Jul 29, 2014




Hold on a second guys....Okay, there. Sorry. I had to come down from what I imagine being on cloud 9 feels like. I have had one crazy, jam-packed, and exciting month so far. The month concluded with two pretty big events. First of all, I finally got around to popping the question...and thankfully she said yes.

On top of that I had the opportunity to travel to Portland, Oregon to attend one of the newly established Healthy Running Courses. In addition to being a course participant I was invited to present the findings of my research on Correct Toes and Lems during one of the lunch breaks! So I wanted to write up a post with my thoughts and feelings regarding this new continuing education course that is geared toward medical professionals, running coaches, and fitness professionals that deal with endurance athletes. There was even a few purely recreational runners in attendance as well!
I was pretty nervous here...but not as nervous as this...

This was a pretty nerve wracking moment.
Additionally, in about a week I will begin a road trip with my new fiance in order to move to Miami. There we will reside for the next 4 years or so while I begin work on my PhD from the University of Miami. A lot of culture and geography shock in my life lately...

Pretty Sweet geography around Portland. I am very jealous of everyone that lives here.
So where do I actually begin with this course review? Initially, before the course actually began I had wanted to create a large, and detailed write-up about this course. I wanted to share a lot of the information that was discussed, reviewed and learned throughout the weekend. However, at the time I didn't realize just how vast, over-reaching, and yet enjoyably specific the content would be. I could actually write or should I say it would require me to write MANY blog posts to cover everything. Instead, I figured that I would share with you all my general thoughts and feelings.

I arrived on Friday afternoon in Portland and was given a tour of the Correct Toes' office and the clinic (Northwest Foot and Ankle) of Correct Toe's creator, Dr. Ray McClanahan, DPM. Northwest Foot and Ankle/Correct Toes was the host for this conference and boy were they ever a hospitable group of people.

This group went above and beyond and I think this added to the overall open and friendly feeling that existed at this course. This wasn't one of those CEU courses where people sit next to each other and only talk the bare minimum, ignore each other in the halls, and bust ass to leave at the end of the day. I felt like this course, it's instructors, and the participants all fostered a very open, inviting, and collaborative format. On Friday evening, there was a dinner and drinks at a local restaurant to work as an ice breaker before the next morning's festivities.

A family physician, massage therapist, podiatrist, athletic trainer, chiropractic student, certified athletic trainer, and a physician from Canada all at one table the night before the conference. Talk about collaboration...Talk about stories...Talk about Passion.
The next morning I woke up early before the conference to enjoy some local coffee while watching the last couple stages of Le Tour de France. Talk about the type of weather that makes you fall in love with a place.

Portland at 6:30AM...Peaceful at worse.
I was probably the first course participant to arrive on Friday morning but the food and beverages that were catered for breakfast beat me (lunches were also provided and catered, the second day we had Chipotle for lunch!).


Upon arrival to my seat I found some sweet swag in my goodie bag...I was very delighted when I began to rifle through the contents. Actually, I am sure everyone enjoys free stuff.


Pieces of swag included: Free Newton Energy Running Shoes, Almond Butter sample, and an item by a company called "Back Joy" that is supposed to be used for periods of long sitting to promote better posture. On top of that, Correct Toes included a tank top, a pint glass, a small ball for self myofascial work on the foot, and a couple pens and pads of paper for taking notes. I love free pens.

The blue thing is the Back Joy device. I am still in the process of testing it out but so far I think I like it.
On top of all of the above swag, this course is taught using Jay Dicharry's book as the course text, Anatomy for Runners, and as a result we were all provided a free copy of it. This didn't bother me because I already own the book and I was a huge fan (Check out my previous review here.) of it. Therefore, I won't mind sharing this book with somebody else to help pay-the-knowledge-forward.

So what about the actual course? How does a person even begin to delve into a two day, sixteen hours continuous hours of knowledge bombs, and information into one post? The first things that come to my mind is stuff like: amazing, engaging, Broad without being skimpy on details, and specific without being needlessly detailed.

The names behind putting on this course are very notable and respected in the running community: Dr. Mark Cuccuzzella, Jay Dicharry, Ian Adamson. We also had Kevin Rausch, PT of Rausch PT show up on the second day to help out during labs and to answer any participant questions. If you are familiar with the world of running injuries, research, gait analysis and running footwear then you probably know who they are. If you don't recognize their names then you NEED to get familiar with them and their work. Especially if you consider yourself somebody that works with runners, endurance athletes, or anybody that runs in their respective sports. Period.

Dr. Mark. "1 second, here is another knowledge bomb for you all."
I love listening to Dr. Mark Cucuzzella talk whether it is on podcasts or videos and in person was no exception. This guy knows so many people, is educated on so many different topics, and is very open minded. I was very happy to be able to finally meet him and if you ever get the chance to hear him speak you will learn how captivating he can be with his knowledge of research, running history, personal anecdotes, and funny stories.

On top of having a passion for running it seems he has a bigger passion for just helping people...including kids too! Oh and if you're going to go for an "easy" group run with these guys after course then you better have some regular mileage under your belt. I am just starting to get back to running now after a long period of time off and I got dropped really quickly! A little sad considering I was probably the youngest person at the conference and easily the youngest person on the group run.

Jay's devilish grin before dropping some knowledge bombs himself.
Jay Dicharry is a physical therapist that now practices in Bend, Oregon at Rebound Physical therapy. Jay used to be the head of the running research/gait analysis lab at the University of Virginia. Jay's name is stamped all over the world of research for gait analysis and running related studies. At one point during the course Jay showed us a quote that he once wrote for a text book. He then went on to bash it to highlight the need (and his ability) to critically think, remain open-minded, and the importance to stay current with research.


