Part 1 of 2
I have been advising my patients to exercise, keep active, and walk as long as they can in order to stay mobile and healthy. However, seniors often tell me activities that require prolonged walking are limited by knee pain from arthritis. They often ask, “What is arthritis of the knee?” How does it happen? What can I do about it? I will attempt to answer these questions, however, keep in mind that having knee joint arthritis is not a death sentence to an active lifestyle. Six years ago, I discussed this topic and used retired local physician, Dr. Joseph Andriole, as an example of someone who had severe osteoarthritis in his knees. He continued to be very active and enjoyed skiing and golfing during his retirement. However, he did go on to have his knees replaced a few years ago is doing very well and continues these activities. So, the next question is, how do I know when I am ready for a knee replacement? This will be the topic in Part II, Knee Arthritis.
Your family physician will examine your knee to determine if you have arthritis. In more advanced cases you may be referred to an orthopedic surgeon or rheumatologist for further examination and treatment. X-rays will show if the joint space between the bones in the knee is getting narrow from wear and tear arthritis. If rheumatoid arthritis is suspected, blood tests and an MRI may be ordered. The diagnosis will determine if you problem if minor, moderate or severe.
In the early stages your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You and your family physician, orthopedic surgeon or rheumatologist will decide which choices are best.
When conservative measures no longer succeed in controlling pain and deformity, improving strength and function then more aggressive treatment may be necessary.
SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons
Visit your doctor regularly and listen to your body.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune. Next Week – Part 2 on Knee Arthritis “How you know when you’re ready for a new knee.”
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in downtown Scranton and is an associate professor of clinical medicine at The Commonwealth Medical College.
USE IT OR LOOSE IT - EXERCISE MIND AND BODY!
October is National Physical Therapy Month! Physical therapists are excited about new research which reinforces what we have all suspected; physical activity improves cognitive function and mental activity improves physical function.
Mariel Consagra, a local teacher, discovered this research while assisting her husband, Atty. Charles “Chuck” Consagra, during his recovery from brain surgery two years ago. Chuck has worked hard in physical therapy at our clinic and has had a tremendous recovery, which he credits to his mind – body exercise.
The new research is encouraging for older individuals who report losses in flexibility, strength, and balance that interfere with walking and other simple daily activities. In this population, physical decline is typically accompanied by a mental decline causing difficulty with learning new tasks, following instructions, planning, organizing, multi-tasking, reasoning, and remembering. Safety often becomes an issue. Reduced mental and physical function can eventually impair their ability to live independently requiring extra care from loved ones or placement in an assisted living facility or nursing home.
In our clinic, we have been fortunate to work with a few exceptions to the rule of aging and support the current studies. Some of you may know Gino Mori, MD at age 80 continues to take classes at the University of Scranton while his brother, Hugo Mori, MD at age 77 plays tennis every day. These “elite” elders, and others like them, defy their age and are in surprisingly great shape! Typically, these individuals report daily physical exercise (e.g. walking, dancing, golfing, tennis, skiing, and swimming) as well as regular mental activity (e.g. reading, sculpting, painting, completing crossword puzzles, and playing memory games). Many of these individuals participate in social events, travel with family and friends, continue to work, and volunteer their time for a worthy cause, all of which require physical and mental effort.
Our current “push-button world” with its modern conveniences has caused a real health crisis. Many people live inactive lifestyles which deteriorate their vascular systems and result in a physical and mental decline. Computer games, television shows, and video games contribute to our society’s slothful, stationary lives. What happened to the old “use it or lose it” philosophy?
Physical activity improves cognitive function! Inactive individuals are twice as likely to develop dementia for several reasons. Physical exercise not only develops new blood vessels in the brain but also increases blood flow to this essential organ. Exercise that improves the heart’s ability to pump blood (i.e. cardiovascular exercise) also enhances the blood’s ability to carry oxygen. Improved blood flow to the brain promotes energy production and waste removal. People with heart disease and high blood pressure have reduced mental capacities partly due to reduced blood flow to the brain. Physical exercise also stimulates the production of new brain cells, develops more connections between brain cells, and improves the function of the hippocampus, a region of the brain responsible for learning and memory and implicated in Alzheimer’s disease. Moreover, the “excess is best” theory applies: a Canadian study revealed that the more a person exercises the greater the protective benefits for the brain, especially in women.
