about you, and facilitate it.

One way I like to think about this is to imagine the best possible version of yourself.  What do you like about that version of yourself?   You're happier, more energetic, better looking, active, interact well with your friends and loved ones, can do whatever you need to do?

Now- what prevents you from being that best possible version of yourself all the time?

For most people, the main barrier is that it never even occurred to them to ask that question.

So, let me ask you- what prevents you from being the best possible version of yourself all the time?  Wouldn't be great to have a clinician who can work with you on developing those strategies.

That is what being a PM&R physician is all about.

Creating an Exercise Infrastructure

One of my parent organizations is the American College of Sports Medicine, and one of their primary initiatives is  the "Exercise is Medicine" campaign.

http://exerciseismedicine.org/

The idea behind promoting exercise as a form of medicine is that if Exercise was a pill, it would be most widely used medication in the world.  It is one approach that hits nearly every health goal for a patient, whether it be stress relief, weight reduction, lowering blood pressure, improving lipid profile, improving mood, reducing the rate of heart attacks, healing tendon injuries- you name it, exercise can help it.

In my opinion, the biggest barrier to more widely using exercise as a treatment is that we don't have an infrastructure to support it.  What I mean by this is that if I want to start a patient on a pain medication, the pathway is relatively easy- my electronic medical record has built in order sets that make them easy to prescribe, insurance readily pays for it, the prescriptions are automatically sent to the pharmacy, patients are used to having pain medications prescribed, etc.  Another issue is cost- even though pain medications are by far the largest real expense for treatment of low back pain (more than imaging, surgery, injections, or physical therapy), the copays tend to be low, so from the patient's perspective, medications are relatively cheap.

That is an easy infrastructure- the health care system makes it easy for me prescribe medications.

Prescribing exercise has less system wide support.  For example, even though physical therapy is cheaper than medication in terms of real world cost, the patient often has to pay more out of pocket, so they may perceive therapy as more expensive.

One of my missions as a Sports & Spine PM&R physician is to improve the exercise infrastructure.  The electronic medical record (EMR) has been a good tool for me in achieving this aim.  It's still not as easy as prescribing a drug, but the EMR does allow me to write macros for my most commonly prescribed exercises.  While I still customize these for every patient, this at least allows me to have a starting point as I review how to perform the exercise for every patient.

It takes more time and effort on my part, but from the patient's perspective, it's just the right thing to do.

It's what you do AFTER exercising that can hurt your back

Exercise tip of the day- many people realize that when they feel back pain after playing sports, it's what they do immediately afterward that injures their back.

One of my favorite examples is from cycling.  Cycling, particularly long distances, places the spine in a flexed forward posture for a prolonged period, which places a lot of stress on the disk.

Oft times after a long ride, cyclists like to plop down- whether it is drink a beer sitting on the grass, sitting in their car to drive home, or sitting on a couch to grab something to eat and watch TV.

This plopping is where many athletes hurt their spine- their support muscles are already fatigued, so sitting in a slumped position exacerbates the loading on their disks.

My recommendation- immediately after cycling, do some exercises to reverse the flexed forward posture from cycling.  My favorite exercise is the prone press-up (essentially the same maneuver as the upward facing dog position in yoga, with a few refinements), but standing back extensions are a reasonable choice as well (standing and arching backward).  Standing back extensions are also a great choice after you've been sitting for a long time on an airplane or car ride as well.

New layout

For my 4 readers out there ....

I am new to blogging, so I am just learning how to layout the blog and make it more functional.  I think the larger fonts and serif font hopefully makes it more readable.

Barefoot running, Chi Running, and the 3 Laws of the Kinetic Chain

A good friend recently asked me what I thought about Chi Running.

I like it.

Chi Running is one of many approaches that teach runners to run softer and absorb more forces in their proximal muscles.  The idea is that by having a strong core, particularly in the buttocks, less forces will be absorbed in structures that are not designed to handle high loads, including the knees and back.

This is similar in many ways to barefoot running.  Not everyone can handle barefoot running, but for those that do like running barefoot, the reason it works is that it teaches you to run more softly.  When you run with a heavily cushioned shoe, you can hit the ground with a very forceful heel strike.  This is not possible when you run barefoot- it simply would hurt too much to slam your heel into the ground.

This is, in my opinion, the reason why all the new barefoot simulator shoes on the market (including MBTs and Skecher Shape-Ups) can be helpful- because they have a rocker bottom sole, if you try to have a forceful heel strike, you roll forward, which dissipates the force.

Back when I was a Sports & Spine fellow in Chicago, my colleague (the late, great Jim McLean) and I noticed that we could explain essentially every musculoskeletal condition through 3 very simple rules, which I now refer to as "3 Laws of the Kinetic Chain":
1. Forces have to go somewhere
2. Range of motion has to come from somewhere
3. If the body cannot absorb forces or obtain range in a way that is anatomically appropriate, it will do so in way that is pathological

A great example is running with bad form.  Every time your foot hits the ground when you are running, the ground pushes back against your body in what is called a ground reaction force.  This ground reaction force can be several times your body weight, and it doesn't just disappear into the ether- those forces have to go somewhere.

So where do you want those forces to go?  Ideally, you want those forces to go into the biggest, baddest muscle you got- that is the gluteus maximus (your butt).  Other good choices are the quadriceps (the front of the thigh) and gastrocnemius (the diamond shaped calf muscle).  The more you can train your body to absorb forces into these structures while you run, the less force will be transmitted into your spine, hips, or knees.

Barefoot running is a method where your body will naturally train itself to use these muscles, because if you try to run by slamming your heels into the ground, it hurts too much.  This works ok if you can adjust your stride appropriately, but many people find this too painful to tolerate.

