Ankle Supination

A patient came in today with lower back pain. When she got onto the table, I saw this familiar pattern: Take a look at her ankles. Before I started work, both of them looked like the “before” (left) side. This tendency for the foot to turn in is called “ankle supination.” It can be caused by many things, but in her case she had some fascial adhesions on the medial (inside) ankle.

She’s lying face down on a table with a pillow under her ankles. Notice the curvature in the left (before) ankle.

The way our feet strike the ground affects the entire chain … the ankle, the knee, the hips, the back. In extreme cases, a dysfunctional gait can even affect your neck! I knew I needed to address her ankle supination for long-term back improvement. Having canted ankles can also contribute to more foot movement inside the shoe and create blisters / calluses.

After acupuncture to treat her back pain, we did some medical massage. I reset the the function of her back muscles and finished with some myofascial release on the medial ankles. After I worked on the left, the difference was so striking I wanted to share it. Of course after I snapped the evidence pic, I went on to correct the right ankle, too.

When she stood up, she felt good, but a little unsteady. This is normal – she was used to the adhesions doing the work of stabilizing for her. I instructed her to go for a little walk. Now that the musculoskeletal system is corrected, light movement will provide feedback between the brain and muscles. They will reintegrate, and start doing the supporting they’ve been neglecting. Typically, at the end of this walk my patients tell me they feel terrific!

Sit or lie down and take a look at how your feet are aligned at rest. Do they curve in (ankle supination)? Out (ankle pronation)? Or maybe just one is crooked? If the answer to any of those is yes, come see me, and let me help you straighten out your gait! :)

Fascia – the best kept secret in healthcare

I’ve talked about fascia before in this blog, but I wanted to share this video:  It explains the work I do beautifully. It’s so frustrating to me that fascia is unknown by average people, and ignored by so many types of healthcare practitioners. It’s ESSENTIAL in understanding biomechanical dysfunction and healing.

https://www.youtube.com/watch?v=swlXzrguPxY&feature=share

Once I bought a rotisserie chicken from a regular grocery store. As I was taking it apart, I was stunned at how bound up the bird was, compared to the free-range chickens I was used to. A lifetime of forced inactivity had created fascial adhesions all over – you know, that white sheeting? The muscles were all shrink-wrapped in place. “This poor chicken needed a massage!” I told Robert. I felt so bad for it. Just another lesson on how important light, frequent movement is for our bodies.

Connective tissue / fascia (white) and muscle fibers (tan)

Tight fascia will pull on our muscles and bones, preventing free movement and potentially causing misalignments. In severe cases, it can constrict nerve and blood vessel function, creating swelling, pain, or numbness & tingling.

Resolving fascial adhesions is as simple as knowing the right medical massage technique, myofascial release. I can do it for you, and I can show you how to treat yourself and your loved ones.

For hard-to-reach areas, you can use a foam roller to soften the adhesions. I advise people to use it against a wall, rather than lying down on it, because you can control the pressure better. Remember you do NOT want to cause intense pain – that will spark an alarm response. The body will think you have a new injury and will send sticky connective tissue to glue up whatever is torn or bleeding – which means the adhesions you just broke up will reform themselves.  It’s best to use the roller gently, then move. Go for a walk or do your usual workout. Movement will help release those weakened adhesions.

Want to learn more? There’s a treasure trove of articles here.

Let me know if you have any questions!

Before and After: A/C Separation

Anterior view of shoulder joint with muscles. SOURCE: Based on AMuscsk_20131017_v0_001.

This 40 year old gentleman separated his acromioclavicular joint 2 years ago, in the April of 2016. Since then, he’s had shoulder pain and a lot of crunching noise with movement.

I treated him with acupuncture and medical massage. The goal was to break up fascial adhesions (scar tissue) and his muscles working properly again.

These pictures were taken on 4/3/18 and 4/25/18. He received 4 sessions of care.

First, look at the outside curves of the shoulders. He is much more symmetrical in the after pic. His deltoid (“shoulder cap” muscle”) has filled out now that he’s using it. Secondly, the shoulder girdle is no longer being held

forward. See the difference in the shadow at Arrow 2? And the A/C joint isn’t sticking out as sharply.

