Staying Afloat, Keeping the Wheels Down and Feet Forward

Report
Staying Afloat, Keeping the
Wheels Down and Feet Forward
Prevention and Management of
Repetitive Stress Injuries in the
Triathlete
Dr. John L. Michie
Experience
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Certified Chiropractic Sports Physician
Certified in Physiological Therapeutics
Certified Exercise Physiologist
Certified in Clinical Nutrition
Certified Myofascial Dry Needle Therapist
Certified Functional Medicine Practitioner
20 years in clinical practice working w/athletes
+2,000 hours of post doctorate education
Program Highlights
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Mechanisms of Injury
Applied Kinesiology and the Kinetic Chain
Connective Tissue Support
Managing Inflammation
Self Corrective Measures
When to Seek Treatment and What
Modalities are Best?
Common Injuries of the Triathlete
 Runner’s Knee/Patella Femoral
Syndrome/Chondromalacia
 Achilles Tendonitis
 Swimmer’s Shoulder
 IlioTibial Band Friction Syndrome
 Sciatica (Discogenic and Piriformis)
 Sacroiliac Syndrome
 Plantar Fasciitis
Common Injuries of the Triathlete
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Medial Tibial Stress Syndrome
Meniscal Tears
Adrenal Fatigue
Degenerative Disc and Joint Disease
Lower Extremity Stress Fractures
Rotator Cuff Tendonopathy
Ken Hutchins
“Exercise is not an Adjunctive
Therapy, Exercise is the
Therapy.”
Mechanisms of Injury
Repetitive Stress Trauma
 Triathlon training consists of massive
repetitive stress to multiple body regions!!
 All endurance training consists of repetitive
stress!!
 In RST, Connective Tissue failure occurs
due to excessive loading and/or poor
biomechanics
Mechanisms of Injury
Connective Tissue
 Tendons connect muscle to bone and
transmit mechanical energy
 Ligaments connect bone to bone - denser
and provide some shock absorption
 Myo-tendinous Junction is a transitional
area and highly vulnerable to injury
 Tendons and Ligaments are largely made up
of Collagen
Mechanisms of Injury
 Exhaustive Endurance Training creates
damage via metabolic disturbances and
ischemia! (Ischemia Induced Muscle
Damage) – restoring blood flow critical!
 Muscle Contusion injuries (Swim?) – may
lead to excessive fibroblastic activity and
formation of bone within the muscle
Mechanisms of Injury
 Stretch Injuries occur when the movement
exceeds the flexibility of the joint/ligament capacity
resulting in micro-tears.
 Biomechanical imbalances are the underlying
causes of most soft tissue related injuries!
 “The Kinetic Chain is integrated and if faults exist
anywhere there will be an insidious development
of injury at or remote to the fault site!” JLM
Inflammation!
Cardinal Signs:
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Heat
Swelling
Pain
Redness
Loss of Function
Inflammation and Repair
 Remove inflammatory debris by
Phagocytosis
 Granulation/Scar Tissue Formation
 Tissue Remodeling ~6 days post injury
 Collagen is laid down randomly
 NSAIDs interfere w/collagen formation!
Inflammation and Repair!
 Immobilization of a healing injury
compromises strength and collagen
orientation
 Mobilization results in stronger, faster
healing of connective tissue injuries!!
 The greater the amount of injured tissue, the
more scar tissue deposition
Inflammation and Repair!
 Ischemia-induced Muscle Injury is caused by
damage to vessels seen in endurance sports
(Compartment Syndromes)
 Extent of injury proportional to duration of pressure
 Nerve injury may result due to persistent pressure
 Can result in excessive scar tissue formation and
cell death
 Kinetic Chain imbalances lead to over-utilization of
muscle groups and this may lead to ischemia
Inflammation and Repair!
Inflammatory Response & Time
Frame of Healing:
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Acute phase: 24-48 hours
Proliferative phase: 3-7 days post injury
Repair phase: few days to few weeks
Remodeling phase: several months…..
Immobilization
Negative Effects of Immobilizing
Injuries:
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Cartilage deterioration
Bone strength/mass loss
Ligament strength and pliability loss
Adhesion formation magnified
Muscle atrophy
Longer rehabilitation windows
Treatment Protocols
Acute Phase:
 Goal: Control Pain and Inflammation
 “PRICE”
 Protect
 Rest
 Ice
 Compression
 Elevation
Treatment Protocols
Physiological Therapeutics:
– Ice 30 minutes per application (Avoid Hunter
Reaction!)
