You wake up one morning, feling great. You bend over to pick up a sock and suddenly you can't stand up. Excruciating pain sears through your low back, just over the left hip. After remembering to breathe again, yelling for help, and quietly screaming expletives through clenched teeth; you hobble to the couch and lay in misery the rest of the day. Missing work, your kids hockey game and ordering take out because it is too painful to cook; you know this is just the beginning. Gradually your pain improves but for weeks you question every movement and twinge.
I hate to say it...classic. We commonly hear a variation of this story and it often suggests injury to the SacroIliac (SI) joint. Sound familiar? This 2 part series gives you some background followed by treatment options.
PART I: THE BACKGROUND
HOW LONG AM I STUCK WITH THIS?
The "lock up" is from muscle spasms which typically improve by 3-5 days, but leave your SI joint (the actual cause of injury) relatively unprotected. Without treatment, pain often reduces to a scale of 1-2/10 within 4-6 weeks. With proper homecare and treatment, we can often reduce pain to this level within 1 week.
WHAT IS THE SI JOINT?
A large joint in the lower back. You have a left and right joint where the pelvic bones meet the large triangular sacrum. These joints are tightly supported by ligaments but move with EVERY movement you perform from walking or climbing stairs to transitioning between sitting and standing.
DEVIL IS IN THE DETAILS...
These joints carry your entire upper body weight and transfer that weight to the larger hip muscles and pelvic girdle. They function throughout the day as a foundation for your spine but also as an anchor point for the most powerful muscles in the body- your glutes.
One cause is trauma like slipping and falling on ice.
More commonly, repetitive strain. There are "good" and "bad" ways to reach into your dishwasher, put on your shoes and pick up that sock. A tiny change in how you move can put excessive force through this joint and these ligaments. Over time, the tissues around this joint can't support the forces you are demanding of them and they begin to break down. This process takes a lot of time and you won't notice pain until it is far underway.
THE STRAW THAT BROKE THE CAMELS BACK...LITERALLY
By the time you picked up the sock, the damage and irritation in those SI joint tissues has already reached a critical stage. Although the act of picking up the sock was "nothing," your daily patterns, habits, strengths and weaknesses have caught up with you.
AS IF ONCE WASN'T ENOUGH, THIS HAPPENS TO ME ONCE A YEAR...
This is the single worst thing to hear. This is a red flag that you have never addressed the injury fully and only on very, very, very rare occasions should I hear this from our patients. If you had a severe traumatic injury (car accident, etc) or have something in your history affecting your healing process or tissues, you are excused (and make up 99% of the rare cases I am allowed to hear this from). Otherwise....
If treated properly, you should only have re-occurrences that are predictable: aka....."I decided to help move a washing machine down a flight of stairs and I KNOW I didn't move properly."
Cases that have never been treated, or treatments that stop when the pain stops will have re-occurrences. It is not an if.....it is a when and it is a disservice to patients without treating and educating you about the underlying cause.
STAY TUNED FOR PART II: Treatment Options
What is spondylolisthesis?
Spondylolisthesis (spon + dee + lo + lis + thee + sis) is a funny word to describe a condition of the spine when one of the vertebra slips forward or backward compared to the next vertebra. If not treated, spondylolisthesis can lead to a deformity of the spine causing complications like, central spinal stenosis (a narrowing of the spinal canal) or foraminal stenosis (compression of the exiting nerve roots).
What causes spondylolisthesis?Spondylolisthesis can be hereditary if there is a family history of back problems. In athletes, a history of repetitive trauma or hyperextension of the lower back or lumbar spine is a common cause. Athletes such as gymnasts, weight lifters, volleyball player, and football linemen who have extreme forces applied to the spine during extension, are at greater risk for developing spondylolisthesis.
What are the symptoms of spondylolisthesis and how is it diagnosed?
