There's a term we use in physical therapy called "respect the healing process." I've decided to shed a little more light on what we mean by this. Ultimately, the body is supposed to go through certain processes after an injury. These phases are inflammation, proliferation, and remodeling. Each phase has its frustration with respect to our patients. Contrary to popular belief, physical therapy will not make any of these phases go FASTER.
The inflammation phase is the immediate response to an injury. It is the swelling and the PAIN! Physical therapy works to help manage this phase through soft tissue work, light joint mobilizations, TENS units, exercise for facilitation and activation of surrounding musculature, gradual return of range of motion and more. The goal of getting into physical therapy this early is so that we can be prepared to move into the next phase: proliferation.
The proliferation phase is when most of the scar tissue will form. Scar tissue is a key component to healing. Whatever tissue we injured NEEDS scar tissue to heal. It reinforces the injured tissue. During this phase, physical therapy targets progressive loading of muscle and tendon structures through exercise. These techniques coupled with hands on work will help reduce excessive scar tissue formation. These treatments help prepare us for the last phase: remodeling.
The remodeling phase is when we restructure the scar tissue to align appropriately with the component it is trying to heal as well as increase exercise demand and tolerance for the surrounding areas. For example, if the achilles tendon was injured or slightly torn, we will emphasize exercise and hands on work to promote the vertical nature of the fiber alignment in the achilles tendon. This is also achieved with select tissue loading that is usually more weightbearing and functional.
This is the phase where physical therapy transitions to a routine more targeting your goals. If you want to get back to hiking, we will start lunges and squats. If you want to get back to running, we would start light plyometric and speedwork. These exercises are built upon the exercises you've been doing in the proliferation phase. As you can see from the chart above, this is the longest phase of healing. I always like to tell my patients that once you injure a structure or tissue once, you are at a greater risk of injuring it again. Physical therapy will give you all the keys and exercises necessary to reduce this risk as much as possible!
The phases of healing are overlapping in nature but never to be rushed. Physical therapy guides each patient individually through inflammation, proliferation and remodeling to ensure the best recovery and reduce your risk of re injury. A key component during your physical therapy experience at Altitude is that we will identify how you injured yourself in the first place which I have found is the best approach to not letting it happen again! Remember, you can start physical therapy even BEFORE you get injured, too! :-)
For more detailed description of the phases of healing, please see the image above or visit: https://www.physio-pedia.com/Soft_Tissue_Healing
Lisa Corken, PT, DPT
There has to be something like over 1 million different types of shoes out there, right? How do you know which shoe is best for you? The answer to that question is one that we hear in physical therapy school a lot….. IT DEPENDS!!! **also note that these are my professional opinions and I have no affiliations or relationships with any particular shoe brands**
There are always going to be fads and trends when it comes to footwear. For example, the finger toes, the barefoot running shoe, the Skecher ShapeUPs, the HOKAS, the skater shoe, Converse, AirJordans, Asics, Nikes, and the list goes on and on. This blog is meant to cover shoe selection generically and finish with the burning question I get from aging runners - Should I switch to HOKAS (or cushioned shoes)??
When it comes to shoewear, there are a lot of things to consider. Are you running? What type of surface are you running on? How often do you run? How far do you run? Are you walking? Where do you walk mostly? Are you in any foot pain? Do you have any pain with walking? Do you wear gym shoes all day? Do you wear high heels for work? Do you wear sandals in the summertime? It’s quite the specialty to pick the perfect shoe for someone and we almost never get it right the first time…
When you come to physical therapy and ask the question, “but which shoes are best for me?” your physical therapist will start asking the above questions. They’ll also follow it with a gait or running analysis in addition to a movement screen. They’ll check the range of motion of your low back, hips, knees, ankles, and the tiny joints in your feet. The most important thing about selecting a shoe is finding one that will SUPPORT your current and preferred movement pattern versus attempting to CORRECT it. In my 7 years of working with runners and hikers in Colorado, I have only once ever recommended a MOTION CONTROL shoe for a patient. More frequently, we are able to address motor control deficiencies before relying on an external source, like a shoe, to correct any gait or running deviations.
Now, to address the most recent fad or trend in shoewear, I’m going to talk a little bit about HOKAS or shoes that have a lot of cushion. I took two intensive running courses over the past 7 years and they presented similar information regarding the theory behind HOKAS. The idea is that the significant cushion will reduce shock absorption through the rest of the body. The reason I write THEORY is that this is almost impossible to prove with the current technology (at least at the time I’m writing this blog). There are studies that show ground reaction forces when wearing HOKAS and when BAREFOOT. Ground reaction forces are a measurement of how hard you stomp on the ground. This measure has an equal and opposite force through your body. Ultimately, the study found that there was no change in the magnitude of your ground reaction force. Where the study is limited is showing WHERE the ground reaction force is being absorbed. Hence, THEORY. With that great of a cushion, the assumption is a large amount of that force is being absorbed by the shoe and not your joints.
