Continuing Ed and Shin Splints

By Damien Howell PT, DPT, OCS

On May 22 I graduated from Washington University St. Louis with a Post Professional Doctorate of Physical Therapy. A relative recent development in the profession of Physical Therapy is the granting of a clinical doctorate degree for individuals entering the profession the profession of Physical Therapy. The doctorate degree in physical therapy (DPT) is now an entry-level professional degree, completed in 3 calendar years after an undergraduate degree. A Postprofessional Doctor of Physical Therapy (PPDPT) degree was designed to serve the needs of physical therapists that entered the profession before the entry level standard was a clinical Doctorate degree, and it also provides experienced professionals the opportunity to enhance their skills as a diagnosticians and evidence-based practitioners.

The four years of real-time internet based course work, on campus week-end course work, and independent study courses definitely, enhanced my diagnostic skills, and practice in an evidence based manner. In 2008 US News and World Reports ranked Washington University St. Louis in the top three Physical Therapy Schools in the country.

I would like to thank my patients who agreed to be subjects for the case reports in my Capstone project entitled "Diagnosis and Management of Patients with Medial Tibial Stress Syndrome Using the Movement System Concepts". I would also like to thank my mentor Shirley Sahrmann Phd. who is the originator of the Movement System Syndrome diagnostic process. Most importantly, I want to thank wife Lynn for her support and encouragement with the process.

You can now call me Dr. Howell, Dr. Damien, but I am very comfortable with you calling me Damien.

The Capstone project involved writing detailed case reports of diagnosis and treatment of 3 patients with shin splints. Extensive review of the literature identified 13 observations which can be visualized using a slow motion video gait analysis which are correlated with shin pain walking/running. Weak muscles of plantar flexion (calf muscles) were found to be related to the development of shin pain, and this is an under recognized observation, which responds positively to strengthening exercise. Two of the three patients were able to continue their running program if they ran up an incline, at a slow speed, with a short stride; whereas if they returned to running on level the symptoms returned. After treatment all 3 patients returned to symptom free running.

The process of writing detailed case reports of actual patients and searching the literature for supporting evidence, and having peers review the case report was a remarkable continuing education process.

If you or a friend has recurring shin pain, give me a call 804-965-9990, I can help.

Damien Howell PT, DPT, OCS
Physiotherapy Associates Richmond West End Clinic
8909 West Broad St.
Suite F
Richmond, Va. 23294

804-965-9990

www.damienhowellpt.com

Damien@DamienHowellPT.com

WADA YA MEAN?

By Sally Young

The World Anti-Drug Agency was pioneered in the exhaust of the 1998 Tour de France, which set the record for the most drug addled sport; team after performance-enhanced team dropping out, until the field dwindled to about half if its original 189 bicyclists. WADA became the global leader in anti-doping capacities the following year, projecting authority over almost every international sport, from chess to triathlons to the Olympics.

WADA publishes an annual list of prohibited substances, and athletes must be available for no-notice drug testing. While the system is good, it is not without controversy. In 2008, for example, cyclist Kevin van Impe was making funeral arrangements for his infant son, Jayden, when he was interrupted by a drug tester who demanded an out-of-competition urine sample.

In 2009, WADA amended its study in human chemistry, with explosions guaranteed. Under "Whereabouts," athletes must file their location 24/7/365, even in the off season, even if injured and not competing. An athlete can be specifically targeted, with no limit to the number of times.

Although it's true that sports have a special stature in the world, and stakeholders are heavily invested, the only other group in the US under this obligation is convicted felons.

Facing Ourselves

By Daniel Shaye, DC

Ah, running. It's a joy to be back, cavorting over hills and through neighborhoods and amidst the trees. A hand fracture (3/20/2010) has forced me back to running, as basketball (my other love) wasn't fully feasible for a few weeks. I must say that I've re-learned much.

Running is special. All sports are, yet running is uniquely peaceful, satisfying, personal. Allow me to expound.

Running is peaceful. Sport has an element of competition to it. Most sports have winners and losers; and in some sports, the losers must be literally pounded into submission. Mixed martial arts and boxing are the most obvious violence-based submission sports, yet I've discovered a surprising level of aggression on the basketball court. Like the classic sprinters, many basketball players "talk trash" and attempt to psychologically devastate and intimidate opponents during competitions. In my experience, this simply doesn't occur in distance running. Should we compete, or just run with others, we join fellow competitors, not opponents. Opponents oppose us, and are akin to the enemy, the force against us. By contrast, competitors join together in a quest for excellence and shared experience. Runners seem to understand this in a way that other athletes often miss.

