The View from Sports Center

What We Can Learn from the Love Lab About Injuries

Dr. John Gottman from the Relationship Research Institute, also referred to as The Love Lab, in Seattle, Washington claims that within five minutes, he can predict with 91% accuracy whether a married couple will enjoy years of marital bliss or crash and burn.

He and his team, after studying hundreds of couples and scientifically scrutinizing their interactions, have found four negative qualities that predict divorce and seven positive that predict success. 

As I read these, it struck me that these qualities, both positive and negative, are remarkably similar to those of people who overcome an injury and those who don't.

First, the negative:

• Criticism: Global negative statements about your partner’s character or personality.

Global negative statements about your injury or situation; failure to find positive changes no matter how big or small.

• Contempt: Sarcasm, cynicism, name-calling, eye-rolling, sneering, mockery and hostile humor can be poisonous because they convey disgust.

"It won't make any difference anyway...that'll never work..."

• Defensiveness: This is a way of blaming your partner and can escalate the conflict.

Blaming others for your predicament; failure to accept choices you made that either created your problem or sustain it.

• Stonewalling: A partner may disengage from the relationship, signaled by looking away without saying anything and acting as though he/she doesn’t care about what the other is saying.

Ignoring symptoms, refusing to discuss or acknowledge the severity of the problem; "It's not that bad....I'm fine."

According to Gottman, the presence of these four qualities in a relationship predict the end of the relationship with an 82% degree of accuracy. I don't know of any similar research in the injury field but I've said many times that the key to overcoming an injury does not rest primarily in the technical domain. It's not in the head where you win the battle. It's in the heart.

You have to focus your thoughts and energies on a positive frame of mind, be willing to face the issues, take responsibility, and be grateful for the improvements no matter how small to over come an injury or the after effects of surgery. If you don't, you won't fully recover.

And what about the seven qualities that build a great marriage and enhance your chances of recovery from injury?

Coming soon.

Lower Leg (Peroneal) Tendonosis: Part II

In my last post, I covered the Five Keys to Solving Lower Leg (Peroneal) Tendonosis and I mentioned at the end of that article that I would describe a few drills.

Just as a reminder, the drill selection is driven by at least three things: the nature of the injury (tissue or tissues involved), the severity and irritability or what we refer to as the "stage", and the mechanics of the involved structures. In Chuck's case, the tissue is the peroneus longus and brevis, the stage is unknown, and the mechanics are deceleration of the lower leg over the foot in a weight bearing position.

For someone who has symptoms either at rest or very quickly with activity, one of the drills we might choose would be a bilateral squat with a less than body weight load. We prefer to use a Total Gym to reduce the bodyweight force.

After testing to find out the appropriate level, the client would perform 3-5 minutes of squats with a focus on pressing the ball of the foot into the footplate. This puts the dosage close to 100 reps per set. The peroneus longus plantarflexes and everts the foot which you can create by simply applying force into the base of the first metatarsal (ball of the foot). Although the foot doesn't move, you'll increase the tension in those muscles from just trying. Near the end of the set, you should feel a mild degree of fatigue and pain or discomfort.

A progression would be to move to a sidelying position and place the foot on a foam pad to create an inverted position (or supinated). Now, as Mike squats, he tries to pronate the foot by pressing the ball of the foot into the foam pad. This increases the load on the peroneus longus and brevis.

For less irritable or severe cases, we might choose a split squat with a lateral vector. The vector or line of force  pulls the leg away from the midline of the body (which is why we call it a lateral vector). In the picture, you can see that at rest, Mike's leg has been pulled out and even rotated out a bit. His job during the drill was to press the great toe into the floor and keep the lower leg straight which he did. And, his comment was that he could feel the muscles on the outside of his leg working fairly hard.

The dosage for this drill is lower than the bilateral squat since the load is higher. It's still fairly high, from muscle training standards, at 20 to 30 repetitions per set. And, we want both a moderate degree of fatigue and pain at the end of the set(s).

The difficult part of this process is finding the right mix of load and reps and pain. We often have to coach clients that all pain is not bad. Some pain is actually good for you as in the case of tendonosis.