So, I always get the question from the aging runner - should I switch to HOKAS? And just as I started this blog, the answer is - IT DEPENDS! If I watch you run, jump, hop and I can see you have a difficult time with absorption through musculature and joints, I may recommend the HOKA-type shoe. But if I think it’s something that you can train and work up to, I would go down that path first. In my opinion, the downside of HOKAS is that the cushion significantly increases the distance between the sensors in your feet and the ground. Basically, your entire lower kinetic chain takes longer to process any feedback from the ground and this can often lead to ankle sprains, falls, and other injuries.
I also mentioned in the beginning of the blog that selecting the perfect shoe is incredibly challenging and that we almost never get it right the first time. There are so many factors in addition to what I’ve already discussed from a physical therapy standpoint. We need to take into consideration cost, cosmetics, comfort, durability, fit, and ease of getting them on and off. I may very well pick a shoe that I think is perfect for you, you’ll test it out and absolutely hate it! This is where your shoe history is incredibly helpful. I often find that whatever shoe you used to wear all the time is likely the correct shoe for you - we just may need to adjust your motor control for efficient muscle firing during walking or running.
And if we simply cannot find the right shoe for you, that’s when we start considering orthotics. The question of “how do I know if I need orthotics?”.... Well, that’ll be for another blog post :)
Lisa Corken, PT, DPT
Why do people get Achilles tendonitis and plantar fasciitis???
There are many factors that can contribute to Achilles tendonitis and plantar fasciitis. The number one factor is usually an overuse of the gastroc-soleus complex. The two muscles in your calf join together at the Achilles tendon in the back of the heel. When this structure gets overused, it can pull the heel bone (calcaneus) in a way that irritates the plantar fasciitis in addition to it just getting irritated right at the Achilles tendon.
The real question we ask as physical therapists is “Why Are You Using Your Calf So Much!?” Ironically, your calf being tight may be the immediate source of your pain but more often than not your pain is probably coming from a lack of strength or range of motion somewhere else entirely. I have found throughout my experience in physical therapy and taking two intensive courses on running injuries that there are two main places that can cause an overuse of your calf muscle: 1. Hip Extension Range Of Motion and 2. Great Toe Extension Range Of Motion
In the gait and running cycle, we have phases called “terminal stance” and “pre-swing,” which is when our toe just barely comes off the ground to take that next step forward. This particular position requires a certain range of motion at the hip and big toe. The hip should be able to achieve at least 10 degrees of extension and the big toe should be able to achieve at least 60 degrees (if walking) and up to 90 degrees (if running) of great toe extension.
If you take a look at this picture, you can see that the femur (thigh bone) is angled slightly behind a totally vertical line (imagine a straight line from the pelvis down to the ground) and that the big toe is starting to extend or bend as the foot/ankle rolls through. This position allows optimal contraction of our gluteus maximus muscle - the huge power generating muscle of the entire lower kinetic chain. When the range of motion is limited in the big toe, we cut the terminal stance and pre-swing phase of gait short. This means we get off of the foot more quickly and we don’t access the range of motion that allows the glute to work. Thus, we use something else - the CALF. The same principle applies with limited hip range of motion. If we can’t get our femurs to extend beyond neutral and into that 10 degrees of extension, the glute cannot properly fire so we again ask the calf to help with power more than we normally would. As luck would have it, when I have a patient come in with plantar fasciitis or Achilles tendonitis, they are usually lacking BOTH hip range of motion and toe range of motion - double whammy.
Can it be fixed?! YES! My approach to treating plantar fasciitis and Achilles tendonitis is to treat locally first. This means treating calf tightness to help with symptom management right away - massage, dry needling, stretching, etc. As the calf responds to treatment, we are able to shift gears to the actual origin of the injury. This usually includes manual therapy to the big toe or the hip to improve any limitations noted. Whilst improving the range of motion is a big component to improving the motor efficiency in your gait cycle, there needs to be accompanying functional exercises to promote muscle activation in the appropriate positions. This is where physical therapy can get really fun and creative using balance equipment, speed adjustments, plyometrics, and sport-specific exercises.
There is this concept we discuss in physical therapy where we describe being strong throughout the available range of motion. What this means is that even if we improve your flexibility and range of motion, you’re still at risk for injury if you don’t know how to CONTROL that new range of motion. But once you learn to do this, your risk of re-injury is significantly less - assuming you keep up with your homework!
This blog was meant to discuss the most common reasons plantar fasciitis and Achilles tendonitis may occur, but is certainly not all-inclusive. Overall, I want to remind all patients that the longer plantar fasciitis or Achilles tendonitis are bothering you, the longer it takes to heal. Don’t wait too long to get it checked out! Key identifying factors are sharp pain felt in the center of the heel, pain felt along the inside of the heel, pain in the arch of the foot, pain in your Achilles tendon, and pain with your first steps out of bed in the morning. If you feel like you have any of these nagging pains, let us know and we can get you started on your road to recovery!
Lisa Corken, PT, DPT
Bob Cranny, PT