Mental stimulation enhances physical ability! A fascinating experiment was performed at the Cleveland Clinic in which participants were able to strengthen a muscle by just imagining that they were exercising it! After just 12 weeks, these volunteers demonstrated gains in muscle strength up to 35% and scans of their brains revealed increased activity. Mental exercise also improves physical coordination by reducing deterioration of the basal ganglia, an area of the brain responsible for voluntary movement and implicated in Parkinson’s disease.
Challenging your mind and body- Try Something new! The physical and cognitive decline associated with the aging process is not inevitable and is reversible! At any age, muscles and bones continually remodel and brains constantly adapt, rewire, and develop new connections in response to “exercise”, but challenging your mind and body is the “key” to preventing declines in physical and mental function. Performing a particular activity, mental or physical, on a regular basis causes our bodies and brains to become efficient at that task. This means that our bodies and brains will complete the known task with very little effort and no “learning” will occur. Leave your comfort zone and engage your mind and body by learning something new or doing something different!
The “mind-body connection” demonstrates that “exercising” through “learning” a new task simultaneously benefits your body and brain. Our bodies and minds thrive, especially in older age, when challenged with new experiences and unique situations. Most importantly, practice balance! Learn new activities that “test” your body and try novel tasks that challenge your mind.
CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College. This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Provisional Bag/First Aide KitIt is one week away from the 16th Steamtown Marathon. This column is dedicated to all the runners preparing for the big day. One small piece of advice; start slowly, avoid the first mile adrenaline sprint downhill, and enjoy the journey! Remember, only one Olympic marathon winner (Juan Zabala, Argentina, 1932) was in the lead at the 5 mile mark. Lesson: The last miles matter more than the first!
Today, I hope to address some common questions for the novice marathon runner or for those coming from other locations to run in the race. What should you pack? How should I dress? What supplies will I need?
Elite runners are so experienced that they know exactly what to pack in preparation for the big day. However, those, running in marathon for the first or second time usually have lots of questions. First, what you need and what you can bring will depend on your support team. If you are running alone and will not have family or friends meeting you along the way, then you are limited to a fanny pack and a few supplies. If you have a support team, then they can carry a bag with supplies, meet you along the course and you can have a sense of security.
Remember; do not do anything different on race day. Try out special clothing, water with supplements and snacks on a practice run. Also, experiment with your best pre-race meal. You will be getting up at 5-6:00am to catch the bus from Scranton to Forest City. You may want to pack breakfast to eat in the high school gym such as; bagel, peanut butter, jelly, banana and coffee or Gatorade. Moving your bowels before the race is a must.
Columbus Day Weekend in NEPA could bring 30 to 40 degree temperatures when you catch the bus in Scranton and at the 8:00 am race starting time in Forest City. Clothing:
If you don’t mind the little pack on your butt, a fanny pack can be valuable. In it, you will want supplies such as: small bandages, small roll of medical tape, ibuprofen, antacid tablets, small tube of lubricant, favorite running snack, and extra shoe laces. One might also consider packing a little money, credit card, ID, emergency contact numbers and medical insurance cards. A cell phone is optional.
For those with a support team.
Have your support team meet you at prearrange locations along the race route and bring your supply bag. In the bag, you might consider all of the above fanny pack items and: A change of clothes such as: extra running shoes, socks, shorts, shirt, water proof wind breaker, according to the weather, especially if rain is predicted. Towels, ace bandages, gauze pads and wrap, antibiotic cream, mole skin, sunscreen, petroleum jelly, safety pins, extra water and favorite sport drink, favorite sport snacks, extra ibuprofen, antacid, anti diarrhea medicine, chemical ice pack, mobile phone, money, credit cards, ID, medical insurance cards.
For those with allergic reactions, remember to pack: epinephrine, antihistamine, and other important medications.
Map and directions to the bus or starting line, course map, race number, and get your timing chip.
Enjoy! Enjoy! Smell the roses, take in the fall foliage and chat with a fellow racer. Savor the moment enjoy the day. You are doing something very special!
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an affiliated faculty member at the University of Scranton, PT Dept.