Here in the side view, you can see how the shoulder has rotated back to its normal position. In the Before pic you can’t see his chest at all at the top. His scapula (shoulder blade) is also sticking out in the Before shot.

Most importantly, the patient reports less pain, less crunching, better range of motion, and generally better performance. :)

Plantar Fasciitis

Plantar fasciitis is a painful condition that makes your feet hurt, especially with the first few steps after being off of them for a while. What’s happening here? First, we have to understand fascia. It’s a system of connective tissue that holds us together. 

Each muscle fiber has connective tissue, called fascia, surrounding it like a layer of Saran wrap.

Connective tissue (white) and muscle fibers. When fascial adhesions form, it can cause unexplained pain.

Connective tissue (white) and muscle fibers. In plantar fasciitis, those fibers get tight and brittle.

It may help to picture a muscle fiber as a new drinking straw in a paper wrapper. The straw is actually the muscle cell, while the white paper is fascia. At each end, that flap of fascia becomes our tendons. It attaches to bone – or, more precisely, to the fascia surrounding bone. These sheaths of fascia are supposed to slide past each other as muscles move. With long periods of no movement, if the muscles are tight, or if there’s an injury, they can stick together and form a fascial adhesion.

When the plantar fascia (the fascia on the bottom of the foot) doesn’t move, it gets stiff and brittle, causing plantar fasciitis. When you do move, it hurts like crazy! The immediate answer – the one most old-fashioned podiatrists give – is to stop the movement. They prescribe stiff orthotics and walking-boot-type shoes that prevent your feet from flexing. That approach does give short-term relief, but in the long run it just sets you up for more pain.

Instead, advanced podiatrists like Dr. Ray McClanahan recognize that our feet evolved to be mobile. For millennia, they were a wide, stable base for our bodies that responded to uneven ground. Most modern footwear is too stiff and constricting, which restricts both toe movement and foot flexing, and reduces us to balancing on a solid block. The best long-term fix for plantar fasciitis is to get things moving again!

ds00508_im00939_r7_fasciitisthu_jpg

The entire bottom of the foot can hurt, although pain is usually focused in the heel.

That means:

1) Gradually changing to more minimal, flexible footwear. In some cases, toe spreaders will be useful. 

2) Strengthen the feet with exercises (more here!). The muscles that create the arch of your foot are actually in your lower legs (they have long tendons down to the bones in the foot). Myofascial release for your legs will be helpful, too. With a little work, your legs and feet will support you as nature intended.

3) Break up the adhesions in the feet, using any combo of myofascial massage, acupuncture, rolling with small balls, etc. You have to do this a little bit at a time. Some people like to get in and dig the adhesions apart, deep-tissue massage style. That works well in the short term, but it also causes inflammation… which causes scar tissue and fascial adhesions to form… putting you back where you started. Myofascial release uses a more subtle massage approach to slide the layers apart. I love doing this type of work because the result is immediate freedom of movement and no boomerang side-effects.

The bad news: This is the only treatment I do that hurts.

The good news: It stops hurting immediately, and the relief is powerful and swift.

NOTE: This is how to treat the underlying problem – stiff fascia. If you are in a painful flare right now, we need to treat the “hot” injury first. That means (just as with any tendonitis) rest, ice, acupuncture and anti-inflammatory help via the diet or a topical medication.

Come see me and let me treat your plantar fasciitis. Won’t it be nice to go for a walk without pain again? I’ll be happy to help you assess your current shoes (sometimes there are tweaks we can make to give you more space in them) or pics of those you are considering on the internet!

 

 

 

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The sacroiliac joint, sciatica, and unexplained lower back pain

I often have patients come in with a “mysterious” chronic lower back pain. Sometimes it’s described as lumbar or hip pain. They’ve been to doctors and chiropractors, but it still persists. As soon as they put their hand on it (low and to the side, where the buttocks meet the back) it’s pretty clear that the problem is the SI – the sacroiliac joint.

