Well, welcome everyone to the next episode of the Redefining Physical Therapy Podcast. I’m your host, Dr. Gray.

And so today’s going to be a relatively quick podcast.

And so this is for all of you physios out there and manual therapists or even any other coaches that are trying to improve your athlete’s squat pattern or your CrossFit athlete’s squat pattern and you’re just finding that their ankle dorsiflexion is just lacking, and you’ve cleared the ankle.

You said, hey, they’ve got good cath mobility.

They’ve got good joint mobility, but they still, when they go, end up on their toes or their heel gets early rise deep into the squat pattern.

Or they may even prone it excessively because of the lack of dorsiflexion that you’re seeing. And it’s compensating and getting motion at the midtarsal joint.

So once you’ve checked all these different things, you’re like, well, where do I go, right?

And so the answer really checks above, to check the thoracic spine.

And so I think this is a lot of times a neglected component to improving an athlete’s squat. And so think about it for a second, right?

And so if I am kyphotic or I can’t extend, I have a bar belt behind my back for a back squat, I need an adequate thoracic extension. Right?

And if I don’t have T-spine extension, I’m going to go into more of a kyphotic posture and that’s going to shift my weight forward and I’m going to not be able to access all of my true ankle dorsiflexion mobility. Right?

And so, as a result, I’m going to have a poor squat pattern.

I’m going to show that I’ve got a lack of ankle mobility, but in reality, it’s the T-spine that’s the problem, right?

So a couple of ways that you can fix it, obviously you can do any high-velocity manipulations. Obviously, you can do any of your openings up the anterior muscles, the lats.

And then obviously all that stuff is all good. Any mobilization movements that are going to help restore that T-spine extension.

So that’s my little clinical pearl for the day because I’ve seen it several times where I’m working with a CrossFit athlete or an athlete and I’m just not able to get ankle mobility.

And I’m sitting there like, what am I missing, right?

And so the answer is usually above, right?

So we want to work on the thoracic spine mobility to enhance ankle dorsiflexion mobility.

The post Is Lack of Ankle Flexibility Stemming From the Thoracic Spine appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Wednesday, everyone. This is Dr. Gray, and we’re going to be talking about hips in this next episode of the Redefining Physical Therapy podcast.

For those of you that are avid listeners, you know that I talk a lot about the hips, the feet, and the thoracic spine.

That’s because these are the three powerful areas of the body that cause dysfunction and chaos.

So if you’re not assessing these areas, then you’re missing a big chunk of what’s really going on with your patient, regardless of what they come in for.

Needless to say, let’s talk about the hips. One thing that I commonly see is, obviously, we see a lack of hip extension in a lot of patients, right, in regards to gait and running, particularly.

One thing that I’ve… mistakes I’ve made is I’ll put them into a Thomas test and they’ll have an adequate hip extension. I won’t see any myofascial tightness.

I’ll then go and check the passive range of motion classical on the table, side-lying.

I even do different accessory glides of the femur, particularly anterior glide and it will come up normal. So I’m scratching my head and saying,

“Hey, but I see a lack of hip extension and I’m seeing quite a bit of a bailout or extension at the lumbar spine. So why is it changing in standing versus laying down?”

That’s because I think a lot of times as clinicians, we forget the two other planes of motion that the hip is going through.

So when that hip is lacking in any of those other planes, it’s going to limit the hip extension, right, the motion that you do see.

For instance, in functional gait, in running, and mechanics, as I go in hip extension, I’m also getting hip abduction and internal rotation.

So if I’m lacking any of those other motions, then I’m going to lack then from an objective standpoint that other motion of hip extension.

In a case, so let’s say, I’m lacking hip internal rotation functionally, when I go into terminal stance, I’m going to then lack hip extension.

The same thing goes with hip abduction, just because that’s the kinematics of the pelvis on the femur when walking.

The way you kind of weed this out from a clinical standpoint is you need to put them in a standing position.

You can test stuff on the table. That’s fine. That’s all good and great. You can test the accessory glides.

You can test for any myofascial tightness that may be limiting those motions. But you’re going to want to put them in standing and you want to just go plane by plane.

What I typically do is if I’m assessing the right hip, I would put the left foot up.

I go stool or chair and I’m weight-bearing on the right. I’m going to have my patient drive their pelvis forward so I’m just looking at the pure sagittal plane extension.

Then from here, I can then have him move his pelvis to the left. When he moves his pelvis to the left, I’m going to be checking for functional hip abduction.