But, since all pain is emotional, you have to be careful in applying this concept to your self or someone else. It's just a lot easier to have a coach - not necessarily right there with you all the time -  but someone who can help you interpret what you're doing and feeling.

DK

Thanks to our physical therapy student intern, Mike Coller, from the University of Wisconsin, for helping me with this post by generously serving as a subject and asking some great questions.

Five Keys to Solving Lower Leg (Peroneal) Tendonosis

Hi Doug...

I was introduced to your practice and subsequently your blog(s) by a local (Austin) Neurologist whom you treated successfully. You receive our praise in absentia at our annual Fall Rocky Mountain hunting trips which involve hiking over rough terrain (as opposed to TX style hunting blinds). I use your advice remotely from Montana to treat various arthritic joints and keep my 62 year old decrepit body active. I have studied your therapy recommendations for tendonosis of of various tendons but have been unable to infer from those a treatment for my disabling peroneal tendonosis (it makes me want to scream while sidehilling or walking on rocks....bad for hunting). I know that it is a somewhat rare diagnosis but I would appreciate a blog dedicated to this diagnosis and its treatment.

Thanks,

Chuck

P.S. I haven't tried downhill skiing yet...it will be interesting to see if the rigid boots stabilize the ankle enough to minimize the pain.

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Thanks for your note Chuck and your question. Here are my thoughts on your situation.

1. The more irritable the condition, the lower the load and the higher the volume you'll need. If your leg hurts quickly and takes a while to subside, days for example, you'll need low loads and high volume of reps to alter the tension capacity of the tendon. You have to sneak up on it and nudge it into a healthier state. The rep range is around 100 reps / set with low levels of fatigue and very mild discomfort. If you can hike for a hour or two and the symptoms subside within a few hours, then you can use a higher load and lower volume - around 30 reps per set with moderate fatigue and discomfort.
2. Move your body over a stable, fixed foot. The peroneus longus muscle likes to restrain motion of the leg and provide stability to the arch of the foot rather than produce motion even though the classical definition of the muscle action is to produce eversion (moving the foot sideways) and plantarflexion (pointing the foot). This is because anatomists define muscle action as creating motion from the insertion of the muscle toward the origin. The peroneus longus inserts on the bottom the foot near the first metatarsal. So, if you  flip the action around so the motion is from the origin to the insertion, the tibia moves back and down. When your foot is on the ground, the muscle is pulling back on the tibia to keep it from moving to quickly over your foot. This is, as you noted, the time when you're apt to feel the symptoms - when your foot is on the ground and you're decelerating your center of gravity as in walking down hill sideways or over uneven surfaces like rocks. Once your leg tolerates a stable surface, you can then advance to unstable surface training.
3. Train to pain. You have to train hard enough that you produce some symptoms and this is where it's often tough to do alone. What's too much? What's not enough? Well, the intensity is too much when you compromise your motion and it's too little if you don't hurt at all. You want the symptoms to show up near the end of each set. And, ideally you want motions that produce the symptoms in real life. You use the very thing that bothers you to heal you but you control the load.
4. Train the hip. Your hip external rotators counter the pull of gravity and the collapse of the leg toward the ground when doing things like walking, climbing and hiking . The stronger your hips are the more they will help the peroneal muscles do their job. 
5. Poke and Prod. Sometimes, I'll use a manual technique to induce an inflammatory reaction. The technique itself is probably less important than the intensity and duration of it. Tendonosis is a condition of tissue weakness. If you can create a mild inflammatory reaction (and this is what some of the drills do as well), you will jump start the production of collagen which is what the tissue needs. Rolfing, Deep Tissue Massage, certain forms of Myofascial Release, and Graston Technique all can create an inflammatory reaction (This is also the framework for Prolotherapy, an invasive technique used to promote soft tissue healing.) You'll need a professional to help you with this though.

As for snow skiing, the boots will help but your foot still works inside the boot as you carve in the snow to turn one way or the other. So depending on how irritable your tissues are, you may still hurt a fair amount.

