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Happy New Year to everyone.

Shin Splints & Achilles Tendonitis:

The muscle in the front is the tibalis anterior.

Shin splints results from tension within the tibial bone itself. There are 2 forms, one at the front of the bone and the other at the back of the bone. It is believed by many that shin splints developing from the front is the main form of shin splints (pic on the right). But in my opinion I have found it to be nearly always the back part of the leg, the tibialis posterior, which is responsible. I usually treat the patient as if they had both forms either way. By the time the bone starts to produce pain, the leg is already in a lot of tension anyway.

Triceps surae is the attachment of the gastronemius & soleus
muscles to the achilles tendon. The soleus is the muscle seen here.

Achilles tendonitis is simply ‘inflammation of the achilles tendon or triceps surae’ (pic below). For reasons to be discussed shortly the achilles tendon becomes under increasing stress and starts to develop micro tears. So when the muscle is engaged again and again in activities such as running, these micro tears become more and more irritated and inflamed. This is the pain felt at the bottom of the leg.

Here are the in depth reasons behind achilles tendonitis and shin splints:

The tibia bone:

The bone (pic above) is designed to transmit forces out of the body via the foot. The outer layer of the bone, the periosteum, is highly innervated and therefore very pain sensitive. When tension from the muscles pulls on the bone, the periosteum develops very minute tears on the surface and becomes irritated and inflamed. This inflammation combined with the increased pulling action of the muscles increases the actual pressure inside the bone. So every time you run or your foot impacts the ground, force shoot up the ankle joint into the tibia bone. Because the tibia bone is already highly pressurised this extra force only increases the stress in the bone further, hence the increase in pain. Repetitive actions like this, without treatment, can often lead to muscle tears, muscle ruptures or stress fractures. After a few years of dealing with this injury I have developed a technique to actually reduce the tension in the bone. Within my treatment I can also use my Bio-energy stimulation machine (B-E-St) to reduce the inflammation.

Toe off - the last action of walking:

The toe off phase is shown by the foot on the right.

Toe off is the expression given to the last action of your foot when it leaves the ground to eventually swing forward. For such a small action this is actually a very important process in walking/running. The function and mobility of the big toe must always be checked in any dysfunction or problem of the lower extremely, especially running injuries.

If the toe is restricted, it means you will be lifting the foot off the ground at a slightly earlier stage than normal. Consequently the tibialis anterior and calf muscles (triceps surae) have to engage earlier to lift the foot off the ground. Your centre of gravity will not reach the point where your body weight is directly over the standing leg. This means you will be leaning slightly backwards and off balance as your body weight passes behind the standing hip. The toe off phase is there to push the body forward enough so that it sits directly on top of the standing hip, knee and ankle. That means the forces generated by gravity will pass though all these joints evenly and out of the body as the other leg swings forward to complete your stride. Because the centre of gravity no longer sits directly over the standing leg, but rather just behind it, the trunk muscles (abdominals) and thoracic muscles have to contract to bring the upper torso forward to give you enough balance to stand on one leg.

So what is the actual consequence of engaging the tibialis anterior and triceps surae muscles at an earlier stage during your run? Normally when you have a smooth ‘toe off’ phase the actual motion of the body naturally enables the foot, knee and hip to work with less effort because the motion of the actual stride aides in the contraction of the various muscles. However by having to engage earlier, the muscles mentioned have to generate this motion themselves and of course this means the muscles generate a much greater contraction and energy output. Repeat this continually during a run over a period of time and the stress will gradually build. This principle is also equally applied to achilles tendonitis. The triceps surae are working harder and the achilles tendon gradually develops micro tears due to the high stress demand. Inflammation occurs and pain results.

The other aspect of having a restricted ‘toe’ off’ phase means your stride will also decrease. This is because the opposite leg has had to finish the swing phase earlier to compensate for the earlier lifting from the toe off phase. If it didn’t do this then both feet would be in the air at the same time and this is not possible when walking. Running is slightly different because both feet are usually off the ground, but the principle here still remains the same. The leg will compensate. Having a shorter stride obviously means the effectiveness of your performance is reduced.

Bunions, blisters, corns/calluses, halux valgus, hammer toe, arthritis, bruising, toe nail injuries (often when running the toe nail can peel off) and verrucas will all, in their own way, create some sort of big toe restriction.