Jay claims to talk fast but he uses tons of analogies and metaphors to help convey long and arduous ideas or topics into concise and easy to understand statements. To me this means he understands what he is talking about inside and out. On top of this, Jay isn't a frilly clinician. What does that mean? To me Jay is the straight to the point, knows what we do and don't know, and isn't looking to find the "coolest" or most "flavor of the moment" treatment approach. He just goes with what he knows and with what works to provide favorable outcomes. Jay provided us the information on what we need to know, what we need to look at, and how we can be the most effective clinicians without the use of his expensive and fancy equipment.

So what did we actually learn? A lot. I've read Jay's book at least 3 times previously and I still learned a ton from this conference. Just check out this list of learning objectives that are listed for this course:
  • Discuss the pathophysiological process behind running injuries and the new treatment concepts relating to these pathologies. 
  • Improve his\her clinical efficiency through a better knowledge of objective diagnostic assessments and their place in the clinical exam of an injured runner. 
  • Discuss the new theories behind tissue stress, adaptation and preventive stress.  
  • Recognize the relationship between running biomechanics and the risk of injuries. 
  • Build a program to help an injured runner return to running using the theoretical principles relating to different energy systems, cross-training and warm-up.
  • Discuss the science behind running shoe technology, plantar orthoses, flexibility and strengthening in the prevention and treatment of running injuries. 
  • Discuss the science and practical application of aerobic development, speed training, and periodization. 
  • Describe the principles and be able to teach efficient running form including supplemental drills. 
  • Evaluate a patient for movement dysfunction during a clinical visit and provide simple corrective measures.              
  • Discuss clinical Injury assessment and exam and specific corrective exercises. 
  • Describe practical gait analysis, cues, and corrections. 
  • Discuss Nutrition for health and performance.
  • Prescribe footwear to complement the patient’s current movement pattern and how to safely transition them to more functional footwear

Dang. That is a lot of information...and they really did deliver but obviously some points were more in depth and detailed than others...As Doctor Cucuzzella put it, It was enough information for us as clinicians to apply but left more for us to learn about. It was entry level exposure on some topics while others were definitely advanced. Enough for us to think about a trip down the rabbit hole if curious. Here is a better Day 1 vs. Day 2 Split of what was discussed. I took this stuff right from their website...

Day 1:
Anthropologic Basis of Running
Training Principals
Aerobic development
The role of intensity
Recovery principals, practice and overtraining syndrome
​Coordination and peaking
Warm up and cool down
Nutrition for performance
Footwear
Performing for ultra-endurance, movie and Q&A
Evolution, Design and Technology of footwear
Influence of footwear on gait
Relationship of footwear to injury
Fitting Issues and adaptive devices
Efficient Running Workshop
Stability / Mobility / Strength
Movement patterns for efficiency and injury reduction
​Form drills to re-enforce motor skills

Day 2:
Assessing the Injured Runner
    Triad of Running Injuries
    Tissue specificity – micro-anatomy
    Baby biomechanics
    Building the perfect runner: how strength and mobility impacts form
​    Identifying and fixing problems
    Optimizing the runner: building a paradigm from distance to sprinting

Medical Issues in Endurance Sports
    Heat and Hydration for the Athlete
    Cardiac Issues 

Assessing the Injured Runner Workshop
​    Clinical running analysis: the Visual Gait Tool in case studies & hands on practice
    Clinical mobility and stability assessment lab
​    Evaluation and treatment workshops - physical exam and exercise prescription

In conclusion, this was a great course. I learned a lot and it definitely left me feeling more confident in my ability to evaluate, and treat running injuries. Additionally, I feel like I took my visual gait analysis skills to a whole different level. I learned things that I may have been thinking or doing previously may have been flawed and reaffirmed a lot of other stuff that I was already doing. It was amazing to get some insight into the "information" that people try to tweeze out of a gait analysis and to find out what you really CAN and CANNOT derive from watching somebody run.

Dr. Ray McClanahan, DPM, myself, and Jay Dicharry, MPT, SCS.
These two guys combined have 4000x the brain power that I do. 
One other point that I loved during the conference was the focus on or the overlap of injury reduction/prevention versus enhancing running performance. Sometimes certain issues held these two ideas under the same umbrella and for other areas they had a direct inverse relationship. This helped when thinking about an individual's goals...and when you start with the finish you can provide a more focused plan. I really do recommend this course.

There is still way too much garbage information out there regarding running form, running footwear, running injuries and endurance training. I urge any interested medical professional, running coach or even motivated runners to see if one of these courses are being hosted near you. If you can't do that then your next best starting spot is probably with Jay's book, Anatomy for Runners. 




Posted on Tuesday, July 29, 2014 by Adam Kelly

9 comments

Jun 23, 2014



Greetings Everybody! I wanted to take a moment today to follow up with my original post regarding my recent research study with some of our final findings. While we have finished the study and I have completed my thesis...this information is far from completing its journey through the peer-reviewed process.