Some commercial products, most notably the Vibram 5-Finger shoes, have been developed that help protect the feet while you are barefoot running.

Chi Running is an approach that helps teach you to engage your core while running, which is the same general concept.  As a general approach, I think it is fine.  If I was seeing a patient in my Sports & Spine clinic, I would try and see if I can be more specific as to exactly which muscles the patient should engage, but as a first iteration, Chi Running is a very reasonable approach.

The key to low back pain- stratification and the Katie Couric effect

What is the best way to treat low back pain?

I get asked this question all the time, whether I am seeing patients in my Sports & Spine clinic, lecturing at national meetings, or meeting with other experts.

There is one key to management of low back pain- stratification.

What I mean by this is that low back pain is not one diagnosis, and therefore trying to treat all low back pain with one approach is not effective. In a typical day, I may see patients who have many different causes of low back pain, all of which are best managed with different treatment approaches. The approach to managing an annular tear in a 23 year old Ironman triathlete is dramatically different than that of a 74 year old with zygapophysial joint arthropathy, which is dramatically different than the approach in a 34 year old woman with post-partum pelvic floor dysfunction.

Some of these patients I manage with an exercise program, others I may manage with an image-guided injection, and others I may manage by working in a team with the physical therapist or chiropractor. The key is that I recognize that every patient is different, and no one approach will work for everyone.

Unfortunately, many treatment recommendations are based on the assumption that low back pain should be treated as one entity, and therefore one basic approach should be used.

So, if you have low back pain, the biggest determinant in getting better is appropriate stratification into the appropriate treatment groups. Some of this is related to determining the appropriate diagnosis, but often times we can stratify patients into appropriate treatment groups even if we don't know the actual diagnosis.

For example, many patients are surprised to find out that if you want to get better, it is more valuable to know a patient's directional preference (i.e., which movements are most painful, such as putting on shoes and socks in the morning) than it is to look at an MRI. If I know that a patient hurts more with certain movements, I can design a physical therapy program that takes this into account. This is of great benefit to this physical therapist, and as Audrey Long demonstrated in her award winning research in 2004, if we design physical therapy programs with a directional preference in mind, the probability of improvement increases dramatically.

http://journals.lww.com/spinejournal/Abstract/2004/12010/Does_it_Matter_Which_Exercise___A_Randomized.2.aspx

But I have many patients say to me "I hear you, but I've always been told that if you really want to know what is causing my low back pain, I need an MRI." MRIs are wonderful tools, but the reason they are not as helpful as you might imagine is because of what I call the "Katie Couric Effect."

We all know Katie Couric. Back in 2000, in the days before we had HD televisions, we didn't notice that she was actually a woman in her 40s. When she started working for CBS on the nightly news, two things happened- Katie Couric turned 50, and many of us started watching her in HD television.

Katie Couric is a very attractive woman, but when you look at her in HD television, many things are suddenly apparent that were not apparent on a regular television. She is the same woman that she was on a regular television, but because of the higher resolution of the TV, we are now more aware of some of the natural changes associated with aging that we would have been blissfully ignorant of otherwise.

Same thing with back MRIs. Just as the natural processes of aging can bring along gray hair and wrinkles, the normal healthy spine has some age-associated changes, including degeneration of the disks and joints. Much of this is incidental, and therefore when we look at a spine MRI, most of what we are looking at is incidental findings. And often times, the main cause of low back pain may not be seen on MRI.

Which brings me back to what is the best way to treat low back pain. The key is to find someone you trust who is able to figure out what is the best treatment approach for you. That person may be a Sports & Spine PM&R physician like myself, it may be a surgeon, it may be a chiropractor, it may be a physical therapist, it may be an accupuncturist, etc.

Ultimately, you need someone who can see you as an individual, and has the skill set necessary to tailor a program that is appropriate for you.

Great examples of maximizing function

This is from the professional website of my colleague, Brad Marcus.

I think it shows a great example of the kinds of things that patients are capable of if we don't set limits for them.

http://www.mrklab.com/capabilities.html

Practicing being joyful

It's been over a year since I last posted .... I will try to make shorter, but more frequent posts

About a month ago I went to a fantastic course on myofascial medicine that was put on by UPMC, and it's had some major impacts on the way I think about musculoskeletal conditions.

The single most impactful thought that someone shared with me at the course is that we need to practice being joyful. I thought that this was a remarkably brilliant insight.

The nervous system is designed to adapt to anything you do frequently as a "new normal." This can have negative consequences if you look at people are who routinely miserable. As a thought experiment. think about the last time you were at the DMV. It's a miserable environment, everyone hunches their shoulders, and there is a palpable tension in the room. Now imagine being like that all time- that would be a horrible "new normal."

Instead, imagine trying to practice a "new normal" by practicing being joyful. Here's a simple exercise- extend your hands overhead like you just crossed the finish line of a marathon. Didn't that make you feel better? I don't think it's possible to put your arms overhead in a victory position and be in a bad mood.

I don't think this is just psycho-babble- I think it reflects a real neurologic phenomenon. Paul Ekman did some ground breaking research that demonstrated that if you have a person put their face in a smiling position, their mood will improve. I think that this is true of the body as a whole as well- if you place your body into the position of happiness, you will feel happier.

I've noticed this when I work on some strengthening exercises in my patients. I often work on them to strengthen their posterior chain (muscles behind their back like the thoracic paraspinals) and stretch their anterior chain (muscles in the front of their body, like the pectoralis minor), and an interesting ancillary phenomenon is that most of them notice that they are noticably happier. It happens almost instantaneously. I don't think this is an accident- by training their muscles so that they can literally walk taller, they also figuratively walk taller- they become happier.

And so do I.