Then from there, I can also take his foot off the stool and test hip internal rotation. The way I do that is how we get it in function.

I’m going to actually just take his left foot and he’s going to step around the corner and rotate his pelvis to the right.

That’s going to create some of that internal rotation at the hip top-down. These are just common things that I’m looking at to see if there’s any compensations or bailout.

A typical bailout you’ll see when someone in the frontal plane doesn’t have hip abduction is they’ll try to rotate or they’ll flex because they want to take the tension off their adductors, right, or that medial hip capsule.

Now, conversely, if I drive his left leg around the corner and into internal rotation, you’re going to see then that foot come off. They may even adduct a little bit, or they’ll just get like a hard stop and balk.

They actually may on their objective tests have a good hip extension, but it’s their abduction and internal rotation that’s limiting their ability to actually extend because, in function, the hip goes through those all three planes of motion at the same time.

I hope that helps clarify a few things, and I hope you can implement this into your practice to help with your better outcomes.

Thank you for listening to Scott Gray’s Redefining Physical Therapy podcast, the number one podcast for orthopedic, sport, and manual physical therapists.

The post Are You Evaluating Hip Extension Correctly appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Thursday, everyone. And welcome to the next episode of the Redefining Physical Therapy podcast. I’m your host, Dr. Scott Gray.

And so today in this quick episode, we’re going to talk about neck pain and how to treat patients that have neck pain.

And I’m actually going to simplify it for you. This is just one strategy of things to look at.

We see clinically back in motion and where are our therapists are being trained. And so obviously when a patient comes in with neck pain, you need to discern is it the joint? Is it a disc injury? Is it fascial? Is it a pastoral pain?

And that’s going to help you decide your strategy. But from a biomechanical standpoint, there are really two places that we want to address, and so that is the subcranial spine and that is the upper thoracic spine.

And so think about that for a second. So the majority of patients that come in with mid-cervical pain, those joints above and below are adjacent to the mid-cervical spine.

And so these are places where things get locked down, and so our body is going to move in the path of least resistance. So think about that for a second.

If my sub-cranial spine is locked down, my upper thoracic spine is locked down, where am I going to rotate? So I’m going to rotate primarily at the mid-cervical spine.

So over time, these muscles are going to become irritated. The joint may become irritated. The disc may become irritated.

There’s a time and place to treat symptoms, so once you really have locked in what is going on, the impairment’s typically at the upper subcranial spine and the upper thoracic spine.

So now in regards to your subcranial spine, you want to check OA and AA. So we know OA’s primarily more of a sagittal plane, chin nod, so a lot of these people are going to be stuck in subcranial hyperextension with a forward head posture.

So when you’re stuck in subcranial extension, it can limit also rotation. So we know AA is primarily where 50% of the rotation should occur.

So these are just a few things you want to test and in a future episode, I’ll talk about the biomechanics of that.

Now, similarly, your upper thoracic spine has a ton of rotation. And if you’re not rotating there, you’re going to be resonating at A, the mid-cervical spine.

And so a quick test that you can do is when you’re sitting with the patient, you want to hold their head and you’re standing behind them, you’re going to palpate C7 down to about T3, T4.

And literally, you’re going to just watch and see if the upper thoracic segments can rotate. So as I rotate right, I should see my spine’s processes move to the left.

That’s how I know that that’s part of the spine that’s getting motion.

If they’re not moving then A, I to mobilize them.

So, that’s how you would go about it. So I think a lot of times we get caught up in the neck is hard to treat or we have a lot of these impairments, but if you look at the subcranial spine first and the upper thoracic spine, and you get them moving, I think you’ll be impressed with your outcomes because you’re going to have a normal potential range of motion.

You’re going to then take stresses and strain off of the mid-cervical spine area, so you’re going to take pressure off those facet joints.

You’re going to take pressure off that disc potentially, and you’re going to reduce some activity of muscles that are working overtime to move and stabilize the mid-cervical spine, but also get muscles that are adjacent to the upper thoracic and subcranial spine moving normally rather.

So, there you have it. That’s my clinical pearl for today and my advice for today. Implement this into your practice and post a comment below and let us know how it went.

The post Neck Pain: Here’s How You Really Should Be Treating It… appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Tuesday, everyone. This is Dr. Scott Gray. Back to you again with another episode of the Redefining Physical Therapy podcast.

And so today, I want to start off talking a little bit more about spinal manipulation. And so, there’s a lot of different camps out there.

Some are specific to the segments involved, while others are about multiple cracks and multiple pops. So, let’s not lock anything up.