The most common symptom of spondylolisthesis is lower back pain. In most cases it is not possible to see visible signs of spondylolisthesis by examining a patient. Patients typically have complaints of pain in the back with intermittent pain to the legs. Spondylolisthesis can often cause muscle spasms, or tightness in the hamstrings.
Spondylolisthesis is easily identified using X-rays. If the patient has complaints of pain, numbness, tingling or weakness in the legs, additional studies may be ordered. These symptoms could be caused by stenosis or narrowing of the space for the nerve roots to the legs. A CT scan or MRI scan can help identify compression of the nerves associated with spondylolisthesis. Occasionally, a PET scan can help determine if the bone at the site of the defect is active. What are the treatment options for spondylolisthesis?
The initial treatment for spondylolisthesis is conservative and based on the symptoms.
· A short period of rest or avoiding activities such as lifting and bending and athletics may help reduce symptoms.
· Rehab will include exercises like core stabilization and proper hip mechanics. Stretches and foamroller will be used on the legs, hips, and upper back.
· Anti-inflammatory medications can help reduce pain by decreasing the inflammation of the muscles and nerves.
· Some patients with spondylolisthesis may benefit from a hyperextension brace. · Patients with pain, numbness and tingling in the legs may benefit from an epidural steroid (cortisone) injection.
For patients whose symptoms fail to improve with conservative treatment surgery may be an option. The type of surgery is based on the type of spondylolisthesis. This option will be discussed with a surgeon. For more information about the diagnosis and conservative management of degenerative lumbar spondylolisthesis, please click here.
Professional Care Options:
In Part I of this series, I discussed the many factors that may cause true Plantar Fasciitis as well as briefly mentioned that a number of other conditions may be similar- the most important step is to know EXACTLY what you are treating. In the second section of this article, I described 13 different variations of techniques that can be used at home to treat this nagging condition.
If you have been diligent for 7-10 days or are not sure if Plantar Fasciitis is your true diagnosis, then it is time to seek professional medical care. Although many people are hesitant to spend the money or keep thinking "it will get better soon," the reality is that the longer you wait, the longer treatment will take when you do finally go in. So it is cheaper and less hassle in the long-run to just bite the bullet and seek help!
When you seek professional care, treatment options will be dictated by your provider, their area of expertise, their certifications and your specific case. Initially I would recommend seeking treatment from a Licensed Athletic Trainer (LAT), Chiropractor (DC) or Physical Therapist(PT) for which you may or may not need a referral. From there, you may be referred to any of these providers as well as your primary care (PCP), Podiatrist (DPod), a pain management specialist (PM), an orthopedic (OR), an acupuncturist (LAc), possibly even a massage therapist (LMT) depending on your needs. Each spectrum of healthcare offers different techniques within their scope of practice, so depending on your case, different techniques may be required.
Below you will find an overview of common treatment options. I have included which disciplines most commonly use these techniques in parenthesis, but please realize that not all providers within a given discipline practice using all of these items.
-"Soft-tissue" Techniques may be used to loosen up overly tight muscles. These may include a variety of options including deep tissue massage, myofascial release, Active Release Technique, Graston or other Instrument Assisted Soft Tissue techniques and many more depending on the preference and certifications of your provider and your specific case. (LAT, PT, DC, LMT)
-Taping may be used to support the arch. Kinesiotape is used to stimulate the muscles of the foot and provide some light arch support while reducing any inflammation in the area. More rigid taping techniques such as McConnell Taping or even athletic tape can be used to provide more support and help to distribute forces away from the Fascia therefore providing pain relief. (DC, PT)
-Ultrasound may be used as a deep heater to encourage increased circulation to the area and speed up the healing process. (DC, LAT, PT).