Pelvis

The SI joint – where the sacrum meets the ilium – is a long vertical area on the sides of the lower back. Back pain is often centered at the top of the SI joint.

At the bottom of your spine is a triangular bone, the sacrum. Attached to that is your pelvis (made up of the ilium, ischium, and pubis). Your femurs, the long bones of your thighs, settle into a socket on the side of the pelvis. A complex set of ligaments and lots of muscles join all these bones. If one or more of these muscles is tight, weak, or spastic, it can throw the balance of the entire pelvic system off. A few of the major players are Iliopsoas, piriformis, and quadratus lumborum. These muscles keep us upright and help us walk, but when they go bad… I call them the Holy Trinity of Lower Back Pain.

Quadratus Lumborum runs from the lower ribs to the top of the ilium. There are also connections to the spine. This is your "hip hiking" muscle - imagine a "belly dance" sort of motion - but if course it's essential in walking and other daily movements.

Quadratus Lumborum runs from the lower ribs to the top of the ilium. There are also connections to the spine. This is your “hip hiking” muscle – imagine a “belly dance” sort of motion – but if course it’s essential in walking and other daily movements.

Iliopsoas starts at the front of the spine and the ilium, goes through the pelvic cavity, and attaches to the femur. It gets tight on people who sit a lot, particularly if you are tense while sitting (motorcylists and people who hate their jobs).

Iliopsoas starts at the front of the spine and the ilium, goes through the pelvic cavity, and attaches to the femur. It gets tight on people who sit a lot, particularly if you are tense while sitting (motorcylists and people who hate their jobs). When tight, it jams the bones together and creates stress on the joints.

 

Piriformis

This is a back view. The piriformis muscle attaches at the sacrum, and goes across the butt to the femur. The sciatic nerve passes under it or through it, depending on your personal anatomy. When the piriformis gets tight, it squishes the sciatic nerve and can cause electric shocks or pain running down the leg.

With every step you take, the sacrum “nutates” – it tilts back and forth in relation to the ilium. If the bones are jammed together and can’t glide properly, it causes pain. Sitting can also be a painful prospect: If the joint is inflammed, the altered pressure of a seated position can be excruciating. I understand this very well because I developed lower back pain and SI problems along with a L4-L5 disc herniation after my car accident in 2001. I wasn’t able to sit at all for the 6 months before I discovered acupuncture and Osteopathy.

There’s rarely only one muscle involved. Usually a primary dysfuction causes a cascade of compensation with other muscles. Nerves can be pinched by either tight muscles directly or by a bone pulled out of place by a tight muscle (bones don’t move by themselves).  Nerve impingement can lead to pain radiating down the leg or into the genital area. Motor control as well as sensation may be affected. The leg may go weak, or a patient may experience bladder or bowel incontinence (If this happens, get to the ER immediately – they will take steps to relieve pressure on the nerve and prevent permanent damage).

In most cases, the first thing we have to do is reset the tension on the muscles. Acupuncture and medical massage will work wonders here. Once the soft tissue is corrected, I can generally realign the bones with fingertip pressure. They just slide back home with no drama or fuss. Now it’s a matter of allowing the irritated nerve to calm down, which can take 20 minutes to months (or never, in worst-case scenario), depending on the extent of the damage. Whenever you are dealing with entrapped nerves, it’s important to get care immediately. Releasing them quickly gives you the best shot at a full recovery like mine. Getting the pain knocked down allows you to rebuild. Rehabilition exercises and stretches (plus some myofascial release) will make your muscles strong and supple again, so they work properly, which will keep your bones in the right places. I no longer have any back pain, and I’m back in the gym doing heavy workouts including Romanian deadlifts!

Anti-inflammatory HTPT – Smell like pancakes *and* feel better!

Last month I mentioned that I was having some trouble with my Arnica distributer (problem resolved – it’s in stock and ideal for bruises, sprains, and strains). I found a fantastic solution: Hai Tong Pi Tang. This is an ancient Chinese anti-inflammatory formula, containing frankincense, myrrh*, saffron, and a number of other herbs. The tincture is in an alcohol base, and made by a local acupuncturist. It comes in a spray bottle, so you can easily apply to any injured or inflamed area. External use only, and not on broken skin, please!