Nevertheless, here is a quick rundown/recap: We had 63 healthy and physically active college age students between the ages of 18 and 29 years that volunteered for this study. All participants were randomly allocated into one of three groups by an online random group allocation generator. We hoped to have more subjects in this study but I ran out of time to recruit more and I needed to cut my losses if I wanted to finish the study and graduate on time. One group received the foot-toe orthosis (Correct Toes - FTO ) and the control shoe (Lems Primal 2 - SO), one group received the control shoe only, and one group was a true control (CON) that received neither intervention. The following table displays our group demographics...ideally I wish we could have made the groups perfectly even and had more subjects overall.
Screenshot 2014-06-23 at 3.43.22 PM.png
Just to review, we used the Lower Quarter Y-Balance Test (YBT-LQ) as our measure of dynamic balance. I’m not going to go over all of the procedures and what not again because you can find all of that information in the above link from the original post. So why don’t we just get down to the fun part...The Findings.
Screenshot 2014-06-23 at 3.49.21 PM.pngThere is a lot of numbers in that table...and it isn’t very pretty. Nevertheless, it does tell us some important information. After adjusting for baseline scores (ANCOVA) there were significant differences between the post-intervention scores on the YBT-LQ. This means that there was a statistically significant difference (p=.001) between the groups at follow-up testing. Also, these YBT-LQ scores are the composite scores. That means they are the maximum reach directions for each reach direction(anterior, posteromedial, and posterolateral), and then normalized for apparent leg length.


Pairwise comparisons revealed that the FTO group was significantly different (p=.001) from the CON group. There was also a significant difference (p=.034) between the SO and CON groups. Additionally, the FTO group was significantly different (p=.007) than the SO group. The FTO group had a strong effect size of .70 while the SO group had a moderate effect size of .45. Phew, that paragraph sounded a lot like a journal article...So lets use a pretty graph to highlight this information even further and it is much easier on the eyes.



So what does this all mean? The purpose of our study was to see if the foot-toe orthosis had any effect on dynamic stability. Our results were the first to show that this type of orthosis could be used to increase dynamic balance with 4 weeks of use in a healthy, young-adult population. These results were similar to other interventions to increase dynamic balance/postural stability using mediums such as textured surfaces, insoles and traditional orthoses. However, due to the difference in metrics and intervention choice...direct comparison isn't really feasible.


There are several theories abound for why such interventions may be efficacious such as increase afferent input to the feet/toes and the potential for passively increasing the base of support. However, it was beyond the scope and aim of this study to determine why they work and unfortunately we didn’t enough measures to control well enough to check on some of these theories.


We do know that when wearing the foot-toe orthosis the base of support is certainly increased, yet pre and post data collection was done without the use of the foot-toe orthosis. This means the increased dynamic balance was not reliant upon the foot-toe orthosis. Additionally, the control shoe only group saw an increase in dynamic balance as well.


This could be attributed that the control shoe was technically advertised as a“minimalist” shoe by manufacturer and despite a lack of universal definition for a minimalist shoe...I would have to agree that this shoe was minimally cushioned, zero drop (ramp from heel to forefoot), offered no support to the foot beyond grip, and had a wider toe box than most traditional footwear. This design could potentially work to increase dynamic balance through increasing the base of support and allowing better afferent input.


In conclusion, our results suggest that the use of the foot-toe orthosis and the control shoe may increase dynamic balance in a healthy and college-aged population. The moderate to strong effect sizes associated with our results are promising; However, it is imperative that future research be conducted to investigate the effects in differing populations such as the elderly, the injured, and people with neuropathic conditions such as diabetes. It must also be investigated on whether these findings have any impact on injury risk and to determine what the long-term effects of use. This information could help researchers or clinicians investigate potential treatment or prophylactic approaches.

Posted on Monday, June 23, 2014 by Adam Kelly

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Jun 21, 2014


If you live under a rock or have been hanging out at Walter White's hide-a-way cabin then you probably haven't noticed anything strange. However, Twitter, Facebook, the global news, armchair quarterbacks, and the world player's union has been up in arms about Álvaro Pereira's head injury in the world cup match between Uruguary and England.

In case you didn't see it...Pereira suffered a blow to the head that rendered him unconscious. Nevertheless, he was allowed to continue to play despite that the team physician for Uruguay motioned for a substitution for Pereira. I won't delve too deeply into a play-by-play of the event but Pereira exhibited these obvious signs and symptoms of a concussion:


  • loss of consciousness
  • poor/altered balance and motor control
  • Mood Swings
    • Angrily signed to decline substitution
    • repeated apologized for being "dizzy"
  • Self-reported anterograde amnesia, couldn't remember much directly after being hit
    • "It was like the lights went out a little bit."
Nevertheless, Pereira continued on and was allowed to play. FIFA has come under much scrutiny in the past couple of days because of this. My first reaction however is instant disapproval and disappointment with the medical staff and Pereira's own teammates. I shouldn't jump to conclusions because I do not know the true policies and procedures for the medical staff, team and the individual.

Regardless, knowing what I know and what the medical staff should know this decision was inexcusable. This stage...the WORLD CUP...sets a huge precedent for children, young athletes, parents and coaches alike of how concussions are/should/could be treated. It is disappointing and unacceptable. 

I honestly make the argument that if I was the team doctor or physio/AT and this event occurred in front of my eyes then I would interrupt the game until Pereira was substituted or I have to be dragged off the field forcefully without Pereira and be relieved of all responsibilities related to this event. I don't know how a teammate, comrade or brother-in-arms would comfortably feel OK with him continuing to play. This wasn't a possible head injury with shades of grey...it was an obvious one that was black and white and clear as day.