-Iontophoresis- a technique that uses ultrasound and a topical gel with a variety of medications to deliver the medication directly into the painful tissue. Shown to be very beneficial for short-term pain relief (2-3 weeks) allowing time to address the underlying cause so the pain does not return. (PT under prescription from your PCP, OR, DPod, or PM)
-Orthotics have been shown to be very effective at short-term pain relief but are highly debated. The problem here is that many people get the pain relief then stay in the orthotic permanently (especially due to cost of custom orthotics)....failing to remember one of the biggest causes of the condition is weakening of the foot musculature. By the very nature of an orthotic, your foot will weaken because it relies on the external support from the orthotic- so always stop to consider the purpose of the orthotic and question the long-term plans with this treatment. For me, orthotics are typically a later step if other techniques aren't working. (DC, PT, DPod)
-Rehabilitation is hugely important and should be a piece of your treatment puzzle in some way. The focus for many people is strengthening the small muscles of the feet which reduces pressure on the fascia. This piece also likely includes improving your balance, stretching or ankle/toe mobility work or strengthening muscles further up in the leg. (DC, PT, LAT).
-Manipulation which involves increasing mobility in joints which are not moving properly has been shown to benefit Plantar Fasciitis. By allowing the foot to move properly in all of the joints, the forces in the foot are distributed more evenly and not focused directly on the fascia alone. (DC and some PT)
-Other treatment avenues may include Acupuncture , Trigger Point Dry Needling, and Anti-inflammatory diets however less research is available regarding the effectiveness of these treatments. Anecdotally and through some case studies, these show some promise as more research comes out. (LAc, PT/LAT and nutritionists/some DC respectively)
-As an absolute last resort there are a number of more invasive options from Cortisone shots, Oral anti-inflammatories, Shockwave treatments, and even surgeries. These options should be considered in stubborn and chronic cases, but should be discussed thoroughly with your provider only after you have explored all of these conservative measures. (PM, PCP, PM, OR respectively).
Hopefully this series has helped you gain a better understanding of a chronic and often frustrating condition to treat. You should better understand why so many cases respond so differently to varying techniques, what you can do at home to help get the pain under control and what to expect/where to go if you do need to seek additional care.
Our Help Others, Help Yourself event is coming up fast! This year, we were lucky enough to have over $2,000.00 worth of services/products donated for our silent auction! Here is our full list of silent auction items:
Stop in and place your bid on some of these amazing items - you won't want to miss them! All of the proceeds, will be donated to St. Ben's Community Meal Program. Help others, Help yourself!
- Chili’s of Franklin - $20 gift certificate
- Movida - $20 gift certificate
- Milwaukee Food Tours - $50 gift certificate
- Rosencutter Ultrafitness Performance – Free Assessmesnt, program and 2 weeks of training - $500
- Gigi's Cupcakes - one dozen cupcakes ($15)
- Extended Hands Massage Therapy – 1 hour massage ($65)
- Oilerie – Private Tasting Party for 10 ($150)
- Keenan Wellness – One Hypnosis session
- Heaven & Earth Acupunture – Free Initial Consultation w/ 2 treatments
- Flash Images Photopraghy – Complete high school senior portrait or family portrait package ($350)
- Fresh Paradigm – One hour nutritional assessment, goal setting and counseling session ($150)
- Sunni Boehme - Life Transformation Coach for 28 years.
- Gift certificate for 1 hour session. ($100 value)
- Sprecher Brewing Company – Beer and cheese pairing for 4 ($80)
- Fred Astaire Studio (Brookfield) – 2 dance classes (for two)
- Moxie Fittness LLC – Indoor cycling/training ($50)
- Arte – 2 hour class for two people ($70)
- YoMama! – Brookfield – two T-shirts, chocolate pretzel, gift card ($50)
- East Town Spa – Gift certificate ($65)
- Hot Yoga Milwaukee – One month Membership ($150)
- TNT Performance – One month unlimited kettlebell classes ($120)
- Klein Hair Design – Gift Certificate for consult and style ($65)
Saturday December 13th9:00am - 1:00pmCome join us for our 2nd Annual Help Others, Help Yourself Shopping Gala! Miller Sports & Wellness Chiropractic, Berry Family Chiropractic & Hands On Massage are excited to host another shopping extravaganza for those looking to get their Holiday shopping done.