But, when do you use those particular manipulations versus the other, right? And so, I want to answer that today.

But let’s backtrack a little bit first, and let’s talk about when you should manipulate, right? And, why.

So, there’s really a couple of different reasons why you should manipulate someone.

The first one is to get someone out of pain, right?

So we know that when you manipulate it can help patients get out of pain and it allows you to get them moving and healing, right?

The second reason why we manipulate is to reduce muscle tone and guarding, right?

As you know, as we manipulate, stimulates the different mechanoreceptors that cause a reciprocal inhibition of the muscles that may be guarding or in tonic spasm.

So, that is another reason you want to manipulate.

The third reason you want to typically manipulate is to improve mobility and function, right?

So if a joint is stiff or stuck, you can mobilize it or you can do a grade five thrust, right?

So, you can crack it.

And so, the way I explain this to my patients and students and clinicians that I am currently training, I tell them like a door that is stuck, right?

So if a door is stuck and it’s not moving, you can gently mobilize it, right? See if that improves.

But if it’s stuck, sometimes you need to crack a joint. And so, that’s where your grade five thrusts come into play.

Now, I would also add in another reason why should we be manipulating and that’s to help with patient expectations and a placebo, right?

So, sometimes patients just want to hear a crack because they think that something had happened to them.

It gets them to think that maybe you put something back into place, even though we know that’s typically not true.

But these are things that you need to be using in your arsenal to deliver better outcomes.

But, let’s jump into when do you use the specific type of grade five thrust, right?

So if I have a patient that is just generally hypermobile, they don’t have any red flags, guarding, or anything like that.

Well, sorry, I take that back. You do actually want to manipulate if they do have to guard.

You want to do then the multiple pops and cracks, right?

Now, conversely, if I say, for instance, I had someone come in with a disc injury, they are guarded.

I don’t want to manipulate that segment, right?

That’s going to be in question because I could potentially irritate that, especially on the hot disc, right?

But I can manipulate the segments above or below it. And so, that’s where I want to be really specific.

And so, people will say, well, you can’t really be specific. And I think that’s a bunch of nonsense because if you study the best manual therapist and you learn these skills and the art of manual therapy, you can lock out specific segments.

And I will tell you just based on when I’ve lockout things, you feel the pop right underneath your hands.

And so, you just don’t want to skip several segments along those lines when you’re trying to be specific.

So another case you might want to be very specific about is if they have a hypermobile segment, and they have relatively hypomobility adjacent to it, right?

So you want to manipulate the hypermobile segments, but you don’t want those hypermobile segments to move, right?

So you think of people that have a thoracolumbar syndrome or dysfunction, where the L1, L2 they’re typical, I would say, almost hypermobile.

They’ll have a crease with their moving just at those segments.

So you don’t want to manipulate there per se, you want to manipulate above and below it.

So you’d want to lock that segment out and then manipulate it.

So there you have it, those are just some things to think about when you’re manipulating.

When do you want to lock everything out and be precise and specific?

Maybe then, when do you want to get multiple pops to make the patient feel like that you’ve done something to them, or they just have general hypomobility across all of their spine or those segments.

So, that’s my take on when to use each. And I used both in clinical practice, it’s just another tool and you just need to apply your clinical reasoning when you want to use one versus the other.

The post Spinal Manipulation: When Do You Use Multiple Cracks Vs. Specificity appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

All right. Welcome everyone to the next episode of The Redefining Physical Therapy Podcast. Happy Monday, everyone.

I hope everyone’s Easter was great and you’re ready to kick butt in the clinic and get your patients better.

And so on that same token today, I’m going to talk a little bit more about the psychology of patient care and different things that you can control that will help your outcomes.

And so a lot of times we think as manual therapists and orthopedic and sports guys that my techniques and just my knowledge is going to get my patients over the hump.

And so these are just a few things I think you need to keep in mind as you begin treating your patients.

So the first thing is the patients don’t really care what you know per se, but they want to know that you care about them. So it all starts with trust.

And so if you can show empathy, you can show trust and listening to them when you’re doing their subjective for that first initial day that you meet them, that’s really going to help develop trust with them.

Another way that you can really develop trust beforehand is if you are an expert, it’s that perceived status of you.

And so that’s why as a doctor of physical therapy, you need to be the go-to expert in your area in town.

You need to be a published author. You need to write for your local newspaper. You need to be writing blog posts.