Last thing specifically for you Chuck. If you have arthritic joints, such as a knee or hip, you'll want to recondition those joints so you get as much help as possible for your foot / ankle. Sometimes one area of the body ends up working too hard because the arthritic joints dial down the muscle power of the muscles around the effected joint (s). This is called arthrogenic inhibition. So, in the knee for example, you can lose some strength in the quadriceps, hamstrings, and even the gastrocnemius. The gasctrocnemius is a direct synergist for the peroneus longus meaning it helps it do its job.

Next time, I'll go over some drills for this condition.

Do You Have Any Suggestions for My Plantarfasciitis?

Below is an email I received from a reader about plantarfasciitis. My answer follows her email.

Hello Doug,

I came across you site and you have the best information I have seen ever!  I have chronic plantar faciitis  and am trying to find a physical therapist or Dr. that uses a newton speed trainer as I read in your previous articles.  I am currently in the process of searching for affordable crutches, the TED sock (found it at Walmart), and ordering the night splint.  I can only stay on my feet without pain in the morning for a few hours then its downward from there.  I went to the site you had suggested on your site to search for a physical therapist but do not know what or whom I am looking for.  Do you have any suggestions for someone in my area?  I have no insurance but have saved money to pay for this.  Your answer will be greatly appreciated.

Thank you for your time,

Kate (not her actual name) -

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Thank you for your note and question Kate.

Unfortunately, I don't know of anyone with a Newton in your area but you should search for a therapist who is board certified in orthopedic physical therapy.

The Newton is only one of the components to overcoming something like plantarfasciitis.
Sometimes you can use a pool and walk in chest deep water to reduce the force on the tissue and then use that as one of the drills to increase the loading capacity of the foot.

Most musculoskeletal problems, like plantarfasciitis, break down into three main components: tissue injury (or disease), biomechanical faults, and mental/emotional attitude and reactions.

For the tissue injury in plantarfasciitis, we've had success by reducing the force on the foot in everyday activity while at the same time using specific exercises to increase the tissue's force capacity. To reduce the force during the day, I've referred a number of people for a pair of Z-Coils. Almost everyone has immediate relief. But, this is not intended as a long term solution. You'll still want to recondition the tissue in your foot and gradually get out of the shoes.

Some people also have restrictions or tightness in the fascial network that connects to the plantar ligament specifically the gastrocnemius (calf) and hamstring. Fascia is plastic but not elastic. So, you can alter the relative length but it's not easy to do and of course it's not supposed to be easy otherwise your muscle system would have inadequate support. There are a number of techniques practitioners use to facilitate change in the fascia such as Rolfing, Myofascial Release, and other forms of manual therapy. I would get someone to assess your flexibility and help sort out if you have biomechanical faults in the lower leg or hip that might be contributing to the overload in the foot.

And, finally, the choices you make each day have a large role to play in what happens with your body. I've had clients with, for example, a tibial stress fracture who simply refuse to stop running even though the leg is very painful and, as a result, interferes with other parts of their life. You have to listen to your body and respect it. After all, your body is you.

Should I Have A Meniscal Allograft or Arthrosurface?

I've enjoyed your blog for some time now and would appreciate your thoughts on my situation:

• 51 years old and 10 years post right lateral meniscectomy.
• Now with valgus deformity and bone on bone laterally. 6'3" and at least 80lbs overweight (290).
  
• Formerly tennis player and snowboarder now windsurfing is all that's still worth the "pain price".

Looking at osteotomy to correct valgus combined with "arthrosurface" partial knee vs  meniscal allograft. What has been your experience with regard to survival of the repair in these scenarios?

Thanks

John

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John, thanks for reading the View and for your question.

Just to bring everyone up to speed, I'll decipher the medical terms and John's situation first.

A meniscectomy is a surgical procedure that removes the meniscus - a crescent shaped cartilage in your knee whose purpose is to both provide some cushioning and stability. Research has shown that people who have had meniscectomies tend to develop arthritis more readily than those who have not had a meniscectomy so most surgeons now will try to save the meniscus by doing a repair or by removing as little as possible.

Valgus deformity is an alteration in the normal angle of the knee such that it angles inward. This is often referred to as "knock knees". The altered angle creates an abnormal stress through the joint and increases the wear on it.