There will be 8+ vendors to shop with to get your Holiday shopping done, including: Thirty-One, Mary Kay, Scentsy, Young Living, KESH Naturals, Norwex and MORE!!
There will be also PICTURES WITH SANTA where proceeds go towards our designated charity, St. Ben's Community Meal. Please find out more at:
There will be silent auction items where the proceeds will go towards St. Ben's Community Meal. We will post these on our business Facebook pages when we have them all set.
Coffee, tea, water and cookies will be provided.
More info to come. PLEASE SAVE THE DATE!
Homecare for Inflammation
These are some of the more commonly known homecare activities for Plantar Fasciitis but are applicable to any injury that causes inflammation. These are important aspects of your home program, but should not be the only home treatment options you use!
-Ice Cup/Ice bottle rolling are the best methods to cool the area and reduce inflammation. If you remember from Part I, PF is no longer related only to inflammation, but many people still find relief with these techniques. Ice cup involves using a styrofoam cup to create a block of ice. Use the block to "massage" the bottom of the foot for 6-8 minutes until the area become numb and always keep the ice moving! The ice bottle is just a bottle of water frozen (take a few sips before putting it in the freezer so it doesn't explode!). Use the frozen bottle to roll the bottom of the foot for 10 minutes. Always use this technique after activity or your other homecare; always take an hour off before repeating, but repeat as often as possible.
- Anti-Inflammatories can be topical or ingested. Talk to your doctor or pharmacist before beginning anything new. I always recommend beginning with topical products because of the reduced number of side effects and risk of interactions with other medications.
Been consistent with your homecare but still having pain? Our next post details other treatment options for Plantar Fasciitis.
Homecare for Foot Strength Concerns:
-Toe Spread stretch- This is another great way to help restore movement. The goal is to spread your toes apart as far as possible then hold for about 10 seconds. Keep repeating throughout the day. This helps stretch some of the smaller foot musculature as well as strengthen the muscles that help maintain dexterity in your foot.
-1 foot balance work- This is an easy way to begin strengthening the bottom of the foot. The trick is strengthen without "flaring." So don't add this until your symptoms begin to dissipate slightly. Also, if your symptoms become worse, you may not be ready for this. The goal is to balance for 60-90 seconds in a progression: eyes open, eyes closed, then finally with head, arm or leg movements. Work up to that time frame; this should be challenging to make progress and is a great way to help prevent PF from returning.
PF and Homecare for Inflammation is next!
Homecare for Foot Mobility Problems:
-Top of the foot stretch- This addresses the balance between the tissues on the top of the foot and the bottom. The easiest way to perform this stretch is to sit on a chair as shown and tuck your toes and ankle underneath your leg. Be very careful not to allow your ankle to bend inward (as shown in photo 2). This causes additional strain on the ligaments that are often involved in ankle sprains- we don't need any stretching of those!. Hold for 20-30 seconds. You will find initially that the bottom of your foot will often cramp- that is a really great sign that you probably need this stretch as well as strengthening of the bottom musculature. Just stretch out the cramp and try again. Within a few days the cramping should happen less frequently.
-"Foot wiggles"- Not a commonly known homecare exercise. I send this home with patients who have very tight feet without a lot of movement in the foot joints. The key is to isolate the movement into each individual joint, not the entire foot. Using a firm grasp with each hand: use one hand to stabilize part of the foot closer to your heel- well call this the base hand. Use the other hand to "wiggle" the part of the foot closer to the toes, but just next to your "base hand." You can do circles in each direction, push the foot up and down or side to side or do figure 8s. After about 5 wiggles in that area, move your hands just a half an inch closer to your toes and repeat again. The whole process should take about 2-3 minutes. Although this is a little tough to explain via photos, it can be a great way to help restore movement to a tight foot.