You need to be writing content on specific things because then when people land on those things, you’re already the expert. You’ve established yourself that the authority, the celebrity, and the expert.

And so they’re already going to be bought in for the most part, but you still need to use good patient efficacy in developing trust and listening to them.

From there, you also need a few other little things that just can make or break you.

And so I was having this conversation with my team the other day. And so one of our providers, was having some of his patients drop off after his initial evaluation, and he’s a good clinician, but there are little things that you can do to develop that buy-in.

And so he wasn’t calling himself, Dr. Kupper. He was saying, hi, my name is Andrew. And so when you go and meet someone, they want to be working with an expert. So you need to be calling yourself, Dr. Gray, Dr. Smith, whatever it is.

So the next thing in line is just dressing for success.

And so if you study any sales books, you study any psychology book, our mind subconsciously is always approving or disproving people.

And so you need to A, be looking sharp, you need to be dressing like a professional, you need to be wearing clothes that a doctor or a professional would wear.

Don’t be wearing khaki pants and polo and gym shoes with your hair barely done, not clean-shaven, and your hair is not dressed or put up. That stuff’s going to affect your outcomes big time.

You may not think so, but it is. And so again, it’s at a subconscious level of these things are happening.

The other side of it is your clinic itself, the experience. And so if your clinic is clean and neat, you’ve got one-on-one rooms with your patients where you can have in-depth conversations versus having just a fold-up table and a curtain, those things again, are going to help you too.

So there are tons of different things that are going on in our patient’s minds, but I do think if you establish yourself and your area as the authority, the celebrity, the expert, you actually take the time to listen to your patients and do a very thorough, subjective and clarifying things.

You are dressing for success.

You’re on time.

And also you’re calling yourself a doctor and having a clean clinic, I think your outcomes are going to go through the roof versus someone who has maybe the same clinical skillset.

You’re going to get people better because of that psychology component. So that’s just my little rant for today. I hope you consider these things and adding them to your clinical practice.

The post Are Your Patient’s Picking Up On These Psychological Triggers appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Friday everyone and welcome to the next episode. Today we’re going to just really hop right in and talk more about how your patient’s feet may be causing their lower back pain.

So, up to this point, we’ve talked about a forefoot valgus, which turns into a Pes cavus foot. We’ve talked about an uncompensated rearfoot varus, how that causes lower back pain and so I’d highly recommend that you tune into those podcasts.

Today we’re going to talk about a compensated rearfoot varus and a compensated forefoot varus.

So, these two types of feet are pretty similar except one’s more extreme. A compensated rearfoot varus foot is a foot that is flat and so is a compensated forefoot varus.

The big thing to note about this is the first foot, the compensated rearfoot varus. They do not have a forefoot issue. They have a rearfoot issue.

They are stuck in rearfoot eversion or inversion, but they have enough mobility at the subtalar joint to compensate.

Now, conversely, the foot I talked about the other day in part two, are stuck in a rearfoot varus, but they do not have the ability to pronate.

They don’t have the mobility, the subtalar joint from the axis in the rotation of that joint. It’s just, you’re not going to get much pronation there.

So, the big difference is, with this compensated rearfoot varus foot can pronate. It’s going to try to get its foot flat as compensation.

So, they’re going to protonate naturally excessively and they’re going to typically pronate through midstance and terminal stance. Now the other end of the spectrum is this forefoot varus or compensated forefoot varus foot.

So if you were to put them in subtalar neutral and look at the forefoot to rearfoot angle, you’ll see that the forefoot is in a varus position.

Because of this varus, this foot can compensate because they have enough motion at the rearfoot. They will actually, again, pronate, but it’s a little bit more excessive.

So this is what we call typically an F foot or failed foot, although they create similar manifestations up the chain with the lower back.

Let’s break it down as far as what happens and then we can go from there.

The first one, when we take a step in the normal gate, we want to have a heel strike where a foot is relatively inverted and as you go into that loading response, then that foot should prone it to the ground to stimulate tibial rotation, femoral internal rotation.

If you’re going to get then the pelvis rotating and get an opposite side trunk rotation.

But what happens with this, typically, if the foot is not controlled, it’s going to be excessive.

Unless you’ve got some stability up the chain, whether it be the muscles, neuromuscular control to help control this. In both cases, the foot is going to go through these patterns.

Now conversely, when I go to midstance and terminal stance when my foot should start to lock up and start to supinate, they either don’t or they don’t get enough.

What that does is, it doesn’t create the rigid lever that we’re needing for propulsion. So you typically see a toed out gate a little bit, because of the splaying of the foot and their foot staying in the eversion.