Ankle restrictions via the mighty talus bone:

The talus is another part of the foot that must be checked in any running injuries. The talus is the one bone (pic to the right) that all forces from the body travel through to eventually disperse throughout the rest of the foot and then out into the ground. The tibia and fibula bone connect directly to the talus giving the ankle joint 2 predominant movements – plantar flexion and dorsiflexion (pic below). To simplify, this is the swinging motion of the foot. To achieve this effectively the talus rotates forwards and backwards within the tibia and fibula joint complex. However, it is possible for the talus to be shunted forward (anterior) or backwards (posterior) (pics below). If the talus gets stuck anteriorly then the movement of dorsiflexion (pic below) becomes somewhat reduced and if it is stuck posteriorly then plantar flexion becomes reduced. This consequently reduces the overall movement of the ankle joint in either direction and will result in very similar patterns as described above in toe off. The stride will reduce, the centre of gravity becomes displaced and the muscles work harder to lift the foot off the ground.

Dorsi flexion is when the toes point up.

The other aspect of talus restrictions is the distribution of force. The talus is designed to sit in the middle of the tibia/fibula complex. Therefore it is important that the force of gravity travelling from the body and down the leg travels directly through the talus. Whether the talus is restricted
anteriorly or posteriorly only means the force will disperse elsewhere in the foot, often in a non-physiological way.

An anterior restriction will result in the force travelling slightly behind the talus (green line in the pic on the right) and out through the calcaneus. (The red cross represents where the force will end). The natural motion of the talus is to slide forward on top of the calcaneus and into the connecting navicular and cuneiforms bones (purple and brown bones). With the medial arch linking all these bones together via the plantar fascia, the whole process acts like a suspension system. The navicular and cuneiforms act like a breaking system as everything compresses and bunches together. The medial arch behaves like a dampening spring to absorb nearly all the shock. However if the force passes behind the talus and straight into the calcaneus then this whole suspension system is missed and so the effect of this is to have a harder impact on the ground, which translates into greater force travelling back up into the tibia. Repeat this over time and it is no wonder the tibia bone becomes stressed. Remember also, when the foot hits the ground the achilles surae and tibialis posterior muscles are already in contraction to maintain plantar flexion as the heel hits the ground. Instantly on impact the tibialis anterior muscle contracts to decelerate the motion of the fore foot as it hits the ground. If the force or shock travelling up the bone is harder than normal, the contracted muscles will be put under greater tension because they have to work harder. 

Consequently if the talus is restricted posteriorly (pic just below) then the force of gravity passes in front of the talus and straight down into the medial arch mechanism, missing the forward motion of the talus on the calcaneus and the resulting bunching together of the navicular and cuneiforms. In time this stresses the medial arch, resulting in many possible foot injuries, such as plantar fasciitis. However the tibialis posterior and tibialis anterior muscles both have strong attachments into the under-surface of the foot, into the medial arch itself. Stress the medial arch and these muscles become naturally elongated and start to behave like contracted muscles. In time they will become weaker as they acclimatise to the elongation stress. When these two muscles become stressed they tighten and create an overall increased pull on the tibia bone – shin splints. This then leads us nicely onto what is commonly talked about – overpronation. 

What is over-pronation and supination?

Pronation is actually a name of a specific type of movement with supination being its opposite movement. When the foot over pronates you get a collapsing of the medial arch leading to flat foot, which is also known medically as pes planus. The medial arch consisting of the plantar fascia, which acts like a bow string, connects the cuneiform, navicular and talus bones together, creating an arch. When the foot strikes the ground the gravity force of the body travels down the tibia bone through the talus into the navicular, cuneiforms and out into the toes. As the foot strikes the ground the talus actually moves forward on top of the calcaneus and pushes into the navicular. In turn the navicular pushes into the 3 cuneiform bones and together everything works like a breaking mechanism. At the same time the arch that these bones form flattens and the spring like structure of the plantar fascia stretches under the increased pressure. This acts like a spring or suspension system.

Medial arch. Looking at the foot from the inside.

So if you have flat feet or collapsed arches then you can understand that both these mechanisms don’t function efficiently and therefore the force has to be absorbed elsewhere in the foot. This is over pronation.

There are 3 places this force tends to go. The heel (calcaneus), the big toe (metatarsophalangeal joint MTP1) or the transverse arch.