-Correct Toes (or similar products)- When you look down at your foot, you should see light or space between each of your toes. Using the toe stretch below helps to restore this and strengthen these muscles, but for many reasons most people have lost this space and our toes are "stuck" on top of each other or squished together. Loss of this normal foot structure can be a big underlying cause of PF. There are many products on the market that can help stretch the toes, my favorite is called Correct Toes (find more info: https://nwfootankle.com/correct-toes). These can be used as a "splint" at night or inside your shoes throughout the day. The key is to work into them gradually (like any big change).
Up next.... Part II C: Home Remedies for Foot Strength
Home Remedies for Tissue Degeneration/Tightness:
-Golf Ball/LaCrosse Ball rolling- Using a small, hard ball on the bottom of your foot is a great way to loosen up the tissue and stimulate circulation into the area. Try using the ball seated or standing; put enough force into your foot that the area is tender but nothing should be painful. When you find an area that is more tense or tender, that is an area that needs some focus. Spend 1-2 minutes several times per day covering the entire bottom surface of the foot- from heel to the ball.
-Rolling with Toe Stretch- If you can tolerate this small addition to rolling the bottom of your foot, I would highly recommend it. By stretching your toes backward, you put the tissue on the bottom of your foot into a stretched position. You are able to get deeper as well as access other fibers of tissue. The plus is that this can help especially with stubborn cases; the down side is that it will make the tissue much more tender.
-Calf Stretch- There are 2 very important stretches shown above, and most people forget about the second. Hold each stretch for 30-60 seconds; these can be used several times per day:
- For the first stretch, keep the back leg straight and use a wall to push yourself further into a flexed position. This version stretches the larger muscle at the top of the calf (see the photo labeled "Gastrocnemius" Stretch.)
- For the second stretch, bend the back knee (again keeping your heel down) and push into the stretch with your knee angled over the outside of your foot. The second stretch is targeted toward the lower muscle of the calf, the Soleus (see photo labeled "Soleus").
-Night Splint- Although many people find relief using night splints I have mixed emotions. On the plus side they help keep the tissue along the bottom of the foot stretched overnight so the repair that occurs can occur over a "normal" tissue length. The downside is that they are bulky and many patients report difficulty/disrupted sleep with them. I typically recommend trying most of the other techniques first, then using these if your case continues stubbornly.
UP NEXT...PF Part IIB: FOOT MOBILITY PROBLEMS
PART II: HOMEWORK- the cheap and "easy" solution
Being actively involved in your care will drastically improve how quickly this nagging condition can be treated. In the last post, we reviewed the underlying causes of true Plantar Fasciitis; remember how every case has a different cause? It would stand to reason that every case will respond differently to each technique used. Not all of these are recommended for every case. Here are a few rules to follow:
Most people are familiar with Night Splint, Ice Bottle Rolling and calf stretching for homecare so they are included (there are details of these as well that many people forget!). My focus here is to address a variety of home tools and techniques that provide additional relief and should be considered but are less commonly known.
- Never stretch or push to the point of pain. Tenderness or a deep stretch is fine; pain is too far.
- If any of these increase your pain- stop; if they make it feel better- continue. If it doesn't make much difference either way, keep it up.
- Be very diligent with these for 7-10 days as soon as your pain begins (many cases are slow to improve because we wait too long or we are not truly diligent about using these methods).
- Try to choose the methods that most closely match your underlying cause of pain (then add additional methods as needed).
- Even if your pain goes away completely, use these tools for at least one more week (they also work great as warm-up/cool down exercises long-term).
- If your pain has not improved significantly after 10 days, seek professional care. Also get professional advice if this becomes a frequently recurrent problem (you need to address the underlying cause not just manage the pain).
STAY TUNED FOR SPECIFIC HOMEWORK TARGETED TO COMMON PF CASES....