I've found that basketball has developed into a VERY physical sport, and some players feel something akin to obligation in using at least some of their allotted 5 fouls. I've been assaulted on the court, sometimes intentionally; and a basketball player who shies away from contact has poured chum into the shark tank. Though I've learned to stand my ground and perform despite physical and psychological intimidation, running has been a peaceful blessing, a return home. I've never heard trash talk during a distance race, and a fight during such an event is unthinkable. We have no fouls to give, and no desire to give them. It's me vs. you, or the clock... or perhaps it's just me, vs. me. Heck, perhaps it's not even about me vs. ANYONE. Perhaps it's just me, exploring me; and you, exploring you. Together we learn our potential, who we are; and revel in the joy of motion, of life.

Running is satisfying. There's a unique joy to each and every sport. I can still remember certain shots I've taken in basketball, or a dramatic steal or blocked shot; yet unlike basketball and certain other sports, running is all ours to hold on our own, or to share if we choose to. There's no bad pass to blame, and no one else to take credit for the day's outcomes. Running is something that can become more than a sport, more than a pastime. Running can become a part of us, it can shape our minds (not just our bodies). Running can inform who we are at rest, at work, in our relationships. It can even help shape who we are after we hang up our spikes or training shoes for the day, or for a lifetime. For me, and for many of us, running is a deep part of life.

Running is personal. Basketball players get together and play. Yes, many of them work very hard; yet you "play" a basketball game. Running can be done ALONE, and still be validly described as "running." We can also get together and "play" running. The Swedish term fartlek means "speed play." A running competition can be a party in motion, and a group run can be a very social event. Then there are runners who are interested in performance, and these runners don't just "play" running-- they train to run. Whether or not you and I choose to race, we must overcome physical limitations and discomfort, balance time pressures and non-running obligations, even stare into the face of nature itself (heat, rain, wind, pollen, bugs, snow, ice, etc) and decide to move forward. Running forces us to face ourselves.

When we compete, we never hurt another. We seek peace, satisfaction, personal transformation. I recall telling a coach (hello, Dave Sobal) that I'd "hurt" another runner with a hard surge. His response stuck with me: "You didn't hurt him. I mean, you didn't punch or strike him, right? You chose to hurt your SELF, and then he had a choice to make." His nonviolent, self-explorative approach to running and competing became a subtle part of me. Though this fractured bone will become part of me in the form of a lump on my hand and possibly a little residual stiffness, running is a deeper part of life for we runners than any physical lump or external equipment (a shoe, a ball, a racquet). I'm grateful for each and every step in this life's running journey. I hope you take the time to appreciate your path, too.

I'll see you on the roads and trails, my friends.


-Dr. Daniel A. Shaye
Certified Chiropractic Sports Physician
Fellow, International Academy of Medical Acupuncture

Do you have a question you’d like answered? Mail your questions c/o Performance Chiropractic1307 Jamestown Road, Ste. 103, Williamsburg, VA 23185; e-mail pchiro@performancechiropractic.com; or visit www.performancechiropractic.com

Science of Sport

The Science of Sport web site has one section devoted to running, covering technique, economy, and shoes. Check it out at http://www.sportsscientists.com/2008/01/running-technique.html

Two Records Fall Today at Queen's Lake

by Rick Platt

There were two outstanding performances at the Queen's Lake 5K today - an all-time Colonial Road Runners open women's record by William and Mary head women's track and cross country coach Kathy Newberry, 32, of Williamsburg (16:32), who finished third overall, and a Virginia state record by Steve Chantry, 55, of Williamsburg (17:06), who placed sixth overall.

The men's winner, Mark Tompkins, is the Bruton High School cross country and track coach, and was the race director for the race. The race was organized by and benefited the Bruton High School Athletic Boosters Club. Second overall was Ryan Murphy, an assistant track coach at William and Mary.

The second place overall female, Jennifer Quarles, 38, of Williamsburg, is a 5-time CRR Grand Prix champion, and leading this year for her sixth title, and had her best 5K time of 2010 (19:10). The third place female, Michaela Cody, 13, is an 8th grader in the Bruton district, running an outstanding 20:27.

New Race Coming to the 'burg

Charity Half Marathon, 8K Planned in City

By Matt Poms - WY Daily
Monday, May 10, 2010
Williamsburg will announce the creation of a new charity race at a luncheon Tuesday, welcoming the director of the Boston Marathon as a manager. A planned half marathon and 8-K run/walk will take place over two days in May 2011, and will benefit An Achievable Dream and the Wounded Warrior Project.

Read all about it at http://www.wydaily.com/sports/4350-charity-half-marathon-8k-planned-in-city.html
and at http://www.wydaily.com/sports/4354-a-couple-phone-calls-and-a-race-is-born.html

PAGING DOCTOR BOT

By Sally Young
Email yo-sal@cox.net

Techno-phobes can relax. Thanks to a few ingenious geek tweaks to the previous "read only" Internet, the wild, wild world of web (www.) has evolved to a new generation. The new "Web 2.0" is intuitive, user-friendly,and interactive. It has changed our social landscape forever, and the difference in heath care is transformational.

On websites like PatientsLikeMe, for example, folks from all over the world can post experiences about their illness, treatment, and medical procedures, harnessing the collective wisdom in a self-correcting, self-policing way. In his book, "The Wisdom of Crowds," James Surowiecki writes, "Groups are remarkably intelligent, and are often smarter than the smartest people in them."

