Lower leg, ankle, foot

Nick is an assistant coach and runner (miler) for Stotan Racing, a Nike sponsored running team located in Central New York.  Over the course of a year’s time, Stotan runners often present at different times for different injuries.  In this particular instance Nick called me complaining of L Achilles tendon pain that was rendering him unable to train.

I usually have some conversation with my clients regarding their client history.  In this case, I wanted to see if I could develop some information about Nick’s foot strike, especially regarding heel/mid-foot/forefoot foot strike.  Nick was pretty straight forward about being a forefoot striker.  I also asked him about any previous medial tibial (shin splint) symptoms.  Nick revealed that he had often experienced ‘shin splint’ pain secondary to Achilles pain.

From the standing postural assessment, I observed that Nick was a bit of a pronator at both ankles, but more so on the left.  I got him on the table, in the prone position, and palpated his L calf.  There was no redness or swelling in the Achilles area, so I thought we were probably dealing with an –osis condition, as opposed to an –itis condition.

Achilles tendon pain typically arises from a posterior compartment problem.  The posterior compartment includes the gastrocnemius, soleus, posterior tibialis, flexor hallicus longus, and flexor digitorum longus.  My first action was to test the four primary movements of the ankle joint.

Summary:                           AROM                   PROM                   RROM

Plantar flexion                   40˚WNL                soft/lig                  pain

Dorsiflexion                        20˚WNL                soft                        no pain

Inversion                             40˚WNL                soft                        no pain

Eversion                               20˚WNL                B.O.B.                   no pain

Keeping in mind the architecture of the superficial back line (from the waist down), I began the Tx by lengthening Nick’s L hamstring group, hoping to release any excessive fascial tension that might be effecting the posterior compartment of the lower leg.   I then continued with the gastrocnemius protocol. Nick’s gastroc responded well, but my pressure on his soleus became uncomfortable.  I reassessed his soleus with a resisted muscle test and Nick put his finger on a painful spot, which was right on the midline of the calf just below the heads of the gastroc. This typically indicates a soleus muscle strain.  I decided to work this area last.

A shortened and contracted soleus is the number one cause of Achilles tendinosis, so I shifted my focus to his soleus.  I spent a good amount of time with myofascial release and cross-fiber gliding, working slowly, superficial to deep and proximal to distal.

I already knew where the muscle strain was, so I continued with multidirectional friction to the strained fibers of Nick’s soleus.  After a couple of 30 second sequences, Nick was able to achieve pain-free movement (plantar flexion).  We moved on to eccentric scar tissue alignment, and it took a couple more sequences of multidirectional friction, working slower and deeper, to achieve a pain-free eccentric contraction.

For the last piece of the Tx, I wanted to lengthen the connective tissue to create myofascial unwinding around the Achilles tendon. I decided to try to directly release the fascia surrounding the Achilles tendon.  For this part of the protocol, I placed Nick in the prone position with his knee extended. In this position, his ankle appeared to be in the neutral position, so I utilized a two-finger gliding stroke working proximally to distally.  Initially, I passively dorsiflexed Nick’s ankle, with my knee, as I performed the gliding strokes.  Eventually, I had Nick actively dorsiflex, as I worked the tendon.

To finish the session, I made sure that Nick was familiar and competent in stretching the gastroc and soleus.  Specifically, I worked with him so he would be able to utilize the PNF techniques, which I think are much safer and more effective than just trying to lengthen the muscles by trying to pull them apart by force.  Nick took my advice and stretched for 21 days straight.  At the same time, I had him work on strengthening his dorsiflexors and inverters, especially the posterior tibialis.

Nick is currently training and racing pain-free.

Neck and shoulder pain

Jen presented on a Physician referral for ‘neck pain’ that had persisted for more than 12 months. This pain was limited to neck, upper trapezius, and levator scapula regions. She was not experiencing any numbness, pain or other symptoms down her arms, or in her hands. She is a teacher who works with special needs children who are at a pre-school age.  Her job requires her to squat and/or bend down and lift children constantly.  She’d already had an MRI.  Her physician felt that the neck pain might be being caused by some disc degeneration, and/or slightly bulging discs.  Previous physical therapy appointments over the course of her symptoms had been ineffective.  Her physician referred her to me, as somewhat of a last resort.