An osteotomy is a surgical procedure that removes some of the bone from your knee to reduce the valgus deformity.

A meniscal allograft is a surgical procedure that uses a cadaver meniscus to replace the missing or damaged meniscus in your knee. This procedure is usually performed on younger people with a severely torn meniscus to prevent or retard arthritic changes in the knee. The cadaver tissue is sutured into place and you usually have about 12-18 months of recovery and modified activity while the tissue heals and becomes firmly entrenched.

Arthrosurface HemiCAP for the knee is a relatively new surgical procedure for people who have relatively focal joint surface damage (cartilage) and may not need or want a total knee replacement. Usually the patient has a relatively small area of cartilage damage. You can see a animated video if it here.

So, now that we have the basics in place, I'll tackle John's question.

Considering your weight, the valgus deformity in your knee, and likely the joint damage, I'm surprised that a meniscal allograft is a consideration and you're not facing just an allograft but an osteotomy as well. An osteotomy is a significant surgical procedure as is the allograft. Then, you'll have at least six months of rehab with at least about two months of that time on crutches. Because the graft is fragile, you'll not be able to exercise with much intensity which means you could gain weight unless you also adopt a weight reduction plan. So, then, you have two major things going on: recovery from two significant surgical procedures and altering your diet and lifestyle to reduce your weight.

I've not seen anyone following an Arthrosurface procedure. As far as I know there's only one surgeon in Austin who is trained in it. In theory, the recovery and rehab should be less than that for a total knee replacement but in your case, I'm not so sure. The osteotomy may delay the recovery time.

If you were my client, the first thing I would talk to you about is getting your weight down into a more ideal range. You can work on that now. For every pound you lose, you gain three pounds of force capacity in the knee. So, if you really are eighty lbs. over weight, your knee will feel considerably better with even just a twenty lb. weight loss without surgery or any other procedure. The most important part of the weight loss plan is your diet. Exercise can't overcome a bad diet unless you're in the elite, professional athlete class. Think of Michael Phelps. He can eat whatever he wants, right now, because his body churns through calories from hours of training. You'll need to take an honest look at your diet and make the adjustments. You may want to meet with a nutritionist to get some customized advice.

For your exercise, training in water could be a great starting point and depending on the drills, can be very demanding. I would use anti-gravity exercise tools to reduce the force going through your leg while increasing muscular demand and drills that require large muscle group activation. This would create a significant metabolic event, drive up your caloric expenditure, and make you feel better all at the same time.

So, at this point, here's what I suggest:

• Get started on a weight reduction program.
• Ask your surgeon why he or she thinks a mensical allograft would work and how many Arthrosurface procedures he or she has done.
• Try to talk to some other people who have had an osteotomy to get an idea of what the procedure is like and what you feel like after it.

Again John, thanks for reading and your question. I hope things go well for you and that my post was helpful.

Image Source: www.zimmer.com

Running Barefoot: Good or Bad?

View reader, Travis, asks,

"Doug,
I was hoping to email you, but I couldn't find a link for your address.

My question for you is about the new running book, "Born To Run". The book's thesis focuses on whether our bodies were in fact made to run. One part of the premise focuses on the benefits of barefoot running. In short, our feet "atrophy" in shoes similar to the way our arm would in a cast. It goes on to say that many of our injuries would go away if we ran barefoot or with minimal support and not the high tech cushion shoes. I was curious to hear your opinions.

I'm an avid read of your blog so I hold your opinion in very high regard."

Travis

---

Thanks Travis for your question. And, here's the thing about email. If you email me and I answer you, I answer it here so all the readers benefit from your question. Submitting a comment like you did is the best thing to do anyway. Sometimes it takes a while for me to respond to a question especially if it involves research as in this case. I had to try my ideas first.

Barefoot running is a hot topic right now although the idea has been around for a while. Ken Saxton has run 38 marathons barefoot and has developed quite a tribe of barefoot runners. And barefoot running is not just for runners who love a fad and jog around a golf course. Ethiopia's Abebe Bikila won the Olympic gold medal in 1960 in world record time of 2:15:15 - barefoot.