Some might argue that Pereira made his own choice, he is a professional, and that this is his life and he should be allowed to make this decision. To me that is akin to saying that a boxer should be able to continue after being knocked out if they want, to allow a race car driving to continue after racing after sustaining life threatening injuries or allow mentally impaired (drugs or alcohol) individuals/patients with brain damage to make their own decisions.

 There is a reason people have living wills, are not allowed to drink and drive or get tattoos under the influence of alcohol and etc. I have never met or evaluated an athlete that wanted me to remove them from competition after sustaining a head injury. They are all brave, courageous and have an incredible drive to compete but they can also make utterly ridiculous and stupid decisions at the same time.

I know that some of you may not agree with this whole-heartedly or may be vehemently against my opinion. However, I am trained to do no harm. Protect and prevent my patients from hurting themselves and others or potentially injuring themselves further. We wouldn't allow Pereira to continue to play with a fracture but one might be able to argue that the risk of permanent bodily harm or death is more likely with the injury that he did sustain that he was allowed to play with. Pereira is a defender on the field but where were the people that should have been defending him? I guess that is enough ranting for one weekend.

Posted on Saturday, June 21, 2014 by Adam Kelly

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Jun 17, 2014

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Supposedly this is a painting of the first chiropractic "adjustment"
That is the question that was asked of me recently by a client. This question was offered to me in a hushed manner as if it was a taboo or risky thing to ask somebody.

In reality, I can understand the demeanor of the question due to the previous issues between the chiropractic profession and societies like the American Medical Association.

Curious to what my answer was? I told her that I do NOT believe in chiropractors...Pause...I also do not believe in physical therapists, athletic trainers, medical doctors or osteopaths. However, I do believe in critical thinking, sound clinical reasoning, clinicians that get results, evidence based practice, and the scientific method. There will always be good eggs and bad eggs in any profession. There will always be some patients that will respond to some clinicians/treatments/therapies/exercises better than others. It doesn't mean they are bad but they weren't appropriate at that moment in time.

I think she has lost her marbles.

As Charlie Weingroff would say, "I don't care if all you do is spread peanut butter on somebody, if it makes them move better or with less pain from baseline to post-testing."

Test - Intervention - Retest.

That is starting to be my new gold standard for how I feel about different clinicians. I could turn this into a profession bashing fest but its almost like discussing stereotypes...they just are not true for everybody. Not to mention it would be unprofessional of me. ;-) 

I am also biased towards systems of evaluation like SFMA/FMS/PRI/MDT because they guide treatment and funnel down issues to specific dysfunctions. This is a step in the right direction compared to trying to guess why somebody strained a hamstring, or treating all shoulder impingements the exact same way.


In conclusion, when you really start to look at stuff on a broader scale you will notice that the overlap between professions of physical medicine is constantly increasing and the points of distinction really aren't that distinct. I also see the need for more clinicians to be willing to work together. Do not let ego get in the way of referring to another provider just for the sake of keeping your cash flow constant. The real future is who can become distinct by delivering the best outcomes and results to the patient. This is customer service after all.

Posted on Tuesday, June 17, 2014 by Adam Kelly

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Jun 10, 2014

"Tight Hamstrings, The Epidemic That Never Existed."

 -Dr. Erson Religioso, DPT

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Trying to touch my toes at my first SFMA seminar.
This little nugget of knowledge developed during a conversation that my good friend Dr. E of The Manual Therapist and I were having together after his recent post. It is crazy how many times you will hear people mention how tight their "hammies" are or how often you can look at people exercising in public and the only thing they stretch is their hamstring group after some light arm circles. It is bewildering to me sometimes.

I think there is a real epidemic in progress and is growing at an exponential rate. However, the epidemic is NOT hamstring tightness...The real epidemic is a plethora of people, old and young alike, that can not touch their toes. Touching your toes without bending your knees is...or should be a fundamental human movement pattern. I know many of us fear lumbar motion and especially extreme lumbar flexion but spinal (that includes lumbar) motion is completely normal and necessary. We aren't talking about lumbar flexion under load here.

On top of the population of people that can not touch their toes...there are plenty of people that can do so. However, I didn't say everyone that could do this was able to do it satisfactorily. Using the Selective Functional Movement Assessment (SFMA) standards a person should be able to touch their toes without bending the knees, should have a uniform spinal curve throughout all of the spinal segments, have a sacral angle of > 70 degrees, and should utilize a posterior weight shift or hip hinge to achieve this goal. An inability to achieve this pattern satisfactorily represents an inability for athletic movements such as the deadlift, and an inability to reflexively stabilize the spine.

So what does this have to do with hamstrings? Most people that can not touch their toes often jump the gun and assume that it is due to posterior chain tightness or tight hamstrings. In reality, this is rarely the case. In fact, I would recommend you always get a second opinion or never evaluate yourself. I actually made this mistake myself and it was evident in a previous post where I did an SFMA video of my own multi-segmental flexion (toe touch pattern). I was wrong in my assessment and I actually had a core stability/motor control dysfunction.

This wasn't evident to me because during a certain breakout assessment I falsely associated the sensation of neural tension to equal soft tissue tension. I didn't realize my mistake until I was auditing the SFMA certification course for the second time. I volunteered myself to be the case for teaching the multi-segmental flexion breakouts. This SFMA course was being taught by Behnad Honarbakhsh, MPT, BHK, CSCS, CAFCI, CGIMS, DO (c) (whom I thought was brilliant) and low and behold in front of the entire class he humbled me and showed me my true dysfunction. Nobody knew that I was humbled because I didn't discuss my prior self-assessment. However, I probably hadn't touched my toes since I was a toddler before elementary school. Michele Desser and Dr. Todd Arnold quickly took me out into the hallway and had me perfom rolling and core stability exercises for about 5 or so minutes. They then brought me back into the seminar and showcased how I went from being about 14 inches from touching my toes down to about 2 seconds. Later that night, back in the hotel room I practiced some more on my own and was able to touch my toes.