– Electrotherapy (IFC, HV, etc.)
– Ultrasound (Pulsed & Continuous)
– Iontophoresis
– Moist Heat – Post Acute Phase
Treatment Protocols
Joint Mobilization/Manipulation:
– Stimulates mechanoreceptors
– Decreases joint congestion
– Relieves compressive forces on articular
cartilage and structures
– Relieves contracture of tissues
– Breaks down adhesions
– Enhances biomechanical alignment
Treatment Protocols
Soft Tissue Mobilization and Cross
Fiber massage:
– Breaks down scar tissue and adhesions
– Activates phagocytosis
– Creates fiber re-alignment
– Accelerates healing and minimizes reoccurrence!!
Treatment Protocols
Biomechanical Adjustments
– Restores optimal kinetic chain alignment
– Facilitates biomechanical integration
– “Resets” neurological firing patterns
– Stimulates healing and joint function
– Reduces pain
– Minimizes re-occurrence
Treatment Protocols
Kinesio-taping
– Mechanical Correction “Recoiling”
– Fascia Correction “Holding”
– Space Correction “Lifting”
– Ligament/Tendon Correction “Pressure”
– Functional Correction “Spring”
– Lymphatic Correction “Channeling”
Nutritional Management
Anti-Inflammatory Protocol:
 Avoidance of Sugar, Trans Fats, Grains and Dairy
(Grain fed animal products + eggs also inflame!)
 Increase Hydration!
 Proteolytic Enzymes – 3-6 tid w/o food (Vegetarian
and/or Non-Vegetarian) – Trypsin, Chymotrypsin,
Bromelain, Papain (Wobenzyme, Protrypsin)
 Omega 3 Fatty Acids/Fish Oil – 6-9g/day
Nutritional Management
 Ginger, Boswellia, Turmeric (Cox 2 Inhibitors) (Inflavonoid
I.C.)
 CoEnzyme Q10 100-200mg/day
 Mixed Anti-Oxidants
 Mixed Bioflavonoids 2-3Kmg/day
 ALA (Flax), Chia
 GLA (Borage)
 Willow Bark Extract
 Devil’s Claw Extract
 30-90 day high dosing for pharmacological effects!
Connective Tissue Integrity
Nutritional Protocol
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Amino Acids (Glycine, Proline, Lysine)
BCAAs (Leucine, Isoluecine, Valine)
Vitamin C
Mixed Bioflavonoids
Green Lipped Mussels
MSM
Horsetail Extract (Silica)
Hyaluronic Acid
Glucosamine/Chondroitin Sulfates
Manganese
(Collagenics, Ligaplex I and II)
Runner’s Knee
Causes:
 Pronation
 Q-angle (Women > Men)
 Quadriceps Imbalances/Weakness
 Tight Hamstrings and ITB
 Short Hip Flexors
 Road Pitch Repetition
 Overly Supportive Training Shoes
 Wearing Training Shoes beyond ~400 miles
Runner’s Knee
Symptoms:
 Pain behind and around the Patella
 Pain with walking, running, squatting,
kneeling
 Increased pain with downhill running
 Popping, grinding in and around the knee jt.
Runner’s Knee
Management:
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PRICE
Acute Physiotherapy protocols (Iontophoresis)
Nutritional Anti-inflammatory protocol
Strengthen Quadriceps
Myofascial release and foam roller @ Hamstrings, ITB,
Hip Flexors
Orthotics for foot imbalances, pronation, etc.
Pool Running
Evaluate Shoes for wear patterns, breakdown, etc.
Manual manipulation, alignment of kinetic chain
imbalances
Bracing for Patella stabilization and compression
Proprioceptive input training with balance board and
bosu ball
Achilles Tendonitis
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Causes:
Reduced Flexibility or weakness in Calf Group
Overuse or increased training intensity or volume
Less recovery time between running sessions
Increased hill or speed work!!
Unequal leg length
Pronation or Supination
Ankle or Foot Joint Fixations
Poor Heel posting, poor shoe selection!
Antibiotic usage (Quinolone group) 
Cortisone
Poor warm-up habits
Achilles Tendonitis
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Symptoms:
Pain behind ankle
Pain just above the heel
Increased pain during exercise
Point tenderness over Achilles Tendon
Worse in AM or after rest
Scar like bump formation or thickening
Achilles Tendonitis
Management:
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PRICE
Anti-inflammatory nutritional protocol + connective tissue support
Ultrasound – 4-6X/week!