Here’s a fun bonus: The aromatic herbs combine to create a “pancake” scent. Much nicer than Ben-Gay or the usual herbal stinkiness! Watch out, though, you might get nibbled on by fans of maple syrup. :) 1oz bottle for $12, or 2 oz for $24.

frankincense resin

Frankincense resin – anti-inflamatory, anti-bacterial, and calming.

*Frankincense and myrrh have been “Moving” herbs in the Chinese pharmacopia for thousands of years. They are used to treat “stagnation,” which translates to muscular stiffness and pain, among other things. I was once on a cross-country flight when my back seized up. This was early in my acupuncture schooling, while I was still recovering from a traumatic car accident. Somehow I had neglected to pack any anti-inflammatory medication, and the flight attendants weren’t allowed to give me any. I was in so much pain, and I had hours left in that horrible seat! Then I remembered that I had brought along my herb samples to study for an identification test the next Monday. I ate the frankincense and myrrh samples – something I DON’T recommend, as they taste terrible! – and within 20 minutes my pain was gone. I’ve been a big fan ever since.

Arnica for bruises, sprains, strains

I generally don’t use topical stuff or supplements. Even when I have a good remedy, I have a bad tendency to forget to use it. Arnica is my big exception. Arnica montana is an herb that has natural anti-inflammatory properties. It makes a terrific topical oil for bruises, sprains, and strains. It’s fantastic for reducing inflammation in the area and speeding up healing.

arnicaoilI have a source for organic, locally-grown, hand-picked, hand-processed Arnica oil. It also contains a little St. Johns Wort for antibacterial and anti-inflammatory effects, and olive oil so it soaks into the skin. I prefer topical application to the pills, because it puts the medication where you need it, rather than spreading it out over the entire body, and because in high doses, taken internally, it can be toxic.

In all my years of martial arts, personal training, and running an acupuncture clinic (not to mention my own boo-boos), this is easily the best preparation I have found. It’s far superior to the multitude of diluted oils, creams and homeopathic pills generally available (most contain only small amounts of arnica), and that’s why it’s the only product I carry. I have bottles for $15 – swing by and pick one up! Use on unbroken skin only, please, and of course discontinue if your skin is irritated.

 

Before and After #2

I usually forget to take Before and After shots but will try to make more of an effort in the future. They are so much fun! Here, we are looking along the patient’s back, from the head towards the feet. She came in with upper and mid-back tension. I found a series of 4 ribs out of place on the right side. After some gentle acupuncture and medical massage, everything was back where it should be and she was thrilled to find that she could take a deeper breath than before.

Before Acupuncture - note the slope of her asymmetrical posterior ribcage.

BEFORE – note the slope of her asymmetrical posterior ribcage.

After Acupuncture - now her ribs are properly positioned, her back is even, and she can breathe more deeply!

AFTER – now her ribs are properly positioned, her back is even, and she can breathe more deeply!

GB-21 (neck / shoulder tension, rebellious Qi)

Jian Jing (Shoulder Well) is a place many people tend to store their stress. Every day, people come into my office and complain about neck and “shoulder tension.” They really mean the trapezius and levator scapula muscles, not the shoulder joint. I’ve been saying for years that we need a better name for this part of the body, but “noulder” isn’t catching on (for obvious reasons!).

Referred pain and trigger points for the trapezius.

Referred pain and trigger points for the trapezius.

The trapezius is a big muscle, and it does a lot. Carrying heavy loads (especially unbalanced ones – so carry a small purse and use both straps of your backback!), working with your arms up (I’m talking to you, hair stylists!), or just general hunchiness over a computer… all are common causes of tension. The traps refer pain over the head to the eyebrow area, so shoulder tension can give you a severe frontal headache.

GB-21 also descends energy, so it’s good for rebellious rising Qi causing headaches, dizziness, heartburn, or vomiting.

GB-21 for relieving neck and shoulder tension.