So lets find out where I went wrong really quick to showcase how you can check to see if your hamstrings are tight or not.

Step 1. Check to see if toes can be touched. If not, continue on. Why can't I? We don't know. Don't blame the hamstrings yet.


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Step 2. Remove Parts and Compare Left to Right. Here I unweight one of my legs and check for change. Nothing. Continue on. Still not the hamstrings.





Step 3. Long Sitting Test - Unload body parts. Now the hips and below will not be bearing weight and only the spine will be partially loaded against gravity. Still can't touch the toes? Continue on. (Still not the hamstrings despite my P.E. teachers scolding me for my tight hamstrings as a kid)



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Step 4. Unload More, Check Left to Right, and begin Active versus. Passive Comparison. In this test you are looking for >70 degrees of hip flexion with both knees remaining straight, feet dorsiflexed, and hips neutral. An inability here STILL is not due to tight hamstrings.


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Step 5. Checking Passive Motion compared with Active Motion from the previous step. An inability here to increase motion here beyond what you achieved actively = Ding. Ding. Ding. Winner Winner, Chicken Dinner. You DO have tight hamstrings! There are a few more steps you may take after this finding to pinpoint where the mobility dysfunction is located. However, If you increase more than 10 degrees compared to active but still do not reach normal hip flexion (now 80 degrees instead of 70) then you have a mobility and stability/motor control dysfunction present! If you find that you go from ~40 degrees to normal like I do below then you sir...DO NOT HAVE TIGHT HAMSTRINGS. You have a stability/motor control dysfunction. Continue on to step 6.


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Step 6. Now you must find out how poor your motor control deficit is. To pinpoint this you regress yourself to the most basic form of stability and motor control...rolling around on the ground. If you can not roll from supine to prone with each of your different limbs then you have a primitive motor control dysfunction. Restoring the ability to roll may fix your inability to touch your toes. However, at this point we are encroaching on the area of the 4x4 matrix of the SFMA. If you aren't in pain currently then I would recommend you finding an FMS certified professional and get screened and start with working on your most dysfunctional issues there first.

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Look at me now...Just a tiny bend in the knees. Working on it. No hamstring stretching needed.

In conclusion, don't evaluate yourself and if you do...Get it rechecked by another set of eyes. The plumbers pipes always leak. Don't be that plumber. Secondly, practice your systems of evaluation or assessment if you have one so you can own it. If you don't use a system how can you be sure you aren't throwing spaghetti against the fridge and hoping that something sticks? What are your metrics for improvement? It has been said a million times and I'll repeat it. You do not need to use these metrics but you should be using something to set a baseline, intervene, and then compare to baseline to check for change.


Posted on Tuesday, June 10, 2014 by Adam Kelly

1 comment

Jun 5, 2014


I have had a few people ask me lately about using the Edge Mobility Band for tibial internal rotation. I kept trying to refer them to a previous video that I had made about this very topic. However, they couldn't seem to find the video on my blog or on my YouTube channel. Turns out I never edited the video or posted about it on my blog. Oops.

Therefore, this is a quick post and video to show you how I use the Edge mobility band to work on mobility deficits when it comes to tibial IR. A few things before I share the video...




-The band is not a necessity for this technique but I find that it helps enhance its efficacy and the ability to grip the skin.
-The band doesn't need to be wrapped on so tightly that it cuts off blood flow.
-This technique should be pain free.
-You are looking to get at least 20 degrees of tibial internal rotation via the SFMA to be functional...Don't confuse a mobility issue with a motor control issue here. (Active vs. Passive differentiation)
-Do more than the two sets of ten that I did for this video. I filmed this quickly on my phone while at work tonight using one of my coworkers. In the first segment of the video he is actually trying to internally rotate his tibia. He definitely isn't functional afterwards but there is a marked improvement afterwards. Rinse and Repeat this continuously for a few days to weeks to restore full motion.


I am curious what others do for mobility issues regarding tibial IR and subtalar inversion/eversion issues...Please share if you have some input!

Posted on Thursday, June 05, 2014 by Adam Kelly

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Jun 1, 2014

The foot on the right is far from ideal, but its great toe position is better


In my previous post I discussed the importance of the "big", "1st", "great" toe, or hallux. I finished that post with a promise to share some ideas and methods for enhancing the health of your foot/toes and here I am to make due on that.

In reality, some people may already be too far gone to see much benefit from conservative methods of treatment. Unfortunately, with enough abuse from faulty footwear, poor biomechanics, and overuse some feet may require surgery. That doesn't mean that you may not find a decrease in symptoms or pain from conservative methods and all avenues to avoid surgical procedures should be explored in my opinion.

Instead of giving tons of in-depth and intricate details on things that you can do for better foot/toe mobility and motor control I am going to give some simple and easy ideas and concepts that can have a huge impact.