Iontophoresis
Myofascial Release (Foot, Calf Group)
Manipulation/Mobilization of Foot/Ankle/Knee
Dry Needle Therapy
Orthotics
Improve heel posting
Heel Pad/Lift
PRP??
Dorsi-Flexion Night Splint
Avoidance and H2O running
Traumeel topically 3X/day
Swimmer’s Shoulder
Causes:
 Faulty Stroke Mechanics
 Increased training intensity and/or volume
 Micro tears from overuse
 Excessive % of Freestyle swimming
 Weakness in Upper Traps and Serratus Ant.
 Weakness/Tightness in Posterior Rot. Cuff
 Hyper-mobile Shoulder
Swimmer’s Shoulder
Symptoms and Signs:
 Pain with Freestyle
 Forward Shoulder Slouch while sitting
 Winging of Scapula
 A.C. Jt. Tenderness
 Biceps Tendon, S.S. Tendon tenderness
 Reduced strength in S.S. and I.S. muscles
 Moderate shoulder Jt. laxity
Swimmer’s Shoulder
Management/Prevention:
 Establish bilateral breathing pattern
 Employ symmetrical body rotation
 Avoid Thumb First H2O entry
 Employ flat hand, finger tip first entry
 Open up chest muscles
 Think “shoulders back, chest forward”
 Avoid midline cross over at front of stroke
 *Employ High Elbow Catch and Pull Technique
 Strengthen External Rotators for Scapula Stability
(Shoulder Horn!)
Swimmer’s Shoulder
Management/Treatment:
 PRICE
 Nutritional Anti-inflammatory protocol!
 Electrical Stimulation
 Trigger Point Therapy
 Iontophoresis
 Dry Needle Therapy
 Mobilization/Manipulation (Cervical, thoracic spine, shoulder, scapula,
elbow, wrist/hand – upper kinetic chain)
 Myofascial release Tx. – shoulder girdle, pectorals
 Topical Traumeel
 Shoulder rehabilitation protocol for A.C. Jt. Decompression (see
shoulder rehab protocol)
ITB Syndrome
**ITB Acts as a Stabilizer during running**
Causes:
 Road Pitch Running
 Excessive Pronation/Supination
 Leg Length Discrepancy/Pelvic Un-leveling
 Varus knees (Bow legged pattern)
 Gluteal & Quad Tightness/Weakness
 Inadequate warm-up and/or cool down
 Excessive Hill running (up or down)
 Toed in position in cycling
 Excessive Breast stroking
 Excessive wear on outside heel edge of running shoes
 Weak Abductors (Glute Med.)
ITB Syndrome
ITB Syndrome
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Symptoms:
Pain @ lateral aspect of knee
Pain below knee (lateral aspect – attachment)
Pain @ lateral lower thigh
Pain @ lateral hip
Pain increases with descending stairs and
transitioning up from sitting
 Pain increases with heel strike
ITB Syndrome
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Management/Treatment:
PRICES
Topical Traumeel + (DMSO) + Biofreeze
Correct biomechanical distortion
Orthotics cast to correct pedal imbalances
Kinesiotape knee and/or hip
Transverse Friction Massage
Physiotherapy modalities (EMS, Ultrasound and Iontophoresis)
Chopat type stabilizing brace
Myofascial release @ Gluteal group, Quads, Lat. Hams,
Gastrocnemius
 Restore strength to VMO to facilitate medial glide of patella
 Foam Roller!
 ITB Stretches
Sciatica
 Discogenic: Bulging or herniated disc
causing compression/irritation of sciatic
nerve.
 Piriformis: Deep Gluteal muscle causing
compression/irritation of sciatic nerve
Sciatica
Symptoms:
 Pain in gluteal and/or down back of thigh
and leg into ankle/foot
 Burning/aching/tingling down thigh/leg/foot
 Weakness and/or numbness down extremity
 Constant pain in unilateral gluteal muscle
 Hip Pain
 Increased pain with straining, cough, sneeze
Sciatica
Symptoms (cont.):
 Diff. Diag. with Piriformis:
 Pain/dull ache in gluteal
 Pain after prolonged sitting
 Pain increases with stairs or inclines
Sciatica
Causes:
 Spinal Stenosis
 DDD
 DJD
 Spondylolisthesis
 Disc Herniation
 Trauma to back and/or hip/gluteal region
 Training with mechanical imbalances in kinetic
chain
Sciatica
Treatment/Management:
Diff. Diag. with exam and MRI
Discogenic:
 PRICES
 Electrotherapy (EMS, Iontophoresis)
 Traction, Inversion Tx.