"Health 2.0" challenges the unbreachable precept that an office visit happens in an examining room. HelloHealth.com has you partnering with an online doctor in your area. Pull up your doctor's calendar, make an appointment in 30 minute increments ­ not the 15 minute practice model with germy waiting rooms - and interact via video, IM, or email.

Want your money's worth? Visit Pricedoc.com where you can bid the cost of hundreds of procedures, shots, and tests in a full spectrum of health services, including dental, mental health, vision, cosmetic, alternative and more.

Dem Bones – Look at Adjacent Joints to Solve Stubborn Injuries

Knowing the where it hurts is helpful, when it comes to allievatig injury, but not always. The phenomena of referred pain may play a role in the diagnosis and management of repetitive use injury. Referred pain is pain percieved at a site distant from the source of the pain. The typical example of referred pain is a heart attack. Individuals suffering a heart attack may describe crushing chest pain, but often the pain is percieved as left arm pain or left jaw pain. The source of the pain is the heart muscle, but the perception is that the arm or jaw hurts, this is “referred pain”.

The phenomona of referred pain is true for orthopedic problems as well as viseral problems. A client came to me for help with a chief compliaint of knee pain. After gathering the history, performing a clinical exam it became apparent that passive movement of the hip joint was restricted and passive movement of the hip joint while not allowing movement of the knee joint provoked the symptom of knee pain. After requesting assistance of the primary care physician to order a radiograph it showed signficant degernative joint disease of the hip, and a normal knee joint. This is an example of “referred pain”, the knee pain is precieved at a site distance from the source of the pain, the hip joint.

Referred pain tends to follow certain principals. The deeper the injured tissue the more likely the pain is percieved at a site distant from the source, as the heart is a very deep tissue, and the hip joint is also a deep structure they are often involved in “referred pain”. If the injured tissue is close to the surface like a tendon at the elbow (tennis elbow) it is less likely for the pain to be precieved at a site distant from the actual injury. Pain is referred from the center of the body outward, not from the periphery towards the center of the body. Referred pain from musculoskeletal tissues does not cross the mid-line of the body.

A similar but less recognized phenomenon is that the mechanical impairment causing the pain may be distant from the joint or area where pain is percieved. For example a common belief is that abnormal foot alignment and movement such as excessive pronation can lead to knee pain.

A recent published case report (Vaughin, DW 2009) described a 25 year old female runner who just prior to competing in her first Boston Marathon developed knee pain. The physical therapist performed all of the clinical examination procedures about the knee, but was unable to do provoke the symptoms or identify any impairment at the knee joint. Palpating all around the knee failed to elicit tenderness or symptoms. Continuing the clinical exam to look at adjacent joints of hip and pelvis provactive tests of the hip and pelvis demonstrated signficant asymmetrical limitations. The patient was treated with techniques to restore symmetry of alignment and movement of the pelvis and hip. After one treatment this patient was able to return to running without symptoms and she achieved her goal of completing the Boston Marathon.

Two different clients sought my assistance regarding shin splints. Palpation of the shin elicited the chief complaint shin pain in both patients. The shin pain was a local problem, not a referred pain problem. However examination of the foot and ankle failed to demonstrate abnormal foot alignment or any signs of excessive pronation in both patients. One patient did demonstrate impairment of the hip on the affected side; the gluteal muscles were relatively long and weak. When she ran the affected leg would frequently cross the mid-line of the body when the foot struck the ground. After pointing out to her the form fault of crossing the mid-line with the affected foot, she was instructed to conciously correct this fault and not allow the foot strike to cross the mid-line of the body. When she ran in this manner she was able to run without shin pain. This was followed up with remedial strengthening exercies to improve the muscular endurance of the gluteal muscles. The second patient partcipated in slow motion video analysis running and the symptomatic leg rotated inwardly to a much greater degree in comparision to the non injured leg. She was instructed to conciously correct this fault and to laterally rotate the affected leg when walking and running and she was able to allievate the shin pain. Again this was followed with remedial strenthening exerices for the muscles responsible for lateral rotation. Both of these cases are examples of pain being related to alignment and movement issues at joints distant from where the pain is percieved.

The old gospel song “Dem Bones” comes to mind with the leg bone connected to the knee bone, and the knee bone connected to the thigh bone, and the thigh bone connected to the hip bone.

With repititive use injuries the question needs to be asked is the pain local and/or referred. Additionally the question needs to be asked is the abnormal mechanics local and/or referred.

Bottom line:

• If you have an injury which is not responding to the obvious standard treatments ask is this problem a local and/or referred problem.

• Look back up the body towards the trunk as a possible source of the pain

• Look back up the body or down to the feet as a possible mechanical impairment being the cause of the problem.

Damien Howell PT, MS, OCS – www.damienhowellpt.com – 804-965-9990