1) Avoid Shoes With a Tapered or Narrow Toe Box

The toes should be the widest part of the foot. This is often a rarity for people of developed nations and many think it is normal. However, if you look at a young child or toddler's foot it is likely that their foot still holds this true form. If you look at most footwear you will find that the toe boxes are often very constraining and the widest part of the shoe is usually not at the toes. They often come to a very distinct point about where the second toe is. One thing that I recommend when picking out a pair of shoes is to perform the "shoe liner" test. This is where you remove the liner or insole of the shoe and place your foot on top of it. If your toes splay over the edges then it is likely that the shoe is too narrow for your foot. This is very important for the developing feet of children and I think this video by Dr. Ray McClanahan does a great job of explaining this.

2) Avoid Shoes With a Toe Spring Design

If you view a shoe from a side profile you will notice that many conventional shoes will have a design where the sole will curve upward near the toes. This places the toes into an extended position relative to the metatarsals when at rest. I believe this was originally designed to help the shoe have a "rocker" effect to help people with poor ankle mobility.

3) Avoid Shoes With an Excessively Elevated Heel, "Ramp", or Heel-Toe Drop Design.

I attribute this shoe design and our cultures disdain for squatting (excessive sitting in chairs) to be major contributors to the poor ankle mobility that plagues many people and athletes alike. These three design flaws are discussed indepthly by Dr. Ray once again and he does a great job discussing them in this other video of his. You can do all the joint mobilizations, stretching, and flexibility work in the world but if you keep yourself or your patients in crappy shoes then you are fighting a losing battle.


4) Ensure Adequate Ankle Dorsiflexion

One thing that I have noticed in many patients with issues in the toes is that they are often accompanied by issues at the ankle, especially regarding decreased ankle dorsiflexion. Chicken or the egg here? I'm not sure but if a person lacks the ability to achieve full ankle dorsiflexion then their toes may be at risk for taking an extra beating. What about if you lack toe mobility as well? Good Luck. Here is a video I made for a quick and easy way to check and see if you have enough ankle dorsiflexion.


5) Increase foot intrinsic muscle strength/motor control

It isn't advisable to dive in headfirst and make drastic changes to your footwear in one fell swoop and expect all to be well. Even if you aren't going to change your footwear choices it is still probably advisable to work on intrinsic muscle strength/control. Here is another video I made previously showing some easy ways to improve foot/toe strength and mobility.


If you are still struggling with issues in your feet, ankles, or further up the kinetic chain and these simple tips aren't enough to resolve them then you may possibly need additional manual therapy from an athletic trainer, physical therapist, physiotherapist, podiatrist or chiropractor. There is also the possibility that a conventional approach may not be enough for some issues.

Some issues may require more time or help from products like Correct Toes. An foot-toe orthosis like them requires a post all to themselves but I personally have used it on myself, my patients and in research with some surprising success and outcomes. One thing that I will say is that I like how that product versus the cheaper generic types that you can find at say Walgreens or CVS will actually fit in your shoes, has multiple sizes, and can be modified for your foot shape.


Posted on Sunday, June 01, 2014 by Adam Kelly

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May 20, 2014

Hallux Valgus is only good for suppressing appetite and skinny pumps

Proper motion, strength, and position of your toes is a concept that is often lost with conventional approaches to health care. The toes may be one of the most commonly disfigured series of joints in the body, especially the big toe. Dr. Perry Nickelston of Stop Chasing Pain refers the big toe as one of the key movement linchpins in the body. For those of you that are unaware of linchpins it is the key piece of a complex system which is vital for holding it all together.

In reality, the above pictured toes should not be as common as they are. Right away the thoughts stray to women who indulge themselves with high heeled or skinny footwear with narrow and tapered toe boxes for fashion. During medieval times the fashion was for men to wear long, narrow and pointy shoes (think like elves?) and cadaveric studies of people from this time show that these disfigurements were more common in men than women which is the exact opposite of modern times/studies.

These sandals are a little too small for this fellow.

A foot or more specifically your toes should ideally look a lot more similar to the above foot. In fact, there really should be a slight gap between your 1st and 2nd toes! Having a big toe that is straight and mobile is beneficial for many different activities. In fact, I would argue that it is probably important for all activities that involve bearing weight through the feet. I've also seen videos of indigenous cultures using their toes with great dexterity.

"Sign here please, sir."
Your big toe is essential for proper balance, running, walking and many athletic activities or exercises. Somewhere around 55-60% of your support should come from your big toe during running. It also helps with foot stability, and explosive propulsion during power movements such as squats or the deadlift. Many bodyweight exercises or yoga positions require a mobile and correctly positioned big toe as well. You should have three major points of contact to the ground through your feet for proper function: the big toe, the calcaneus, and the lateral aspect of the foot around the base of the 5th metatarsal.

I dare you to try barefoot pushups without adequate toe mobility. Ouch.
I'm sure there are many people out there that are looking down at their feet and are taking notice of a slight to severe hallux valgus angle, or currently suffer from conditions such as hallux rigidus or limitus. You may even be functioning quite well in your prospective sports or activities of daily living. However, I can guarantee that a few things are probably true for you. 1) You are compensating for your poor positioning and/or mobility. 2) Your performance is lacking and could only be improved with improvements made here. 3) Finally, there is a chance you may be part of the 15%ish of the population that presents with Morton's foot.


If this is the case your 2nd toe will be longer than your first toe. In this circumstance your second toe is now taking an excessive load compared to what it was designed for. This is genetics at play and is arguably a less evolved toe structure from when the big toe was opposable like a thumb similar that of other primates.