Now that NEPA has just supported another successful “Race for the Cure,” and with October named as National Breast Cancer Awareness Month, I am dedicating today’s column to the brave women and their families and friends affected by breast cancer. Presently, in our clinic we have several women suffering a tight or “frozen shoulder” as a consequence of breast cancer treatment. They were diagnosed with breast cancer, had mastectomies, radiation and chemotherapy. Additionally, some had residual effects resulting in tight painful shoulders and asked me to address this topic in an effort to educate others. Fortunately, due to advances in early detection and treatment, frozen shoulder is much less common than in the past, but it continues to impact daily activities for those who develop it. Prevention and early intervention are essential.
Currently, conventional management for early stage breast cancer is mastectomy with either sentinel lymph node biopsy and/or axillary dissection. In addition, radiation therapy, chemotherapy, and hormone treatments may be used as additional therapies. Of those who have surgery, 7 out of 8 experience some ongoing problems with shoulder/arm function. Sometimes these problems are minor and other times these problems can have a major impact on the individual’s life. The shoulder and arm problems identified by women after treatment for breast cancer include arm and breast swelling (lymphedema), shoulder stiffness, weakness, pain and numbness. Most of these problems are present within 3 months of surgery and many do not resolve up to 2 years after surgery. Most of these symptoms are attributable to surgery involving the axilla (arm pit) and to radiation treatments but sometimes shoulder /arm complications can arise from lumpectomies or even simple biopsies.
Shoulder/arm problems caused by treatment of early breast cancer is associated with reduced quality of life. These problems cut across many aspects of quality of life including role, emotional, social, and physical functioning as well as body image and lifestyle. Women with these problems experience long-term difficulties in everyday activities which most of us take for granted, such as an inability to sleep on the affected side, drive, dress, and wash one’s hair. For some women, these impairments become a psychological burden possibly due to the belief that they may never return to full capacity. As a result, for many women, the “cure” produces another whole layer of health problems.
Physical therapy can be very effective in treating these shoulder/arm problems. Treatment for these shoulder complications always begins with a complete evaluation of the shoulder to determine the source and extent of the problem. A program is next developed to regain the lost shoulder motion and to reduce the pain and the swelling in the shoulder. Depending on the severity of the problem, treatment may last a few weeks to several months.
If you are experiencing shoulder problems following breast cancer treatment there are many things that you should do. First, make sure that your doctor is aware of these problems. Not everyone that undergoes breast cancer treatment has shoulder complications. Next, listen to your doctor. The doctor will give you simple exercises to address the problem. If you continue to have problems, physical therapy should be the next step. Seek out a physical therapist that has experience treating these specific problems.
The following are exercises that might prove helpful in treating shoulder problems associated with breast cancer treatment. Before you attempt these exercises, ask your doctor if and when these exercises are appropriate for your particular case.
Overhead Wand - For this exercise and all the following exercises you will need a light-weight pole or wand. Many common items can work quite well as a wand including a wooden dowel, plunger, old broom handle, a ski pole or cane. While lying on your back on the floor or on your bed, hold the wand with your hands being a little wider than shoulder length apart. With elbows straight, slowly raise the wand over your head. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain…only stretch discomfort.
Side to Side Wand - While lying on your back, grasp the wand with your hands being a little wider than shoulder length apart. While clasping the wand, reach straight up toward the ceiling. Next move the wand as far as you can to the right. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain…only stretch discomfort.
Behind the Back Wand - While standing with the wand behind your back. Move the wand up your back as high as possible. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain…only stretch discomfort.
Contributor: Dr. Gary Mattingly is a physical therapist with a doctorate degree in anatomy. He is a professor at the University of Scranton, Physical Therapy Department. His research and clinical practice at Mackarey & Mackarey Physical Therapy Consultants, is almost exclusively dedicated to the shoulder.
Photos: Paul Mackarey, PT, DHSc, OCS, Mackarey & Mackarey PT
Photo Model: Amanda Brown, PTA, ATC
Visit your doctor regularly and listen to your body.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at TCMC.
One of the most common questions I receive from patients is related to the management and care of their cast or splint. Given the fact that one has to live with a cast or splint for four to six weeks (sometimes less, sometimes more) many people have concerns about hygiene, swelling, pain and function while wearing a cast…
Casts or splints are used to support and protect bones and soft tissues after injury or surgery. A broken bone or severe ankle sprains are two good examples. The immobilization provided by a cast or splint protects the injury, allows healing with proper alignment, and reduces pain, swelling and muscle spasm.
