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Treating the biomechanics of athletes


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Power Point Presentation for Podiatry on the Biomechanics of treating athletes

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Treating the biomechanics of athletes

  1. 1. Treating the Biomechanics of Athletes: Clinical Biomechanics by Richard Blake, DPM San Francisco, California
  2. 2. Thank You!! Greg Lawrence and His Committee OOLAB for their Sponsorship
  3. 3. What do I want to accomplish? Introduce the Broad Topic of Clinical Biomechanics in Podiatry Challenge you to get better in your mechanical treatments of pain and deformities Discuss Some General Rules of how Biomechanics fits into a clinical practice of treating injuries Emphasize Lower Extremity Injuries and their relationship to pronation, supination, short legs, and poor shock absorption
  4. 4. What do I do on the first visit? 1. I talk to the patients 2. I watch them walk and run in the clinic 3. Try to correlate motion or position with their injuries (cause #1) 4. Measure what is very important for them (like FHL and achilles flexibility in all cases of big toe joint pain 5. Start with simple biomechanical changes (OTC arches, taping, dancer’s pads, varus or valgus wedges, etc.) 6. Come up with a plan for future visits as needed 7. Check whether I am addressing the Implied Need of the injury severity or patient’s need
  5. 5. Clinical Biomechanics We, as a profession, are past the stage that we can just take a good impression cast for custom orthotic devices and the expect success 100% of the time
  6. 6. Clinical Biomechanics What Changed That? First of all, We found that the Root Theories applied primarily to Walking only, although these theories do remain vital in treating patients We must make our patients stable, control inflammation, relax muscle tension, and reduce nerve hyper-sensitivity in creating our healing 0-2 pain level environment. Orthotic devices are crucial to this endeavor.
  7. 7. Treating athletes has led to Variety of Orthotics and Theories
  8. 8. Clinical Biomechanics The Shoe Explosion gave us new challenges (sometimes helpful and sometimes not) in trying to influence biomechanics in day to day life and in sports participation From Minimalist to Maximalistic or Cushion to Motion Control or dress shoes or high heels to ballet slipper and basketball shoes, etc.
  9. 9. Is it amazing what people run in!! Very supinated left foot presenting with a supination related injury
  10. 10. Clinical Biomechanics We found Sport Specific Indications of What is Normal and Abnormal which taught us that biomechanics involves technique, strengthening, stretching, taping, braces, so much more than just foot inserts. Right side over pointes and the left side wings, aka over pronation
  11. 11. When you are involved in a sport as a doc Get to Know the Normal and Abnormal Mechanics of that sport Talk to coaches, listen to videos, read, find out who else treats these athletes
  12. 12. Clinical Biomechanics We found challenging concepts involving short term use of orthotic devices, OTC vs custom inserts, strength alone without orthotic devices, or using strengthening, gait changes, and orthotic devices together
  13. 13. I Encourage Everyone to have a favorite OTC insert like Sole or Powerstep that you can customize from day one Learn what they can do for you and your patient—stock them in your office
  14. 14. Customized OTC insert Here with added medial arch and varus wedges
  15. 15. Clinical Biomechanics Soooo, 39 Years After I Graduated from Podiatry School Treatment of Biomechanics involves all these wonderful things: 1. Various Forms of Shoe Inserts 2. Strengthening of the Foot and Ankle, and Above 3. Sport Specific Mechanics and Rehab Programs 4. Stretching Key Muscle Groups 5. Gait Changes for more Stability or Less Overall Stress 6. Taping and Bracing Explosion 7. Miscellaneous Products like Yoga Toes, Toe Separators, Plantar Fascial Socks, Mountain Bike Shoes, etc.
  16. 16. Biomechanics Checklist for Your Patients which may take several visits to accomplish 1. What does the Gait Evaluation tell me about their injury? 2. Can I correlate their Injury/Pain Syndrome with their Mechanics? 3. Is there an OTC insert that may work at least temporarily? 4. Would I call them a pronator, supinator, short leg patient, do they have poor shock absorption, or a combination of these? 5. Is the right foot/leg different than the left side? 6. Is there some taping, like KT or support the foot, that may help? 7. Are there muscles that should be stronger? 8. Are there muscles that should be more flexible? 9. Do they have a short leg that is causing pain? 10. Is there overall core or lower extremity muscle weakness adding to poor shock absorption at the bone level or other problems? 11. Is their shoe selection for all activities okay? 12. Are they technically sound in their individual sport or should someone evaluate this?