The calcaneus bone has no shock absorption except the fat pad underneath it. Repeated stress in this area will likely lead to plantar fasciitis or heal spur type injuries.

During the normal walking cycle the heel hits the floor first, following to the outside of the foot where it reaches the little toe (this is called the lateral roll). From here the natural motion and weight travels across the transverse arch to the big toe (this is called the medial roll) and then lastly to toe off. When the medial arch has collapsed the lateral role of the foot during this walking cycle will be either partially or completely missed. So instead of having a lateral role movement the force just travels straight across the foot to the MTP1 joint, hitting it more directly and more forcefully. This will lead to chronic stiffness of the big toe and reduced ‘toe off’ function, discussed above. Additionally when the arch has collapsed you can develop an unnatural inward rotation or twisting of the MTP1 joint, albeit it a mild one and this leads to the inner part of the joint taking the biggest brunt of the force. Repeated stress and offloading of force here can lead to painful calluses, bunions and halux valgus type injuries.

Longitudinal arch = medial arch.

The transverse arch is the arch between the metatarsalphalangeal joints, travelling from the little toe to the big toe (pic to the right). It is smaller than the medial arch. The purpose of the transverse arch is much the same as the medial arch, to dampen the gravitational force as it passes from the lateral roll movement to the medial roll movement of the foot. Stresses to this arch can lead to plantar fasciitis as this is the other insertion area for the plantar fascia.

Future installment:
I am currently in the process of writing about knee mechanics and their impact on these injuries. I will also look at the fascial chains running through the leg and how the viscera play their role. I hope to get this released soon. Thanks.

Wear the correct shoes:

When looking for the correct shoes it can be quite a jungle out there with so many different types to choose from. Shortly I’ll give a list of the top shoe brands out there. Visiting their individual website will give you a lot of information about the best shoe for you. As a general rule there are categories for the type of terrain you are using; such as trail, mountain, road, race and long distance running. Within these categories you also have the type of fit you need depending on the severity of pronation or supination you have, plus other special requirements you may have. Lastly there is the type of shoe to suit your running style whether it be heel strike, midfoot strike or forefoot strike.

All the different shoe companies have many patented technologies that all sound highly intelligent and impressive, but whatever it is they say, you want to make sure you check and consider the following with regards to your own feet.

Dorsiflexion:

Check the amount of dorsiflexion you can achieve and how stiff this movement feels to you. You should be able to achieve 10 degrees of dorsiflexion in a non-weight bearing seated position (you may need someone to help you). Also note how stiff it feels to push your foot into full dorsiflexion.

Determining this will help you understand how high a heel you want. Personally I think modern running shoes are developing far too high a heel and this can lead to something known as ankle equinus. Ankle equinus is the medical term given to shortening of the achilles tendon leading to reduction of dorsiflexion in the foot. So running with a high heel can lead to a shortening of the achilles tendon. Long term shortening of a tendon like this will undoubtedly lead to achilles tendonitis and/or shin splints. This is what happened to me. I started wearing asics kayano and within a few weeks I developed very painful shin splints in both legs. I believe this particular model of shoe had too high a heel. HOWEVER if you have a reduced dorsiflexion movement or a stiff movement in general, it may help to start off with higher than normal heels and gradually acclimatise over time to a reduced heel size. Having the slight heel increase will help with supporting your reduced dorsiflexion and prevent overstrain to the achilles tendon.

Determining the degree of heel raise you want to look for phrases such as, heel to toe differential, heel to toe offset or heel to toe lift etc.

Ankle Support:

If you have sustained any form of ankle sprain in your life you should consider this when buying your shoe. Lateral sprains (outside of the ankle) are the most common with medial (inside of the ankle) being the most severe. The subtalar joint (pic directly right, formed by the talus in grey and the calcaneous below), which I haven’t mentioned up until this point, produces the small movements called inversion and eversion. When ligaments are torn, which is what a sprain is, they are permanently stretched. Ligaments do not contain any elastic properties, so any unnatural force that causes the ligament to elongate will mean that ligament is permanently elongated because there is no elasticity to bring the ligament back to its original position. This means the ligament no longer functions properly to support the subtalar joint and therefore the inversion/eversion movements can increase.