Your question is a good one, not just for barefoot running, but for a larger issue of culturally induced atrophy. Many people lead sedentary lives and as a result muscles, tendons, bones, cartilage and other biologic tissues atrophy. This creates a narrow window of physical capacity or reserve. So, when we are faced with some new physical demand, like spending four hours on a Saturday morning in the yard raking, digging, planting, etc., we end up injured. Instead of changing our lifestyle from sedentary to active or even athletic, we seek solutions to eliminate the pain and remain sedentary.

But, back to barefoot running. First, to run barefoot means running with different mechanics than what most people use. Some runners follow the Pose method of running or Chi Running both of which promote using gravity to propel the body and using the forefoot for ground contact. The idea is to keep the stride short, increase the frequency of leg motion, lean forward, and keep your foot under you instead of reaching out in front for a long stride. Both sites have quite of bit of learning material for a beginner.

But, running barefoot is tough on your foot, of course, unless you can run on grass or a sandy beach. My first choice was a pair of Nike Free shoes. And, compared to a regular running shoe, the Nike Free did alter my running mechanics although you can still land on your heel. The shoes are light but it doesn't feel like you're running barefoot.

My next choice was a pair of Vibram Five Fingers. Vibram's are like a glove for your foot. Running in these completely changes the way you run and feels very much like running barefoot. I started with about 400 meters of running and 400 meters of walking. The muscular work in the foot and lower leg is significantly different than in a typical running shoe and I had some sore muscles for a few days after just a 15 minute session.

Now, I guess the question is, is it worth it? Is the effort and time to make the switch to barefoot running worth it? The Pose method site has some data about the forces produced in the knee with conventional running shoes and styles compared to landing on the forefoot and altering the stride. The force in the knee is less although the force in the lower leg is more. If you choose to run barefoot or close to it as in the Vibram's, make the switch very, very slowly. Your body, your foot and lower leg in particular, are not used to working that hard. But, if you give your self some time, you'll adapt. 

I think there is some merit to the argument that by not using muscles and tendons and ligaments in the foot and lower leg that those tissues lose some capacity. The whole point of first going through rehab then reconditioning is to build up strength and capacity. Sometimes we have to use a more supportive shoe to assist the tissues. I've suggested shoes like the Z-Coil to people who have plantarfasciitis and they work great. But, the purpose of using a shoe like the Z-Coil is to get out of the shoe and into more conventional footwear. Likewise, there's an argument that the purpose of using a highly cushioned running shoe is to get out of the shoe too.

I like the way I feel running in the Vibram shoes (or gloves or whatever they're called) and will probably keep working at changing over to that style. But, my time line to do this is months and as my wife likes to say, "You're a very patient person."

And, I don't mind people staring at me.

10 Million and 10 Years

Suppose someone gave you $10,000,000 and, at the same time, you learned you had exactly 10 years to live?

Now, a lot of people have posed the question, "What would you do if you had a year to live?" like the basic plot of the Jack Nicholson movie, "Bucket List". But adding another nine years shifts the thought process a little. There's a sense of urgency but not panic; a sharpening of focus and purpose perhaps.

Try this as an exercise. Answer these questions keeping the idea of $10,000,000 and 10 years to live in mind:

• What would you do? Where would you put your energy and time? Who would you spend the most time with? Would you travel? Where would you go and why?
• How would you spend your money? Would you buy your self things? A new house or car?  Would you give it away to charity?
• Would you quit your job and do something else? Maybe chase your childhood dreams?

If you spend some time with this thought of $10,000,000 and 10 years, you'll discover things about your self, your circumstances, and your life that will surprise you, maybe scare you, and put a real sense of urgency in you.

Some people realize that they're living someone else's dreams; not their own. Some find that they have strapped themselves to a financial treadmill and the speed just keeps picking up. Others realize they hate their job and find the courage to go off and do something they really enjoy while some suddenly realize that their life is just racing by them and the question feels like a massive emotional brake.

What would you do with $10,000,00 and 10 years to live?

Why not do it now?