In conclusion, the big toe can have a big impact on your health, performance and movement all the way up and down the kinetic chain. Even if you are not an athlete proper big toe health will be paramount when you reach an older age. The elderly are at risk for falling which has very serious impacts on life quality and expectancy post falling. Proper position of the big toe increases stability by widening the base of support and proper mobility of the big toe gives greater proprioceptive input for better neuromuscular control. Both are critical concepts for everybody.

In my next blog post/videos I will be going over ways to promote increased toe mobility and position! Stay tuned for more...

Posted on Tuesday, May 20, 2014 by Adam Kelly

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May 14, 2014

Howdy Folks! Today I wanted to take a quick moment to comment on some discrepancies that I have noticed when hearing people discuss thoracic mobility and the need for thoracic extension. Anyone that is familiar with the Functional Movement System is probably well aware of the lack of thoracic mobility that many people seem to suffer from. This is something that you often see targeted by FMS corrective exercises or may be a common finding during an Selective Functional Movement Assessment (SFMA) for some.

On the other hand, there is the kind folks associated with the Postural Restoration Institute (PRI) that are trying to promote thoracic flexion and minimize hyperextension of the thoracic spine. Then I have heard stories from colleagues at PRI courses mention how they are lacking thoracic extension only to be told they have too much. So what is the answer? Do we need thoracic extension? Who is right here?

Well I believe that both of these systems or schools of thought are trying to achieve the same thing, and are essentially saying the same thing despite it sounding different. I am arguing that people are not differentiating between the different hinge points of the spine and the exact levels of the thoracic spine that they are referencing. Look at this first squat picture below. Nobody from either school is going to like this squat form and PRI'ists will notice the excessive thoracic extension from T8 and down while FMS'ers will notice the lack of thoracic extension from T1-T4.


Now if I hit my first sticking point and decide to take another breathing cycle to help draw my ribcage down and promote lower thoracic flexion I am able to come down even further in my overhead deep squat as you can see below in the next picture. However, it is still less than ideal squat form. I still struggle with getting adequate upper thoracic spine extension


Now what happens if we lessen the burden of the upper thoracic spine and by switching this experiment over to a front squat? I am still hyper-lordotic in the lumbar spine and still extend the very last few segments of the thoracic spine.


If I perform another big exhale into the balloon I am able to decrease the lordotic curve, increase thoracic flexion from T8-T12 and my femurs actually break parallel! However, if you look closely you will still see a little bit of hyper-kyphosis in the first few segments of the upper thoracic spine.


In conclusion, I think there is a lot of confusion by some people when they learn about or speak about the thoracic spine between these two different schools of thought. In reality, I think that both schools are really trying to achieve similar things but sometimes there is definitely a lack of differentiation. I also think that these pictures can also help signify the importance of proper breathing, and the power of the diaphragm, obliques and transversus abdominus over form, function and movement. Just some food for thought! Thoughts?

Posted on Wednesday, May 14, 2014 by Adam Kelly

7 comments

Apr 29, 2014


Howdy Readers! Today I wanted to take some time to report on a case that I was presented with during this previous basketball season. Then I will discuss how I addressed the case and what I wish that I could have changed about the case. I will also be using my findings from the patient's Selective Functional Movement Assessment (SFMA), and so here is the SFMA acronym legend:

FN: Functional & Non-painful
FP: Functional & Painful
DN: Dysfunctional & Non-painful
DP: Dysfunctional & Painful

Background:

A 21 year old NCAA division III basketball player was competing in a JV basketball game when he suffered a direct blow to the low back by an opposing player's elbow. The supervising athletic trainer (I was busy prepping the varsity team to play) determined there were no gross deformities, ruled out neurological involvement (dermatomes & myotomes WNL), and ruled out any potential fractures. Nevertheless, the player was unable to return to play and finish the game due to pain.

This player had a previous history of catastrophic injury as a high school basketball player when he was undercut by an opponent. He fell on his upper back and hit his head suffering a fractured scapula and traumatic brain injury that lead to him being placed into a medically-induced coma. Additionally, he had a history of low-back pain during high school. The year previous to the current incident this athlete suffered a season-ending concussion as well.

After the game was over this athlete returned to his hometown with his parents. The parents and the athlete planned to see a family friend that is an orthopaedic surgeon in the following days. Upon consulting with the doctor it was revealed to the athlete that he had degenerative joint disease (DJD) in his lumbar spine and he was sent back to me for rehabilitation at my discretion.

Upon hearing this I definitely began to dismiss the DJD because I knew that suffering an elbow to the low back in one game of basketball didn't give this player DJD. I began to talk with the patient about pain science, how it didn't matter if he had DJD because he had it before when he was pain-free, and how we weren't going to attempt to change it. I did discuss how we would perform an SFMA and evaluate in which patterns he was moving dysfunctionally & why they were dysfunctional.