 Aggressive Nutritional Anti-inflammatory protocol!!!
 Correct Biomechanical imbalances
 Dry Needle Therapy and Acupuncture
 Training modification/low impact
 Resistant cases: Prescription NSAIDS, Prednisone,
Muscle Relaxers Epidural Injections, Surgical Consult
Sciatica
 Piriformis:
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Trigger point therapy
Myofascial release tx.
Correct biomechanical imbalances
Electrotherapy (EMS, Ultrasound, Iontophoresis)
Dry Needle Therapy
Orthotics and/or running shoe modifications
Foam Roller!
Piriformis stretches
Epsom Salt Bath
Kinesiotape
Sacroiliac Syndrome
 Large joint connecting the sacrum to the
ilium bilaterally via ligaments and cartilage
Symptoms:
 Pain over one SIJ
 Referred pain to the buttock, hip, groin and
posterior thigh
 Tenderness over the SIJ
Sacroiliac Syndrome
Causes:
 DJD Changes
 Pregnancy – late effects
 Pelvic Un-leveling
 Pronation
 Poor shoe selection + extended wear
 Road Pitch
 Excessive tightness in LB and/or Hips
Sacroiliac Syndrome
Management:
PRICES
 Diff. Diag. with exam (Gillet, provocation…)
 X-Ray
 Correct biomechanical imbalances
 Orthotics and/or modify shoe wear
 Gait Analysis
 Spine, Hip, Foot, SIJ Mob./Manipulation
 Foam Roller @ Gluteal group, lower back, hip flexors, hams and
quadriceps
 Physiotherapy modalities (EMS, US, Iontophoresis)
 Topicals (Traumeel, DMSO, Biofreeze)
 Training modification
Plantar Fasciitis
Microtears and microruptures of the thick fibrous
band of connective tissue originating @ bottom
surface of calcaneous and extending along sole of
foot toward toes
Symptoms:
 Pain @ underside of heel
 Pain is most intense with first steps of day
 Painful dorsi-flexion
 Tight calf muscles
 Most likely 40-60yrs. Women>Men (Prevent!)
Plantar Fasciitis
Causes:
 Pronation and/or Supination
 Tight Soleus and Gastrocnemius
 Faulty Foot/Ankle biomechanics
 Prolonged shoe wear
 Road pitch
 Speed/Track training
 Excessive mileage or training intensity
 Improper training cycle pattern
 Age!
Plantar Fasciitis
Management:
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Diff. Diag.: MRI, Diagnostic Ultrasound and examination (dorsiflexion of foot,
ankle and great toe while knee is extended)
R/O Metatarsalgia, Heel Spur
PRICE
Orthotics cast
Kinesiotape
Myofascial release @ Calf group
Stretching of both calf muscles and Achilles
Rolling TX with cylindrical device, tennis ball
Manipulation of foot/ankle/knee/hip/pelvis for ROM and alignment
Ultrasound tx.
Hot Water Immersion
Radio Frequency Ablation (Extracorporeal shockwave therapy)??