Casts, half- casts or splints are made of plaster or fiberglass. A doctor or assistant individually makes them for each person and injury. Also, custom-made splints are often made by occupational therapists for the hand or physical therapists and certified prosthetists for other body parts such as the trunk or limps. Fiberglass splints are made with Velcro straps and are removable. You may have seen these used for the wrist for carpal tunnel or the foot for ankle sprains.
Both plaster and fiberglass comes in rolls and fiberglass comes in different colors. The rolls are dipped in water and wrapped around the injured part. It is often necessary to apply the cast to the joint above and below the injury. The material will dry and harden in minutes. The cast must fit the shape of the injured part snuggly but comfortably. If a cast is applied to a new injury or immediately after surgery, the cast will be too big once the swelling subsides. Then, a new cast is applied. Padding is used under the cast to protect the skin. Sometimes special padding can be used under fiberglass to allow the cast to get wet in the shower or pool.
Most fractures or severe sprains require 4-6 weeks of casting, sometimes less, sometimes more. Often, once the cast is removed, a removable half-cast or splint is applied. This allows the injured part to be washed and exercised several times a day without the splint and then reapplied.
The American Academy of Orthopaedic Surgeons offers the following recommendations for cast care and warning signs of cast problems:
If the above recommendations fail to provide a reduction in swelling or pain or if you have the following warning signs, contact you doctor:
Visit your doctor regularly and listen to your body.
Keep moving, eat healthy foods, and exercise regularly
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.
Guest Columnist: Janet Caputo, PT, DPT, OCS
September is National Childhood Obesity Awareness Month!
As a child, I was a “chubby” and I still struggle with my weight. I preferred playing indoors with Barbie dolls while my “skinny” cousins played softball and rode their bikes. My parents, remembering many nights when they went to bed without supper during the Great Depression, did not want me to experience the pain of hunger. My Nona, remembering how skinny her children were, fed me bread, butter, and sugar. Also, considering my Italian heritage, everything was about food! Food helped no matter how you felt: happy, sad, or mad!
According to the Centers for Disease Control and Prevention, childhood obesity has more than tripled in the past 30 years. Fast foods, processed foods, and computerized games have contributed to our children consuming too many calories and expending very little energy. It is well known that childhood obesity not only contributes to low self-esteem and depression, but also damages the cardiovascular system (pre-mature development of diabetes, high blood pressure, and high cholesterol). However, recent studies show that damage to the bones and joints of overweight children can lead to arthritis and joint deformities.
A study published in Pediatrics in 2010 found that leg injuries were significantly higher in obese children compared to their normal weight counterparts. Common musculoskeletal injuries in obese children include sprains and broken bones. Increased joint and bone forces, excessive body weight, and poor balance collectively contribute to the higher incidence of leg injuries. Obese children typically suffer more traumatic injuries requiring surgical intervention.
Childhood obesity may contribute to flat feet, mal-alignment of the knees, osteoarthritis, deformities of the hip and bowed lower legs. Excess body weight increases foot pressure and puts developing feet at risk for pain and dysfunction. Many obese children present with a flat foot and complain of ankle/foot pain with running and jumping. Typically, practitioners recommend custom shoe inserts to improve alignment in the flat foot but obesity impairs the child’s response to this intervention. Overweight and obese children often develop knocked knees. Abnormal joint movements from flat feet and knocked knees coupled with excessive joint forces from increased body weight may interfere with joint integrity over time, possibly resulting in the pre-mature development of arthritis. Clinicians report an increase in the frequency of hip deformities, typical of overweight and obese, adolescent bones. Obese children develop these hip, knee, ankle, and foot problems, because the excess weight interferes with the structure and function of developing bones and joints, resulting in pain and deformity.
Obesity can also affect a child’s neuromuscular system resulting in abnormal changes in walking patterns and problems with balance and stability. Walking pattern typically changes with age as individuals develop arthritis, leg weakness, and loss of balance. Elderly people tend to walk more slowly without swinging their arms and without lifting their feet. Shockingly, clinicians have noticed similar changes in obese children. Obese children report greater exertion with walking which may be the result of the decreased hip, knee and ankle movement as well as the decreased walking speed demonstrated in this population. Also, obese children tend to walk with a rigid posture and spend more time with both feet on the ground. Researchers believe that these differences in walking style may be the child’s attempt to compensate for poor stability, decreased balance, and reduced joint position sense.