So it is important to consider solid ankle support to reduce this increased inversion/eversion movement. If this movement is severe in some people they are more prone to spraining their ankle again when running. Additionally your leg muscles will have to work harder to prevent and stop the ankle producing too much of this movement and maintain balance.

Over pronation:

A. Normal foot, B. Pronation (collapsed arch or flat foot),
C. Supination (high arch).

With a wet foot, walk on an A4 piece of paper (preferably a coloured piece) and see what happens. You foot should look something like A on the picture to the right. If you foot looks like B then you are over pronated and if your foot looks like C then you have high arches. Most people have normal to over pronated arches. This means you will want to look for a shoe to support your medial arch to the degree to which it has collapsed. High arches on the other hand mean you will want support for the toes, especially at the little toe area. This is where most of the pressure will go as the spring mechanism of the medial arch is bypassed. So you want shoes that accommodate this. This is often called mid sole cushioning or lateral arch cushioning.

Other considerations:

Shoe companies often talk about foot spread or how wide the shoe is. This is also beneficial to consider to you that have quite wide or thin feet. When you run your feet will naturally expand and so you will want shoes that can accommodate this expansion, rather than squashing your toes together during your run. With this you can also consider any calluses or bunions you may have too. You want make sure your shoes will have a good mid sole width (that is often where the shoes laces begin at the bottom of the shoe).

It is also worth noting that not all two feet are actually the same. I for example have quite a reduced arch on my right foot as opposed to a normal arch on my left foot.

Here are some of the top running shoe brands and like I say their websites are often worth checking out for extra information.

Asics

Newton Gravity

Salomon

New Balance

Brooks

Saucony

Hoka one one

Vibram 5 fingers

Nike

Addidas

For months now I have been writing this article about scar tissue. I have found quite a lot of information, but as usual nothing on a deeper level. A lot of books and websites will say scar tissue can create blockages, but I want to know why and how. So I hope what I have written will provide some of these answers.

What is scar tissue?

In my line of work we tend to use other phrases like abdominal adhesions or fibrosis to accurately explain scar tissue.  Abdominal adhesions are pretty specific to internal workings of the body, usually linking an organ to an organ or tissue to an organ. Adhesions are fibrous bands that connect one tissue to another tissue, forming a connection that physiological shouldn’t be there. These bands are fibrous, meaning they are tougher and less flexible than their surrounding tissues to which they make the connection. Hence the phrase ‘fibrosis’.

When adhesions form between two different organs it can create a tethering, much like an anchor on a boat. One organ becomes partially fixed and therefore permanently struggles to expanded, stretch, move or glide. Sometimes a tether can also behave like a torsion and actually constrict an organ, creating a physical blockage. This is especially true in tubular organs. Within both of these examples, movement and physiological function is lost. I want to focus on the movement aspect first. Reduced movement in anything, especially with regard to the body, is a bad thing. Whenever there is a reduction in movement there is also a reduction in nutrient supply and reduction to toxin expulsion. Too much toxin build or not enough nutrient supply can lead to cell death. Any form of death in the body automatically triggers an inflammatory response. Similarly if stagnicity is present then there is a much greater chance of infection. Stagnicity indicates a lack of sufficient blood supply and therefore a lack of immune response to the targeted area via the blood supply.

So what happens?

In the case of surgery, the natural healing process is kick started by inflammation. Inflammation brings all the materials needed for repair and clears the site from harmful microbes. Fibrin is then laid down, acting like glue and eventually creates a fibrosis. Collagen is the last substance to be introduced.

Collagen is present in pretty much every tissue of the body and is usually laid down in a random, chaotic pattern [picture to the left]. 

However in scar tissue, collagen is laid down in heavy concentrations in a linear pattern or a straight line pattern. This is what gives scar tissue that white smooth linear look [pictures below].

When collagen is laid down in thick fibrous bundles the blood supply becomes very insufficient. Collagen is very inflexible and together with the poor blood supply, it makes an area of scar tissue quite lifeless. So the vitality that was once present in the healthy tissue pre trauma (operation) becomes a rigid, tense and almost lifeless area.

If you think that collagen is the primary ingredient in bones and ligaments you will begin to understand the far reaching consequences of putting a material like this directly into a healthy functioning tissue, especially an organ.