 

Find GB-21 at the top of the upper thoracic area (aka “noulder”), halfway between the shoulder joint and the spine. Press firmly for 10-15 seconds with a healing intention. NOTE: Do not use GB-21 on pregnant women.

Also – look into some better ways to release your stress!

Foot Pain, Foot Function, & Shoes

My personal health issues, combined with frustration with lack of results using the current common answers, continually take me to new and interesting places. In the past year most of what I know about metabolism, nutrition, and now feet (and foot pain) has shifted drastically. It all comes back to evolution.

I’ve had intermittent stabbing pain for about 7 years, focused at the 1st MP joint (where the big toe joins the foot). I walk a lot, and the more I walked, the more it hurt. It had been diagnosed as a stress fracture years ago, and and for years I would wear Danskos* (hard soles, so my feet didn’t flex) when the pain got bad. Basically the Danskos acted as a walking boot. I am heavy (180lbs, due to muscle and bone from my bodybuilding days, plus all the extra padding I’m currently carrying) and have small feet and a stompy gait… It just refused to heal.

The foot pain had been interfering with my workouts, but it was getting worse and now messing with my weekend fun, too … that’s no good! So I started investigating and it turns out the solution was simple. I didn’t have a stress fracture at all.

diabetes_foot_problems_s13_hammertoesWearing tight shoes, especially heels, can cause bunions (angled big toe), neuromas, and hammertoes (bent toes), too. Fortunately my problem was easier to fix than the poor feet in this stock photo!

I had to change my shoes.

That wasn’t all of it, of course – I also needed some fascial adhesions stripped out. Acupuncture reduced the pain and swelling, and the minimal shoes I transitioned into have had the cool side-effect of forcing me to soften my gait. I wear CorrectToes spacers when I remember. Still, changing the shoes was key . Shopping guide here.

Rolfer Karin Edwards-Wagner does a lot of work with feet, and she pointed me towards the brilliant Dr. Ray McClanahan. He’s got a bunch of videos and articles on his site, so rather than reinventing the wheel I’ll just let you look at his stuff.

Here’s the deal: See those bones on the top of your foot? Your toes should extend in a straight line from them. For centuries we have crammed our feet into shoes that gathered the toes together, creating a sleeker pointed look instead of the spread “duck-foot” that nature intended.

Available here in the office, Correct Toes spacers help separate and flatten your toes into a natural spread for better stability. Use them along with changing your shoes, and getting some acupuncture and medical massage to break up fascial adhesions and relax the muscles of your feet. Your knees, hips, and even lower back will be happier once your gait is correct!

ct-before-during-after__smCorrectToesLogo_small

 

Under your big toes are tiny floating bones called sesamoid bones, which provide leverage and assist in tracking as a tendon moves over bone. The knee cap is a sesamoid, too – in fact you can imagine a miniature knee cap under that joint in your foot. The bones have grooves that the sesamoids are supposed to follow. If the toe angles inwards, the bone is pulled off track. Ouch!

The funny thing here is that my feet look pretty “normal.” I don’t have bunions or any obvious deformation… just a few degrees was enough to cause that foot pain for me. I haven’t worn heels for years. Even so, I had a huge pile of shoes and boots (some of them practically new) that I had to sell, donate, or toss. The trick is finding shoes that:

1)   Have flexible soles across the ball of the foot and also longitudinally, for twisting.

2)   Have the heel at the same level as the toe. Now that I’m used to “zero-drop” shoes, even a half-inch heel feels weird.

3)   Fit well in the heel and instep, but have lots of room in the toebox. This is why regular “wide” shoes don’t work for me – the rest of my foot isn’t wide. See the pic below.

4)   Don’t have a lot of  “toe spring” – that’s when the toe of the shoe comes up off the ground. It pushes you into an unnatural position all the time.

When buying shoes, remember to check for fit with the shoe liner test. Take out the inserts and stand on them (with all of your weight). If your toes drip off the edge, they are too small. Standing  on the bottoms of the soles of shoes is another good way to assess how much room you’ll have. If your favorite shoes are just a smidge too tight in the toe box, you can remove the inserts, which gives you a few more millimeters of room to stretch out.  If they are lace-up shoes, skipping the first set of holes can also let the toe box open up.