Greater risk of injury, difficulty walking, and more complaints of musculoskeletal pain should not be used as excuses to avoid being physically active. To help an obese child become more physically active you must first consider what the child enjoys doing. The “exercise” must be fun! Second, ensure the child safety with supportive footwear and the appropriate protective equipment. Next, explore activities that challenge the cardiopulmonary system without stressing the musculoskeletal system such as swimming and cycling.
There are many fun and effective options available. For example, Wii Fit by NintendoR offers many fun low impact sports and fitness programs. Also, Airobics (trampoline based aerobic exercise) or a modified martial arts program are low impact and address stability and balance. A Pilates-for-kids program or stability ball exercises will target muscle strengthening and body. Some fitness centers have programs specifically designed for children. SubwayR Restaurant has a special program called “Random Acts of Fitness for Kids” to promote healthy lifestyles in youngsters. Also, www.kidnetic.com offers a website for that teaches children about the body and how it works regarding health and fitness. You can even get a fitness trainer specifically for kids (www.benefitfitness.com). However, my personal preference to insure a comprehensive and safe program for the individual needs of your child is to discuss the problem with your family physician or pediatrician and get a referral to see an orthopedic physical therapist that specializes in bone and joint problems. Remember, helping your child “get in shape” may also rub off on you! Good luck and have fun!
Visit your doctor regularly and listen to your body.
CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.
This weekend marked the beginning of high school football in NEPA! While a warm September may be a wonderful time of year to watch football from the bleachers, it often plays havoc on athletes as they suffer from severe muscle cramping. This year was not exception as many players limped off the field in pain and many concerned players, parents and grandparents repeatedly ask me about the problem. What exactly is a muscle cramp? Why does it happen? How can it be prevented?
A muscle cramp is defined as an involuntary contraction or spasm of a muscle that will not relax. The tight muscle spasm is painful and debilitating. It can involve all or part of the muscle and groups of muscles. The most common muscles affected by muscle cramps are: gastrocnemius (back of lower leg/calf), hamstring (back of thigh), and quadriceps (front of thigh). Cramps can also occur in the abdomen, rib cage, feet, hands, and arms. They can last a few seconds or 15+ minutes. They can occur once or multiple times. It can cause a very tight spasm or small little twitches.
Although the exact cause may be unknown at this time, there are several theories why muscle cramps occur. According to the American Academy of Orthopaedic Surgeons, when a muscle is flexible and conditioned, the muscle fibers are capable of changing length rapidly and repeatedly without stress on the tissue. Also, overall poor conditioning or overexertion of a specific muscle leads to poor oxygen/carbon dioxide exchange and build up of lactic acid and cause a muscle spasm. Also, this process can alter muscle spindle reflex activity and stimulate the spinal cord to send a message to the muscle to contract. If uncontrolled this leads to cramps and spasm.
Muscle cramps are more common in hot weather due to loss of body fluids, salts, minerals, potassium, magnesium and calcium. This leads to an electrolyte imbalance which can cause a muscle to spasm.
First Aid
Prevention
See you family physician if cramps persist or worsen. There are other medical reasons for persistent cramps and spasms
Read Dr. Mackarey’s Health & Exercise Forum – every Monday in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at TCMC.
In addition to the static support provided by orthoses, the body has several muscles that, because of their anatomical positions, can either directly affect the arch or assist the posterior tibialis tendon (PTT). Performing 3 sets of 10 repetitions of these special exercises every day can strengthen the muscles to help manage PTTD.
See the end of the article for photos of the following exercises.
If conservative treatment of PTTD fails, surgery is considered to restore anatomical alignment, but reserved for the most severe cases despite the stage of PTTD. Therefore, in management of PTTD, be aggressive with non-operative methods (i.e. orthoses and exercises) and the earlier, the better!
Source: Lower Extremity Review. 2012
Visit your doctor regularly and listen to your body.
If you missed them, you can read Part 1 and Part 2 of this three-part series on flat feet and PTTD.
CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.
Photos: by Jennifer Hnatko, Mackarey & Mackarey Physical Therapy Consultants, LLC
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.