PRP
Medial Tibial Stress Syndrome
 “Shin Splints”
 Periosteal inflammation due to overuse and pulling of
the muscle from its muscle/tendon origin
 Symptoms:
 Pain @ inside/back of Tibia
 Dull Ache progressing to sharp
 Pain starts with activity, reduces then increases again at or
near end of activity
 Swollen lower leg
 Redness
 Lump and/or bump @ lower leg
 Pain with ankle/foot/toe plantar flexion
Medial Tibial Stress Syndrome
Causes:
 Increase in training intensity and/or mileage
 Running down-hill
 Uneven running surfaces and road pitch
 Weak dorsiflexors and/or stronger plantars
 Over-pronation
 Inadequate calcium intake
 Compensation
 Shoe fatigue
Medial Tibial Stress Syndrome
Management:
 PRICES
 Kinesiotaping and Compression Hose
 Orthotics cast
 Manipulation/Mobil. Of Foot, Ankle, Knee, Hip and SIJs
 Clear out imbalances @ External rotators of hip, Hip
Flexors (Psoas), and Adductors
 Reduce volume and cross train
 Nutritional Anti-Inflammatory protocol
 Topicals: Traumeel + DMSO + Biofreeze
 Iontophoresis
Meniscal Tears
Meniscus: Rubbery C-Shaped disc of cartilage
attaching to the tibia that act as shock absorbers
Symptoms:
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Painful “Pop”
Gradual stiffness ensues
Gradual swelling ensues
“Catching” or “Locking”
“Giving Way” feeling occurs
Loss of ROM
Meniscal Tears
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Squatting
Twisting Knee
Degenerative changes
Age
Biomechanical Imbalances
Repetitive Stress
Meniscal Tears
Management:
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PRICES
R/O degree of tear (minor, moderate, severe) via MRI
Kinesiotape
Physiotherapy modalities (EMS, Iontophoresis)
Biomechanical adjustments @ kinetic chain
Orthotics
Strengthen Quadriceps
Training modification (pool)
Nutritional anti-inflammatory protocol
Nutritional connective tissue protocol
HA, Orthovisc, Cortisone injections??
TIME
Adrenal Fatigue
 Stress whether physical, emotional or
chemical exhibits a response that stimulates
the release of catecholamines (hormones)
and taxes the endocrine system (H, P, T, A)
 The severity and longevity of the stress
response as well as the adaptive capacity of
the person will determine the resultant
affects!!
Adrenal Fatigue
Symptoms:
 Fatigue!
 Blood Sugar Fluctuations
 >BP and >HR
 Depressed Immunity
 Increased fat storage
 Depression (decreases Serotonin)
 Elevated cortisol levels promote Inflammation
 Altered sleep quality despite exhaustion
 Tight muscles and aching joints
Adrenal Fatigue
Causes:
 STRESS!!!
 Lifestyle (exercise,
nutrition, work and sleep
habits)
 Environmental (exposure,
chemicals, toxins)
 Worry, guilt, frustration,
anxiety, depression
 GI disturbances, CVD,
Chronic pain, etc.
Adrenal Fatigue
“The story is complicated, the intervention is simple.”
Jeff Bland
Diagnosis:
 Adrenal Fatigue Signs and Self Tests
 Health history, clinical evaluation, applied kinesiology
assessment, dietary assessment
 Lab work – biomarkers for stress, fatigue, etc. (CBC
w/Diff, CMP, ANA, CRP, HgbA1C, Vit D, Vit B12,
Thyroid, EBV, Lyme, 24 hour urinary cortisol
 ASI and/or Neuro-Endocrine Comprehensive panel –
salivary/urine - precise measuring of adrenal hormone
status
Adrenal Fatigue
Management:
Nutrition:
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Consume whole, fresh, organic foods
Eat small frequent meals
Identify and Address food allergies
Sleep hygiene (Neuro-sleep panel for def.)
Adaptogens!! (Tulsi, Rhodiola, Ginseng, Cordyceps, Shisandra,
etc.)
Glandular extract – adrenal
Amino Acids - L-Tyrosine, L-Taurine, L-Theanine
Inositol, GABA, DHEA, Pregnenolone
Vitamins - > B5, B6, C
Support as needed based on labs, upstream involvement!
Degenerative Disc/
Joint Disease
 Gradual breakdown of joint substances such as
cartilage, hyalgin, proteoglycans etc. The loss of
these critical tissues deplete the joints and
musculo-skeletal system with much needed
support, cushion and lubrication!!
 DDD and DJD can lead to pain and significant
mal-adapted compensatory patterns
 DDD and DJD generate inflammation
 DDD and DJD create loss of ROM and overactivate adjoining muscles
DDD/DJD
Causes:
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Age
Repetitive Stress and Over-use
Excessive loads/Resistance training
Excessive body weight
Biomechanical and Structural imbalances!
Deficient nutrition (Omega 3s, Bioflavonoids,
Silica, Manganese, Vitamin C, Amino Acids)
 Inactivity, prolonged postures (sitting/standing)
 Poor intersegmental joint function (Jt. Play)
DDD/DJD
Symptoms:
 Joint Pain – Sharp and/or Ache
 Referred Pain – Primary and Secondary HyperAlgesia
 Mechano-receptor pain
 Loss and Painful ROM
 Swelling and localized inflammation
 Crepitous
 Excessive Stiffness
 Frequently pain lessens with activity
DDD/DJD
 Management:
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Diff. Diagnosis with X-Ray, CT and/or MRI
Perform Wt. Bearing imaging to assess for biomechanical causes!! (MRI, X-Ray)
Aggressive physiotherapy (EMS, US, Iontophoresis, ICE/MH)
Aqua therapy – Exercise and Epsom Salts baths
Anti-inflammatory nutritional protocol!!!