So you’re not going to get potentially true dorsiflexion, they’re going to get it because the rear foot is staying everted, you are going to get a lot of it at the midtarsal joint still.

So the dorsiflexion really isn’t going to happen. Because of that, you’re not really going to get that windlass mechanism.

So then, the big toes are going to get chewed up here and eventually have hallux rigidus or limitus.But then the big thing is, again, you’re not going to be able to get that internal rotation at terminal stance because the pelvis isn’t going to be able to rotate around.

The knee is going to stay relatively flex. You’re going to get knee extension. On top of it, you’re not going to be able to get hip extension.

This type of patient, again, is going to have a lot of lower back pain because they’re not able to extend the abductor in front and rotate during the propulsion phase, and nor are they going to have the strength typically in the glute to propel off.

So again, they’re getting more than lumbar extension moment that is going to just chew up their back over time.

In the same token to that, just from a postural standpoint, if this person is just standing. So in the opposite, posture has its time and place. It’s big, it’s highly debated.

Does posture cause back pain and I would argue it does with certain people and other people not? But typically we’re moving from posture to posture.

We don’t typically want to think about pathology in a static realm per se, but it does influence function. When someone is in this type of foot, again, you’re going to be in more of the pronated feet.

You’re going to see tibial internal rotation, femoral internal rotation. You’re going to have the pelvis and that’s going to anteriorly rotate and that’s going to then really lock up L four, five, and S one and more the extended position.

So this person is typically going to be more lordotic and if you have, potentially, someone who has stenosis or facet dysfunction, these are things you want to correct potentially because it’s going to change muscle imbalances around the pelvis.

It’s going to mutate the sacrum, which then is going to compensate and get an extension of the lumbar spine, which is going to compress the facet joints.

It’s going to limit rotation of the lower back at those lower segments because the facets are locked up and you may even have some foraminal narrowing for a patient that may be older.

So needless to say, you’re going to have some dysfunction there at those segments. But even then above that, because those segments are locked up, you’re going to maybe have some hypermobility at the other segments.

You’re going to have thoracolumbar dysfunction, you may have painful irritation there.

As you can see, the foot gait is very powerful and it can create an array of problems, up or down the chain.

If you’re not clearing up some of these patients’ back pain, I would advise you to review these past podcasts and look at how the foot is affecting, potentially, that lower back.

So if you’re usually missing something, that’s usually down with the feet, because I think as clinicians we think it’s too far away and it’s too far-fetched and it’s really not.

It starts with the feet.

They set the normal reaction up and down the chain. They provide the stability or mobility for the shank to do its part. So if that’s not doing its job, then how do you expect the lower back to do its job in regards to function?

So, there you have it. Use these techniques in clinical reasoning to help your patients.

The post Is Your Patient’s Lower Back Pain Stemming From Their Feet (Part 3) appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Wednesday, everyone. This is Dr. Gray from the Redefining Physical Therapy podcast.

And so in today’s episode, I want to build off on this theme we’ve created here. So yesterday I talked about is your patient’s lower back pain stemming from their feet part one.

And so there’s a highlight of yesterday, so we’ve talked a little bit more about how a forefoot valgus can cause that pes cavus foot and how that usually turns into lower back pain. And so I think this is, at times where clinicians will miss things because they have more of a pesky equinus foot.

So they are not able to get a shock absorption during loading response, but they’re also not able to get adequate dorsiflexion. So they end up in early heel off which limits hip extension, which causes lumbar extension.

But also during that loading response, basically get poor shock absorption and then that was forces need to be traveled somewhere.

And one thing, I also forgot to add in, that type of foot for any neck rotational athlete like a golfer, they’re not going to be able to pronate. So they’re going to have the potential.

So they’re potentially going to have reduced hip internal rotation, and external rotation in those a golf swing. So if I am rotating to the right and my backswing, if my left foot can’t pronate, then my pelvis can’t rotate back to the right.

So I’m not getting external rotation on the left hip and I’m not going to get good adequate internal rotation on the right.

So I might use those facet joints, use muscles that maybe your not used to you using, or shouldn’t be using during a golf swing.

So you can apply those mechanics anywhere.

But now today we’re going to switch gears a little bit and we’re going to talk about the most common foot type and that’s an uncompensated rearfoot varus.

So what does that mean? And so if you were to put a foot in subtalar neutral, you’re going to see that their heel is in a varus position and that’s the most common type of foot.