  17. 17. What do we need to Know? General Definition of Biomechanics General Rules of Treating Biomechanics All Theories Teach Us Something if we want to learn Rule of 3 for Biomechanics Rule of 3 for Injuries
  18. 18. Biomechanics Definitions Definition #1: The study of the mechanical laws related to movement or structure of living organisms. Gait Analysis is Crucial for the Motion (try to tie an injury with a motion) Biomechanical Evaluation is Essential for the Structure (try to tie an injury to structure)
  19. 19. Biomechanical Definitions Definition #2: Detailed Analysis of Sports Movements in order to minimize the risk and improve sports Performance Know the Motions of the Sports the patient Is Involved In That Are Normal and Abnormal Know the Rehabilitation Criteria for These Sports for Return to Activity
  20. 20. Biomechanical Definitions Definition #3: The mechanics applied to biology and its response to forces or displacements (how we react to the ground, our bike pedal, the treadmill, etc., etc.). What do your patients do in their workouts? Know how to Modify Machines or Workouts in General to help the safety in Return to Activity Programs and Possible Cause of Injury in first place
  21. 21. Don’t we wish all shoes could do this?
  22. 22. Where does Biomechanics Fit In as We Rehab a Patient? Phase I: Immobilization and Anti-Inflammatory Applies to Acute and some Overuse Injuries to create a 0-2 Pain Level Healing Environment We will look to change the biomechanics, like off-weight a sore heel, shift the weight to a non-painful location, stabilize the foot/ankle, etc. Knowledge of Biomechanics and Why the patient got Injured is Crucial (we begin to look for the cause(s) for future prevention and speed of rehab)
  23. 23. Phases of Rehabilitation Phase II: Re-Strengthening All Injuries whether Acute or Overuse We really should begin some form of strengthening as soon as the injury happened Keep 0-2 Pain Level Throughout the Rehab
  24. 24. Phases of Rehabilitation Phase III: Return to Activity All Injuries whether Acute or Overuse General Rehab and Sports Specific Knowledge of Biomechanics of Why the patient got Injured is Crucial (reversal of 3 possible causes is important by now) Keep 0-2 Pain Level Throughout the Rehab
  25. 25. Biomechanics is now a Sophisticated Science Yet Still in its Infancy Clinical Information is still vital to see how General Rules created at the lab stack up to Clinical Testing General Rules are also being Created and Tested in Clinics such as Yours We are all part of the Process Neither Less Valuable Every Study and Every Person Has Biases so Stay Objective (make observations even if they do not agree with what you believe)
  26. 26. What is abnormal Biomechanics? Of course, it is a motion or position that causes an injury sooner than it should be just from overuse of that body part Part II: Correction of that motion or position blamed should result in a good healthy positive change for the patient If you do not practice biomechanics, you will never understand Part II, and if you do practice biomechanics you will!!
  27. 27. The Day to Day as a Biomechanical Podiatrist Start with History of Present Injury Advance to Previous Injuries of Problems (looking for patterns) Know the Injuries related to abnormal pronation, abnormal supination, limb length discrepancy, poor shock absorption, tight Achilles and weak muscles Watch the patient walk, run if they run, bike if part of their injury, or have them send video of their main activity you can not observe in the clinic (like ice skating) Evaluate their injury with attention on their biomechanics as it ties to the injury
  28. 28. Injuries Related to Biomechanics An abnormal motion or position affects the Weakest Link in the Chain: Think Injury Rule of 3 in Treatment Abnormal Mechanics and 2 more causes other than overuse itself as a cause For Example, they pronate, but why did they get medial knee pain not posterior tibial pain, or plantar fascial pain Every Injury has other causes that can work with the pronation to cause a weak link in the chain Bone Density or Vitamin D Deficiency Muscle Weakness or Tissue Inflexibility Poor Shoe Selection or Abnormal Structure