No more foot pain! See how the medial (inside) edge has a square-ish corner, instead of being rounded? Wide at the ball of the foot isn't enough - that big toe needs to be able to move and spread outwards. These are my new favorites, Clark's "Faraway Field," available in other colors if you aren't into blue suede shoes. :)

No more foot pain! See how the medial (inside) edge has a square-ish corner, instead of being rounded? Wide at the ball of the foot isn’t enough – that big toe needs to be able to move and spread outwards. These are my new favorites, Clark’s “Faraway Field,” available in other colors if you aren’t into blue suede shoes. :)

The sad truth is that most of the anatomically correct footwear out there is hideous, but I have found some cute options! Shopping info here. My winter boot review is here.

In addition to going shoe shopping, I also got some socks! The regular “mitten” sock can encourage toes to gather together, especially if they get pulled tight as you slip into your shoe.  When I wear those, I stretch out the toe seam to give myself some room. Sock Dreams is a fun local company that carries a variety of toe socks, and they ship for free.

Can’t give up the heels due to work or your fashionista status? Check out this article on ways to mitigate the effects of high heels. 

So… the real question is, did it work? My emphatic answer is YES! A week after switching, for the first time I finished a LARPing weekend without being in agony. My foot and knee may have grumbled a few times (I run for miles during these weekends) but that searing pain was gone. At the end, instead of waiting miserably for Robert to be done cleaning, I was out doing extra trash sweeps, because I felt that good!  Plus, at my next workout, I had to ask Brandie to throw extra weights on for the leg extensions and squat press, because the weight we were doing before suddenly felt ridiculously easy. Correcting my foot function helped my knee normalize, too, which is a bonus I hadn’t expected. It makes sense, though. If the toes can spread out and do their job creating stability, it takes a lot of pressure off the knees.

The next adventure is the perfect intersection of SCA / LARP / craftiness, and healthcare: I’m going to try making my own shoes!

*Setting aside the issue of the heel height for the moment, it’s true that Danskos and other hard clogs make it easier on your feet. The trouble is, they make it too easy. It was obvious once I thought about it…

When a patient comes in with a brace (on the wrist, knee, back, whatever), we always have this discussion: “Immediately after an injury, a little support is very helpful. As you heal, though, you need to wean off the brace. It’s good to wear it for sports, or challenging events, but not all the time. If you baby the muscles, they won’t work and get stronger, which is what you really need to heal. Eventually you should be brace-free.”

I’d been over-bracing my feet. *headdesk*

Wearing softer, more flexible shoes that allow / force my feet to get to work makes them stronger. Here’s a cool exercise you can do to strengthen your arch. I still prefer some shock absorption when walking on man-made surfaces like concrete, but for dirt and carpet I like to go more minimal. More exercises! And even more!

What about arch support? Modern shoes actually give us TOO much support, so our foot and leg muscles don’t work, and get weak. Remember we evolved without shoes. Our feet are designed to support us, given the chance. By doing foot exercises and gradually transitioning to more minimal shoes, your arch will support itself. This is awesome because it means your feet take a lot of the load back from the ankles, knees, and hips in terms of balancing. The whole body works better when strong and supple.

Now that I have spent some time opening my feet up, I love the thin toe-separated shoes like Vibram 5 fingers. Just ease into them… minimal footwear takes some transition if your feet have been over-supported in regular shoes. I have a pair of Filas that are similar (just have shorter toes, so they fit me better) and I adore them! They are phenomenal for running around in the woods.

EDIT 7/1/13: Here’s an awesome article on another reason to wear good shoes – neurological challenge! Also – I get asked about foot pain due to Morton’s neuromas and plantar fasciitis (inflamed fascia) a lot. YES, I can treat them! The good news is that the treatment is immediately and highly effective. The bad news is that it’s the only treatment I do that hurts… Sorry. But only briefly, and it’s worth it, speaking personally!