And so this type of person will have kind of a neutral foot. And so they won’t have any abnormalities typically at the forefoot. So the last one was more of the forefoot valgus, which caused the pes cavus.

This type of foot is an uncompensated rearfoot varus. And so what that means is they don’t have, even when they’re embarrassed, they don’t have enough motion at the subtalar joint to compensate into pronation.

So it’s uncompensated.

And actually what this type of patient will do is they’ll actually toe-out.

And the reason why they do that, is they are trying to get their foot flat to the ground. So this type of person will have a ton of hip external rotation going on when they walk and they’ll walk like a duck, you’ll spot it dead on.

And so they’re not getting true ankle dorsiflexion.

They’re getting a little bit of potential with trying of their rearfoot trying to go through diversion and they’ll have calluses on the inside part of their big toe. So it creates a bunch of Pathologies. So it’s going to limit hip extension to some degree.

Because they’re toed-out, they’re not getting full ankle dorsiflexion as we kind of saw last time.

But that’s also what is going to happen is these are the type of people that are going to have that piriformis type syndrome.

And where their piriformis is always tight. And so, which is going to cause back pain potentially sciatica.

So that’s because their hips are always an external rotation. So it’s going to shorten those hip rotators. And so if you don’t fix the progression of the gait, by fixing it with a potential orthotic.

The Crux Shoe wear, you’re going to constantly have it toed-out gait where their hips are on external rotation.

And so you got to be careful on this, you got to be able to discern if this person retroverted.

So, someone who has a structural hip issue can mimic those. But once you’ve cleared the hip, you would look at the foot, you put the foot in subtalar neutral, you then do your glides and you see, they don’t have any eversion of the heel.

You’ll see why they toe-out. And so again, this type of foot will also be stuck in external rotation, they’re not going to have any good potential hip flexion or internal rotation.

So this type of person is predisposed, if you don’t have hip flexion, you’re going to get lumbar flexion.

So they may become more mobile at the lumbar spine when they’re bending and their movement patterns.

They’re not going to have internal rotation, and we know internal rotation is very important to people with back pain. So if this person is an athlete? They’re not going to be able to sit and load their hip as much.

So, they’re going to potentially get more lumbar rotation and to some degree. And then, they’re going to have that say sciatica.

So, but from a gait standpoint, because their foot is toed-out and they’re not going to be able to get adequate excursions through their hip into hip extension.

When walking, your hip actually goes through internal rotation, both in the loading response.

And as you go into terminal stance, they’re not going to get adequate of that either way.

And so they’re not going to be loading their glutes as much as you would think they would help out their back.

That was a kind of recap. So uncompensated rearfoot varus type, is afoot that is stuck in varus. Is the most common type of foot, they’ll be having a neutral arch, there’s no forefoot deformity.

Because they don’t have enough eversion at the heel. They’ll toe-out, and they’ll walk like a duck.

Because this externally rotates the hip, you can get constant shortness of the external rotators that compress the sciatic nerve.

A lot of that gluteal pain type of patient. That’s how you’re going to fix it. You’re also going to see a lack of hip extension, hip flexion, and hip internal rotation, a deduction.

So they’re not going to be able to load that hip. So, in order to fix this type of foot.

Typically, what we see is you need a foot orthotic, you got to bring the ground up to them.

You need to change the progression and the toe-out angle, to allow those internal rotators or the external rotators to relax a little bit.

And the back is going to thank you, and that person’s going to be able to function more because now they’re going to be able to get adequate hip internal rotation.

So stay tuned for part three.

Tomorrow, where I’m going to talk about a different type of foot that’s causing lower back pain.

The post Is Your Patient’s Lower Back Pain Stemming From Their Feet (Part 2) appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Tuesday, everyone.

Welcome to the next episode of the podcast.

I had some people message me and they really wanted to learn and understand how the feet can cause lower back pain, from a biomechanical standpoint.

In today’s podcast, I did want to talk about part one of it because this is going to be a multi-step episode, or episodes rather, of how your feet can cause lower back pain, and so I think a few things we need to begin with first off is the end in mind.

Before I disclose the mechanics of it, we need to really understand what is the function of foot in regards to gait?

As you take a step in gait, a heel strike and basically want to absorb those forces.

It needs to become a shock-absorber during this phase, but it also needs to become a torque converter. That’s where the eversion of the heel in the subtalar joint and then getting the foot flat to get pronation, which then causes rotation up the chain.

We’re trying to create force in rotation.