  29. 29. Injuries Related to Biomechanics As you improve in Biomechanics, consider the Biomechanics Rule of 3: For Example, they pronate, and they injure the tibial sesamoid, think pronation, plantar flexed first ray, tight Achilles Or, they supinate, and they develop a stress fracture in their fibula, think supination, unstable lateral column, short leg
  30. 30. So What if we overly pronate? Medially unstable Excessive Rotation/Torque on our Structures Poor Shock Absorption if we are fully pronated Excessive Medial Foot Weight Bearing Excessive Lateral Knee Joint Weight Bearing
  31. 31. Injuries Related to Abnormal Pronation 1. Big Toe Joint Capsulitis (Hallux Limitus/Rigidus) 2. Sesamoid Injuries 3. Metatarsalgia 4. Morton’s Neuroma/Neuritis 5. 2nd MPJ Capsulitis 6. 2nd Metatarsal Stress Fractures 7. Hammertoes 8. Intrinsic Muscular Strain 9. Plantar Fasciitis 10. Sinus Tarsi Syndrome
  32. 32. Injuries Related to Abnormal Pronation 11. Cuboid Syndrome 12. Anterior Tibial Tendinitis 13. Posterior Tibial Tendon Injuries 14. Lateral Ankle Impingement Syndrome 15. Tarsal Tunnel Syndrome 16. Peroneus Longus Strain 17. Achilles Strain 18. Tibial Stress Fractures 19. Medial Soleus Strain 20. Lateral Knee Compartment Compression Pain
  33. 33. Injuries Related to Abnormal Pronation 21. Pes Anserinus Tendinitis/Bursitis 22. Patello-Femoral Injuries 23. Medial Hamstring Strain 24. Ilio-Tibial Band Syndrome 25. Piriformis Syndrome
  34. 34. So what if we overly Supinate? Laterally Unstable Excessive Out of Phase Rotation in Contact and Midstance Poor Shock Absorption Excessive Lateral Weight Bearing Foot Excessive Medial Knee Joint Weight Bearing Extension of the Knee at Impact, not Flexion
  35. 35. Injuries Related to Abnormal Supination 1. Hammertoes 2. Lateral Metatarsalgia 3. Tailor’s Bunions/5th MPJ Capsulitis 4. 4th and/or 5th Metatarsal Stress Fractures 5. Cuboid Syndrome 6. Peroneal Strain 7. Lateral Ankle Instability 8. Haglunds with Retro-Calcaneal Bursitis 9. Medial Ankle Impingement 10. Posterior Tibial Tendinitis or Long Flexors
  36. 36. Injuries Related to Abnormal Supination 11. Fibular Stress Fractures 12. Proximal Tib/Fib Sprain 13. Medial Knee Compartment Compression Pain 14. Knee Arthralgias 15. LCL Sprain 16. Lateral Hamstring Strain 17. Ilio-Tibial Band Syndrome 18. Femoral Stress Fractures
  37. 37. Injuries Related to Abnormal Supination 19. Hip Arthralgias 20. Sacro-Iliac Joint Pain 21. Low Back Pain (poor shock absorption and excessive pull of the hamstrings)
  38. 38. Short Leg Syndrome 80% with Long Leg Pronate more than the short side, 20% pronate more on the short side Short Leg may Supinate with Early Heel Off for compensation With a short leg, we tend to have a limb dominance (more weight on either the long side or the short side)
  39. 39. I Prefer Full Length Lifts over heel lifts Please keep lifts separate from the orthotic device
  40. 40. Limb Dominance from Possible Short Leg
  41. 41. Short Leg Syndrome Body gets in trouble from 4 common reasons: 1. Pronation of the long leg or supination of the short side 2. Collapse to the dominant side (more weight bearing) 3. Trying to self correct (example, Achilles pain on short leg trying to correct with early heel off) 4. Rigidity developing over the years in the back or a breakdown in joints, etc.
  42. 42. Poor Shock Absorption 1. Fat Pad Atrophy as we age! Yuck! 2. Weaker muscles, and sedentary life styles, as we age mean less overall motion and more shock to our bodies as we try to move 3. Limb Dominance with one side more pressure 4. Over Supination robs our Shock Absorption and also makes us unstable (evil!!) 5. Functioning Maximally Pronated (we need to pronate some for shock absorption)
  43. 43. Big Suggestion!! When evaluating an athlete, look for: 1. Pronation Issues 2. Supination Issues 3. Short Leg Issues 4. Shock Absorption Issues 5. Measure their Achilles Tendon 6. See What their Resting Heel Position Is 7. See if they have Functional Hallux Limitus 8. Learn if Right side is different from the left 9. Learn about the normal motions of their sport of choice
  44. 44. Thank You and Have Fun!!!