Here is an example to try and explain the consequences of abdominal adhesions:

Imagine taking a normal balloon, it blows up normally and evenly. Now imagine putting a strip of duck tape on it, like a plaster. When you blow up the balloon again, everywhere expands except the area of duck tape, which stays fixed. The balloon then expands around the duck tape and forms an asymmetrical blob. It no longer looks like a normal balloon. This is how scar tissue or collagen functions when laid down in places not originally designed for that purpose. This leads on to the model of Osteopathy I’ve tried to explain before. Everything is motion, moving, fluid, and breathing. Put a fixed, fairly lifeless structure into this system where it is not designed to be and it will start to become a stress on the system, all bit a minor stress to begin with.

So what are the consequences of surgery?

When surgery is performed external air will get into the abdomen and this dries out the natural lubrication and viscosity of the various abdominal organs and tissues. Often blood is split  and becomes sticky, producing the same consequences. When the layers become dry or lack lubrication, this will increase the friction of movement between the layers. The various layers are now pinned together, and the once free movement upon each other, is now dictated by the scar tissue. They can no longer slide and glide upon each other. This increases the friction between the various layers.
If you take two glass panels and put water between their two surfaces and slide them over each over, it is effortless. Remove the water and slide the glass again and it becomes a lot less smooth. This is the principle here. The viscosity changes after trauma or surgery and so in time this can add small repetitive stresses. [see video below - laparoscopic appendectomy].

I want to thank 'Kiplinght' for permission to use his video.

The other aspect here to consider is when an organ becomes unnaturally fixated its axis of movement changes. This has far reaching effects on the other organs because the organs all rotate and move to a certain rhythm. The ascending colon has attachments to the kidney, duodenum and liver. All these organs move and they move together, effortlessly and cohesively. When the axis of movement changes, say at the ascending colon for example, then instantly the colon will pull away from its natural pattern of movement and therefore pull on the other 3 organs just mentioned. In time this can put stress on these organs and they can go into dysfunction too.

If the axis of movement to which an organ rotates around changes, then this can also alter the dynamics of the mechanoreceptors. Mechanoreceptors are neurons that pick up changes to pressure or stretch. So if a stretch or distortion exists that shouldn’t exist, then this could unnaturally trigger the mechanoreceptors. The feedback goes to the spine/brain and comes back resulting in spasms to the muscles of the organ.

In the stomach, when the mechanoreceptors are triggered, the stomach begins to release hydrochloric acid (HCL). So if there is a fixation on the stomach, due to some external input, the mechanoreceptors can fire and produce more HCL acid. This increases the acid production which in time can lead to possible ulcerations or a hiatus hernia. The mechanoreceptors are designed in this case to be triggered when the stomach is becoming stretched as a result of food entering it, not through other stimuli.

So here comes the million dollar question; can scar tissue be treated?

Yes I believe scar tissue can be treated after surgery. But first we must look at scar tissue from a slightly broader perspective. When the body heals from a wound, it usually has some consequences that stick around after the healing processes have finished. The wound site is often bigger than the resultant collagen scar tissue. There is nearly always an affected area around the scar that usually presents with stiffness, reduced vitality and reduced function. It is this area that is treatable.

By pulling, stretching, twisting or lifting an organ we can release the tensions spreading in and around the site of scar tissue. During an appendectomy a cut is made down to the large intestine from the skin, through a fat layer, through fascial layers, through the abdominal muscles and then finally into the abdominal cavity (recently they have started using laparoscopy, which minimalises scarring). The cut to reach the Cecum is actually relatively small and often the resulting scar tissue is small. However we often find that the entire Cecum and ascending colon is fixated and has lost its functional movement. So the area of injury or trauma is no longer actually focused towards to the site of scar tissue. The aim would therefore to be to lift the Cecum off the posterior abdominal wall, stretch the iliocecal ligaments located inferiorly and to also stretch the ascending colon. This often nearly always clears up the problem and functional movement returns to almost normal. I do not believe however that the physical scar tissue, made of collagen is treatable. But this is just my opinion.

Bag It!!!

I recently watched a very profound documentary on plastic called 'Bag It'. It talks about how we are struggling to deal with the waste of plastic, the problems we are  facing with global consumerism and the health effects of using plastic in our foods. Although its delivery and presentation was ok, the underlying story and information was fantastic. I would strongly advise purchasing this DVD, albeit an expensive one, and give your support to the works of this organisation. As usual the link is above.