Guest Columnist: Janet Caputo, PT, DPT, OCS
“Flat feet,” considered the most common foot deformity, affects 60 million people in the United States (approximately 25% of Americans). Posterior tibial tendon dysfunction (PTTD) results from flat feet or may develop from an accumulation of prolonged, repetitive over-pronation of the foot. If not managed properly, PTTD can progress over time and interfere with work and recreational activities.
How can you tell if your PTT is dysfunctional? “Too Many Toes Sign” and “Jack’s Test” can help determine the integrity of your PTT. “Too Many Toes Sign” tests for flat-foot deformity or over-pronation and “Jack’s Test” determines if the PTT can correct this abnormal position. If one or both of these tests are positive, your PTT is at risk, and you may have PTTD!
To perform “Too Many Toes Sign,” stand facing away from someone and have them draw an imaginary line from the center of your calf to the floor. This test is positive if your heel lies outside this line and if more than two of your toes can be observed.To perform “Jack’s Test,” lift your good leg off the floor, rise up on the toes of your bad leg, and hold that position. A diagnosis of PTTD is confirmed if you are unable to perform this one-legged heel-raise or if your heel remains turned outward in the tip-toe position.
The primary goal in PTTD management is to prevent progression to the next stage by correcting the over-pronation or flat foot deformity. Treatments for PTTD include orthoses, exercises, and surgery.
Orthotic management can be considered “first-line defense” against the progression of PTTD, because it targets and corrects or accommodates the CAUSE: improper alignment from a flat foot or over-pronation. Because orthoses align the foot and ankle joints, they reduce pain by eliminating abnormal stresses on compensatory structures (e.g. PTT). If the flat foot position is flexible, the orthosis corrects deformity, but if the flat foot position is fixed and rigid, the orthotic design accommodates and supports deformity. Improving alignment with orthoses allows the PTT and other accessory muscles to work better, which improves foot/ankle mechanics.
“Orthoses” include supportive foot-wear, taping techniques, shoe inserts, and a variety of custom-molded braces. Stability running shoes (picture A) control over-pronation with a post on the inner side of the foot made of dual density foam which is easily recognizable as a darker piece of foam on the inside of the midsole. Motion control running shoes (picture A) support the flat foot with similar technology plus a special sole unit/upper construction for enhanced support. Taping techniques (picture B) lock the heel inward which reduces excessive flattening of the arch. Shoe inserts (picture C), over-the-counter or custom-molded, either control abnormal pronation with a post on the inner side of the heel that tilts the heel inward or accommodate the flat foot deformity. A variety of custom-made “braces” (i.e. ankle-foot-orthoses; e.g. double upright AFO, gauntler style AFO, low articulated AFO; (picture D) are used to manage severe flat-foot deformities. Because the arch of your foot is not a weight bearing structure, placing a pad in the arch of your foot to correct alignment is not recommended. For proper orthotic prescription, consult with a licensed professional (e.g. podiatrist, physical therapist, prosthetist/orthotist).
Join us next week to discover exercises that strengthen key foot and ankle muscles to enhance the dynamic support for the over-pronated or flat foot, and to discuss several surgical options that are warranted if conservative treatment fails.
Source: Lower Extremity Review. 2011
Visit your doctor regularly and listen to your body.
CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.
MEDICAL REVIEWERS:
James Haggerty, DPM: Dr. Haggerty is a podiatrist in private practice in Dunmore, PA.
Vincent Grattolino, DPM: Dr. Grattolino is a podiatrist in private practice in Scranton, PA.
Photos:
Jennifer Hnatko, Mackarey & Mackarey Physical Therapy Consultants, LLC.
"Picture A: Motion Control Running Shoes" from "ransacker.co.uk"
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune. Next Week: Flat Feet -Part III of III.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.
Guest Columnist: Janet Caputo, PT, DPT, OCS
Part 1 of 3
While walking in the sand on the beach, did you ever notice your foot print? Have you noticed that some foot prints on the beach are wider than others and show the width of the entire foot? That imprint would indicate a very flat foot with poor arch support. The arch of your foot should be apparent by age 6-11. However, some people are born with “congenital flat foot,” and never develop arches. Others are born with foot deformities (e.g. club feet) and are destined to develop flat feet. Still others develop normal arches but, their arches flatten as they age (acquired flat foot).