Joint integrity nutritional protocol!!!
Avoidance of pro-inflammatory mediators (Grains, Dairy)
Joint mobilization/Manipulation at and adjacent joints (ROM and Align)
CV exercise with Joint Friendly movements (Erg, Bike, Swim, etc.)
Orthopedic Intervention - Surgery or Hyalgin/Orthovisc when applicable
Spinal – Decompression
Orthotics
Brace and Compression
Topicals!!
Myofascial Release and Foam Roller to ease Joint compression
Lowe Extremity Stress Fractures
 Partial Fracture in bone caused by repetitive
loading. Usually an acute onset/mechanism
of injury but may be unaware due to gradual
nature. Can progress to acute fracture.
Lower Extremity Stress Fracture
Symptoms:
 Acute onset pain after long training session
 Pt. tenderness over FX site
 Pain dec. with rest and inc. with activity
 Aching and Throbbing late at night at rest
 Swelling, Heat and Radiating over FX site
Lower Extremity Stress Fracture
Causes and Characteristics:
 Non-Critical: Heal well and full return to sport after 6-8 weeks or
relative rest
 Critical: Non-union of bone after 6-8 weeks
 Due to poor blood supply (Ant. Tibia and Distal Tibia (Malleolus) – slow
healing
 Increase in training mileage/intensity
 Non-cycling of training surfaces
 Poor Shoe dynamics or over-wearing
 Poor Heel Posting
 No Metatarsal Support
 Pronation
 Biomechanical imbalances
 Gait imbalances
 Inadequate osseous nutrition
 Inadequate strength training
Lower Extremity Stress Fracture
Management:
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Diff. Diag.: X-Ray inadequate! MRI , Bone Scan!!
PRICES
6-8 week “Relative Rest” in non-critical FX. (H20, Alt. CV work)
Aggressive Bone Nutrition: Vitamin D3 (5K) IU, K2 (45mcg), MCHC
(2Kmg), Ca (500), Mg (250mg), Choline Stabilized Orthosilicilic Acid
(Silicon) (3mg), Horsetail (10ml)
Increase Dark Green Veggies, Cruciferous!!
EMS, Iontophoresis
Orthotics
Correct Biomechanical Distortion Patterns
Kinesiotape!, Compression hose
Brace/Cast/Boot and Ortho eval. in critical stress fxs.
F/U with Gait Assessment
Revisit appropriate shoe design
Strength training
Rotator Cuff Tendonopathy
 In response to physical training demands,
the RC Tendons increase in diameter and
thickness & consequently tensile strength
 Excessive training or poor technique leads
to significant collagen synthesis (Type 3)
rather than functional Type 2.
Rotator Cuff Tendonopathy
Symptoms/Mechanism:
 Elevated pain sensitivity due to increased development of nerve and
blood vessels (neovascularization)
 This leads to degenerative changes
 Weaken Tendons
 Leads to Impingement Syndromes
 Adjacent Bursa inflames!
 Pain in front of shoulder (Aches!!)
 Pain radiates down arm but not below elbow
 Pain increases at night and if lying on
affected side
 Painful arc movement – up or down
 Short Pectorals and anterior shoulders!!
 Intrinsic shoulder/RC muscle weakness
 Scapula rhythm altered!
 Inadequate extension emphasis
Rotator Cuff Tendonopathy
Management:
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Diff. Diag.: MRI, Clinical Examination
PRICES
Physiotherapy (EMS, US/Phonophoresis, Iontophoresis)
Dry Needle Therapy
Myofascial Release Tx.
Manipulation/Mobilization @ Shoulder & spine
Aggressive Nutritional Anti-inflammatory protocol
Aggressive Connective Tissue Protocol
Topicals!
Kinetic Rehabilitation - RC isolation with progressive resistance
(tubing), Pendulum, Shoulder retraction/extension based movements,
scapula rhythm
Open shoulder girdle and pectorals
Evaluate swimming form, weight training techniques!
Avoidance of overhead and push movements temporarily
Orthopedic Eval. (Cortisone and/or decompression in difficult cases)

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