Then conversely, on the other end of the spectrum, when I step through in gait and get ready to propel, we want the foot to be stable in a rigid lever, so we can propel off of it.

If you can understand those concepts, then you’ll can kind of understand why certain types of feet cause lower back pain. Let’s start off with the first type of foot that typically will cause lower back pain.

This is what we call a forefoot valgus foot. This is someone with a forefoot valgus or a pes equinus foot, and so these are your people that are super high arched.

They have no pronation typically at all. You’ll usually hear them walking towards you. These are the people that I kid with that you can throw quarters underneath their arches because they’re that high.

They just don’t have any shock absorption.

These are the people, they’ll get the lower back pain for a couple of different reasons. Typically, again, the first one is shock absorption. These type of people don’t have the ability to absorb shock.

During the loading response, they’re not getting any pronation and they’re not getting, typically, any rotation up the chain at the hip to take stress off of their back.

Again, you’ll watch them walk and you’re just not going to see any pronation.

Now, on the other end of the spectrum, when you go through in terminal stance, typically they’re not getting any hip extension because they have lack of ankle dorsiflexion.

It’s more, again, of a pes equinus foot at the same time, so their dorsal flection is just limited as well.

Because they’re not able to get dorsiflexion at the foot and ankle, they’re going to have early heel rise, which is also then going to limit potentially the amount of hip extension that they get.

Sometimes you might see them even in somewhat of a functional limitation of hip extension or anterior pelvic tilt, which then can cause compressive forces in the spine.

Instead of getting hip extension, they may get lumbar extension.

Again, I think to recap today, we want to begin with the end in mind.

If you know what the function of the foot is, you can trace it up or down into the back. Today, we talked a lot about what they call a forefoot valgus type of foot or pes equinus foot. They usually go hand in hand. These are your high arch people.

They lack shock absorption, so in loading response, they’re not getting any pronation.

Those forces have to be directed upwards and they’re not able to absorb them, so they typically go through the spine.

Also, in that same token, they’re not getting any rotation because they can’t really evert, so they are missing out on that plane of motion.

We know that the butt muscles and the hip love internal rotation to help absorb it and they can’t.

Now in terminal stance, they usually will get early heel lift.

That’s because, again, they have lack of ankle dorsiflexion from the pes equinus.

They’ll have super tight calf potentially, but then they’re not able to get through their hip. Instead of getting hip extension, they’ll get lumbar extension.

Stay tuned for the next episode where I go over the next type of foot that causes lower back pain and how you can treat it.

The post Is Your Patient’s Lower Back Pain Stemming From Their Feet (Part 1) appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

Happy Friday everyone, and hope everyone’s week was great and that you guys have implemented some of the things that we’ve talked about over the last couple of weeks with your clients or patients.

But today I want us to talk about a case study of a patient I was treating, who was a golfer.

And he had come into the clinic with lower back pain. He was a right-handed golfer and he had back pain on his backswing, right?

And so anytime you treat a golfer, you really want to look at the three big areas, the thoracic spine, the hips, and the feet, right?

And so you need a ton of rotation in this sport.

And if you’re not getting rotation at the right places, you’re going to typically jam up the lower back in the facet joints and get lower back pain.

And so this individual was getting back pain on the left-hand side, on his backswing.

And if you know the mechanics of the spine, right, you’re going to be compressing there.

And so that’s really what was causing his back pain. But, I had cleared up his T spine, I cleared out his hips and all the different planes.

He even had good foot mobility, right?

And so I was like, kind of stumped. And I was thinking to myself, well, what am I missing?

And I started looking at his neck and this is something I had missed.

He was actually not getting enough cervical rotation back to the left.

And so as a result of that, he was trying to go back further and further to get a bigger backswing, but it was just further creating more and more pathology.

And he was further taking his eye off the ball because he didn’t have the relative left rotation of his subcranial spine.

So for those of you who know mechanics, right?

So if I rotate from my thoracic spine into my backswing, I need a relative.

If my eyes are still looking at the golf ball I need left rotation, whether that be mid-cervical, subcranial, upper thoracic, I need probably some rotation back to the left there.

And so I had checked his mid-cervical spine, which looked good.

I checked his CTJ, that looked good. So then I went to subcranial and it was a mess, right?

And so he was having a hard time being able to do a forward nod when you lay him down, right?

So that could be your AA not getting an anterior glide.

But then when I put him inside bending right and rotate him left with our AA test, he was locked up, right?

And so what I had found, actually it was on that right side of his subcranial spine. He wasn’t getting that anterior glide of his AA going forward.