Assessment:

SFMA Top Tier Results & Breakout Findings--
Cervical Flexion = DN: Tissue Extensibility Dysfunction
Cervical Extension = FN
Cervical Rotation = Left - FN / Right - DN: (Tissue Extensibility Dysfunction)
Upper Extremity Pattern 1 = DN (Bilaterally, Left worse than Right): (Functional Shoulder Pattern Stability/Motor Control Dysfunction)
Upper Extremity Pattern 2 = FN (Bilaterally)
Multi-Segmental Flexion = DP (Posterior Chain Tissue Extensibility Dysfunction)
Multi-Segmental Extension = DN: (Thorax Extension Stability/Motor Control Dysfunction, Hip Extension Tissue Extensibility Dysfunction)
Multi-Segmental Rotation = DN (Fundamental Rotational Pattern Stability/Motor Control Dysfunction, Hip ER Tissue Extensibility Dysfunction)
Single Leg Stance = DN (Lower Posterior Chain Tissue Extensibility Dysfunction)
Overhead Deep Squat = DN (Hip and Lower Leg Posterior Chain Tissue Extensibility Dysfunction)

Plan:

Based upon my SFMA findings I decided to attack the greatest areas of dysfunction first. I determined that the hip flexion/posterior chain TED (~40 degrees passive SLR), and cervical flexion & rotation were the patient's greatest limitations. This is what I formulated my initial treatment plan around as well. I began with an easy 5 minute warm-up on a stationary bike followed by some instrument assisted soft tissue mobilization (IASTM) to the posterior neck, proximal hamstrings attachment near the ischial tuberosity and distal attachment of the biceps femoris to prepare for some Muscle Energy Technique (MET).

Day 1: Pain (7/10)

Upper Trap MET

I performed MET techniques (redundancy?) for the upper trap, scalenes, and posterior neck extensors. I performed 3 sets of autogenic isometric inhibition on the right side and an extra set on the left side. This brought cervical flexion and rotation to FN immediately following application of the MET treatment.
I then instructed the patient to perform a couple sets of supine kettlebell carries. Each set lasted until the patient neared fatigue and was unable to retract and "pack" the shoulder/scapula. This was performed bilaterally. Reassessing the upper extremity pattern 1 revealed decreased winging compared with baseline.

MET for the Scalenes
Before Treatment
Next, I performed MET for the posterior hamstrings. Specifically, I also instructed the patient on performing an autogenic isometric inhibitory technique. I performed this bilaterally and found that the patient's passive SLR increased ~20 degrees immediately by the end of treatment.
After Treatment
The patient was unable to attempt rolling exercises due to passive back pain so instead of attempting to restore rolling I had the patient perform some light stretching hip external rotation and calf stretching after having their glutes and gastroc/soleous worked out using a rolling stick by my student.
Easy Hip ER Stretch
Straight Leg Gastrocnemius Stretch - Towel prevents pronation

Bent Knee Soleus Stretch - Towel prevents pronation again

Day 2: Pain (4/10)

The patient returned the second day with increased cervical flexion and rotation patterns but they were no longer functional. I repeated the previous days IASTM and MET techniques and once again these patterns were FN after application. In attempt to prolong these gains, I applied some Rock Tape to the upper traps and scalenes. Once again I had the patient do some kettlebell carries while in a supine position. 

The passive SLR was still increased from the previous day but was still about 15 degrees short of normal. The patient was able to foam roll without increased pain and so I had him foam roll the entire posterior leg chain before IASTM to the aforementioned patterns. Again, we used the previous day's MET application to the hamstrings and this increased the passive SLR to normal.


Due to the patient's ability to have such drastic increases in mobility in such a small amount of time I suspected crucial core stability issues. In attempt to progress this patient quickly I wanted to restore rolling ASAP for the supine to prone upper extremity rolling pattern. I spent about 15 minutes working on rolling with him before calling it a day. Rolling was definitely not perfect but was much better than when we began.


Day 3: No Pain?

On the third day of treatment the athlete returned with FN cervical flexion, and rotation patterns and now Multi-Segmental Flexion was a DN. The athlete reported being sore in the shoulders and hips but no longer was experiencing any pain. We were now about 7 days out from initial injury. I continued to work on rolling patterns and was able to progress to some quadruped and tall-kneeling exercises before the day's end. I could tell that the athlete was very excited to return to basketball so I began his RTP progress with some easy free-throw shooting.


Return to Play and Further Treatment:

Unfortunately, the next day the athlete returned home for spring break and was no longer under my supervision. Despite my best efforts to provide a substantial home-exercise program for this athlete he was so enthused by his progress that he did not stick to his HEP and instead played basketball and rested his entire break.

Upon returning to school the athlete was no longer compliant with his rehab despite the presence his many dysfunctional movement patterns (MSF, MSE, UE #1, MSR, SLS, ODS) and would no longer come for rehab. Reluctantly, I continued to let him participate in practice and JV games. It wasn't because I didn't care about making him better but more because of it being an issue of me being stretched too thin between other athletes that had issues and wanted my help and patients like him that needed my help but wanted none of it because they no longer suffered. It is not an ideal situation but it is the way the world works sometimes. Ideally for me I wish I had been in a position where there was somebody(like a strength coach) that was familiar with the FMS and corrective exercises to help these athletes overcome their dysfunction.

Points of Distinction & Conclusion:

What I thought was interesting regarding this case was the patient's history of traumatic injury to the left scapula and the presence of ipsilateral hypertonic neck muscular and poor scapular stability when compared bilaterally. I do not know if this was present since his previous injury but its hard for me to ignore such a glaring "coincidence" when I see it. When I initially worked with this athlete I had a little contempt for the incomplete rehabilitation that he must have been put through following his previous injuries. 

However, I soon began to feel and conclude that much of this could have been the athlete's own doing and not that of previous clinicians. I even tried the route of touting injury prevention, performance enhancement and how he may be a ticking-time bomb for re-injury and recurrence of back pain. Some people, patients, and athletes just do not seem to want help unless they are physically writhing in pain and unable to walk. I am not sure if this is pride or pure laziness! 

Posted on Tuesday, April 29, 2014 by Adam Kelly

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