Acquired Flat Foot (Photo Source=Jen Hnatko, Mackarey PT)
This “acquired flat foot” is often due to a combination of factors that would put additional, excessive stresses on the bones and tendons: (1) alignment issues of the foot or leg (2) repetitive stress from high impact sports (e.g. basketball, tennis, and soccer), (3) training errors (e.g. running on crowned roads), (4) obesity, (5) diabetes (6) hypertension, (7) rheumatoid arthritis, (8) age-related degenerative changes. In extreme cases, an acute, traumatic rupture of the tibialis posterior tendon (the tendon that helps support the arch) can also cause collapse of the arch of the foot.
If the bones in your foot and ankle are perfectly aligned, their ligaments, tendons, and muscles function correctly. Ligaments hold the bones in your foot and ankle in proper position, providing static support to your arch in weight bearing positions. Muscles and tendons move the bones in your foot and ankle, affording dynamic control to your arch during walking and running. However, if you have a flat foot, your arch lacks adequate static support from its ligaments and will excessively flatten (i.e. pronate) in weight bearing positions. In this case, the foot needs help to maintain the arch by relying on muscles and tendons for additional support.
The posterior tibial tendon (PTT) is the primary muscle/tendon that supports the arch as it travels diagonally across the inside of your ankle and then dives into the bottom of your foot to attach to multiple bones in your arch. This strategic trajectory places the PTT in a perfect position to support and control the arch of your foot.
The arch of the foot requires more than just the bones for support. The posterior tibialis tendon (PTT) plays a critical role and works hard to assist even in the normal arch. However, in the flat foot the PTT works overtime making it vulnerable to overuse and injury.
The location of this tendon allows it to work like a dynamic sling that contracts when needed, however, it is not designed to perform the job of a ligament. Moreover, excessive flattening (i.e. pronation) of the arch during stance phase over-stretches the PTT, and, because the arch excessively flattens, the PTT must work harder to raise (i.e. supinate) the arch during swing phase in preparation for the next stance phase. Eventually, the PTT will exhaust if made to endure this dual role for an extended period of time.
The arch of your foot changes position during the walking cycle. The walking cycle has two phases: stance and swing. Stance phase begins as your heel hits the ground and ends just as your toes lift off the ground. Swing phase starts just as your toes lift off the ground and finishes just before your heel hits the ground. Your foot and ankle “pronate” (i.e. your arch flattens) during stance phase to allow maximum contact with the ground. During swing phase, your foot and ankle “supinate” (i.e. your arch raises) to prepare your foot and ankle for the next stance phase. This “rise and fall” of the arch in your foot is the primary responsibility of the PTT. Because your PTT functions all the time while you walk, it never gets a rest and, therefore, is at great risk for injury.
Take the “wet foot test”! Pour a thin layer of water into a shallow pan. Wet the sole of your foot. Step onto a shopping bag or blank piece of heavy paper. Step off and look down. Observe the shape of your foot and match it with one of the foot types below:
"Wet Foot Test" Source: "http://aneclecticblog.com"
If your foot appears to have a flat arch, your tibialis posterior tendon is at risk for injury.
Even if you appear to have an “arch” after the “wet foot test,” you may still be an over-pronator. Pronation is a necessary component of the stance phase because this motion allows your foot to conform to the contours of the ground and absorb shock. However, over-pronation over-stretches and over-uses your PTT, as described in the flat-foot scenario. Eventually, you may experience pain on the inside of your ankle every time your foot hits the ground. This painful condition is called tendonitis, and if not managed properly, your ligaments will become over-stretched. This is what leads to the collapse of the arch of your foot.
If you have a flat foot or are an over-pronator, your PTT is at risk for injury! Please join us next week to discuss the symptoms associated with PTT dysfunction (i.e. PTTD).
Visit your doctor regularly and listen to your body.
CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.
MEDICAL REVIEWERS:
James Haggerty, DPM: Dr. Haggerty is a podiatrist in private practice in Dunmore, PA.
Vincent Grattolino, DPM: Dr. Grattolino is a podiatrist in private practice in Scranton, PA.
Photo Credit:
"Acquired Flat Foot." Source: Jennifer Hnatko, Mackarey & Mackarey Physical Therapy Consultants, LLC
"Wet Foot Test." Source: http://aneclecticblog.com/2008/05/why-good-shoes-matter/
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune. Next Week: Flat Feet – Part II of III.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.