And so it was really causing his golf game a bunch of problems, right?

And so the take-home lesson of today is like, you may have adequate mobility of the thoracic spine, the hips. You may have normal foot mobility, good strength and balance, and stability with a golfer.

But if they’re still not getting better, be sure to look up at the cervical spine, right?

So the cervical spine is powerful because it’s going to limit how much trunk rotation you can get at the T spine, right? And so it’s a very powerful concept, and I think sometimes as clinicians, we forget that whether it even be any of our clients that maybe are not golfers, it could be an athlete, a field sport athlete.

It could even just be in your typical 50 to 65 plus patient that has some back pain, but they get back then because they rotate primarily there, because they don’t have cervical mobility.

Whether that’d be looking behind them, looking up, down, you name it, but typically it’s rotation. But that’s my case study for today.

And so be sure to check the subcranial spine and mid-cervical spine.

The post Case Study: How a Golfer’s Back Pain Was Stemming From Their Neck appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.

All right. Welcome everyone to the next episode of the Redefining Physical Therapy podcast. I’m your host, Dr. Gray. Happy Wednesday, everyone.

And so today, I want to talk a little bit more about the first ray and the first MTP joint.

So obviously, this is a very important point that I think sometimes gets overlooked, or maybe it’s kind of misconstrued in the way that it gets extension functionally.

And so up to this point, over the last few weeks, I’ve really talked about how the rearfoot and the ankle joint and just different ways of mobilizing them, but then I’m going to talk a little bit more about how that impacts the first MTP.

And so I’ve been seeing quite a few patients coming in with hallux rigidus and limitus, where they just don’t have any real big toe extension. And so, as we propel off and gate that big toe is important because all the weight goes through that big toe to propel off towards the end, the terminal stance, and heel lift.

As we’ve reviewed in other podcast episodes, which I would highly recommend, you need a normal reaction at the subtalar joint and ankle and even up at the hip to get the mechanics right, and so for the MTP to function the way it needs to. And so let’s break that down step by step.

As I step in the gate and as I go heel contact, the foot’s relatively inverted, but then my foot, as I step, my foot wants to get its flat onto the ground.

So it’s going to want to go through pronation at the rear foot, and that’s going to go faster relative to the forefoot. And so relatively speaking, the forefoot and midfoot are going to go through inversion.

Now, all of this changes as I step through with my opposite foot.

So my rear foot then is going to go through supination and I’m going to get a pronation twist at the forefoot midfoot complex, because my rear foot is going faster, so it’s a relative.

And so to keep my foot flat on the ground, I need pronation at my forefoot midfoot complex.

And this is so important because what that does is allows that first TMT joint to glide plantarly so that it then clears the first MTP, the phalanx there to get big toe extension.

Now, it’s necessary to have ankle dorsiflexion in terminal stance, hip extension in terminal stance, and also rearfoot inversion because then you’re not going to get that relative pronation twist at the forefoot midfoot.

And so therefore over time, you’re jamming up that joint and not going through the full range of motion of it. And so eventually, you can get this hallux rigidus and limitus to the big toe joint.

And so basically in a nutshell, if your rear foot and your ankle isn’t functioning, you’re going to overtime never be able to go through and propel off your first ray because the biomechanics are all thrown off.

And so basically what you need to do is A, make sure that you’ve got enough rearfoot inversion mobility and strength to supinate.

You also need to make sure that you have enough calf sensibility.

You also need to know that you’re going to post your glide of that tailless.

You might need some adequate joint play of the syndesmosis between the tib fib complex, but another part of it is adequate hip extension.

So if I don’t have an adequate hip extension, I’m never going to get full ankle dorsiflexion. And if I don’t have full ankle dorsiflexion, I’m not going to get my rear foot to invert.

And so then, I’m not going to get that pronation twist at the forefoot and midfoot, and eventually, I’m going to wear out my MTP joint.

So I know that was a lot, but if you do apply those mechanics and understand what drives that joint and how it really does extend itself.

I think you’ll have better clinical outcomes in treating this joint because anyone can mobilize that joint and sure, there’s time and place just to give that joint some love and distract and get that mobility back.

But at the end of the day, you got to get this stuff more proximal working right to help that distal joint.

So apply that with your patients, leave any comments in the feed, and I’ll be glad to answer any questions that you may have.

The post Are You Making This Mistake With Your Big Toe Mobilizations appeared first on Dr. Scott Gray-The Sport and Spine Physical Therapist.