A postural assessment strongly suggested the presence of both upper and lower-cross syndrome (layer syndrome).  Her upper posture included forward head, increased cervical lordosis, rounded shoulders, and increased thoracic kyphosis. Her whole primary anterior curve appeared short, suggesting a short superficial front line, which would include short/weak rectus abdominus and probably short/tight hip flexors.  Her lower posture was characterized by hyper-lordotic lower back and anteriorly rotated pelvis, which also suggested a short/tight hip flexor complex, tight lumbar region, weak abdominals and weak gluteus maximus.

Initially, the transverse alar ligament test, vertebral artery compression test, and cervical compression/decompression were performed as contraindicative ‘precautionary’ tests. These precautionary tests were all negative, and were followed by active range of motion testing of the cervical spine which included cervical flexion, extension, left and right lateral flexion, and left and right rotation.  AROM for flexion (80˚) and extension (65-70˚) were both WNL but guarded due to discomfort. Lateral flexion was guarded on both sides with some restriction L (15-20˚) and R (20-25˚).  Lateral flexion elicited pain in the levator scapula and cervical region on both sides.  Rotation was the most guarded and restricted with L (65˚) and R(60˚).

Following this assessment (during her first visit) I gently proceeded through the first part of the cervical protocol which included Dural Mater and Dural Sheath Mobilization, Atlanto-Occipital/Atlanto-Axial Lateral Mobilization, Atlanto-Occipital/Atlanto-Axial Anterior-Posterior Mobilization, Velvet Glove Myofascial Release Technique, SCM/Scalene Protocol, Cervical Spine Mobilization Techniques, and the interspinales/rotatores/intertransversarii release.  All these techniques helped to significantly reduce her discomfort and improve her restricted ranges of motion.  To say the least, Jen was both surprised at the results and grateful for the pain relief, which was significant.

Two days later Jen returned for her second session. Her neck pain was reduced by 80%.  She couldn’t believe it.  The session I had planned for that day started with some elements of the shoulder protocol to begin addressing the upper-cross issues.  I was particularly focused on releasing the pec, pec minor, sub-scap, middle deltoid, and upper trapezius before I began the cervical work.  This time around, I completed the entire cervical protocol starting at the beginning but adding the suboccipitals and levator scapula releases, upper thoracic work and neck decompression, and stretching during therapy.  At the end of the session, I went over the home stretching exercises and explained their importance.  I included both cervical and shoulder stretches.  Then I instructed her on the appropriate strengthening exercises, and made copies from the self-care manual of all appropriate stretching and strengthening exercises for her to take home.  Again, the outcomes at the end of the session were excellent, and we rescheduled for a follow-up session in 7 days.

Two days after the second session, I got a text from Jen telling me that her neck was feeling awesome but, she was experiencing some low-back and thoracic symptoms of tightness and discomfort which began immediately after leaving my office.  To me, this sounded a bit like the possibility of an ascending syndrome that might actually be originating from the hips and eventually ending up in her neck…maybe all a part of the overall layer syndrome posture.

A week later, Jen came in for her 3rd session.  I explained what I thought the back symptoms might be coming from (the lower-cross syndrome/ascending syndrome idea). Then I tried to put it all together. 

Jen indicated that her back discomfort seemed to be centered more on the right side at about the T12-L1 level.  Her standing posture revealed a slightly lower right shoulder, and higher right hip.  Her right lateral line was clearly compressed.  I put her in a prone position on the table and tractioned her hips from the ankles.  Upon releasing her ankles her right hip rebounded to a superior position compared to the left hip.  I followed that with a check of her iliac crests and PSIS landmarks.  Her right hip seemed a bit upslipped, so I palpated her QLs for tender points and found that her R QL was significantly facilitated and tender, compared to the left.

I began the treatment by releasing the R QL, returning it to its normal resting length (including stretching during therapy) and then moved inferiorly to the gluteus maximus, TFL, and ITB/hip abductors, repeating the process (I did not release the entire lateral line). The pelvic stabilization work balanced her hips and sacrum effectively and her back discomfort disappeared. Next, I worked through the shoulder and cervical protocols, just as I had done during Jen’s second visit.

To complete the session, we reviewed her home stretching/strengthening and I reiterated the importance of this aspect.  Jen reports that she has been pain-free for the past month.