Daily Foam Rolling

Myofascial release is a hands-on technique using sustained pressure to the connective tissue restrictions to relieve pain and restore motion. But does it work? Dr. Betsy Webb certainly thinks so, stating “this is one of the most common modifications I suggest to patients. Maintaining soft tissue and joint mobility is so important in preserving joint health and building strength.”

According to a systematic review conducted by Beardsley and Škarabot, myofascial release can help to increase flexibility and reduce soreness. Regular maintenance helps with joint and soft tissue extensibility and mobility, will improve tissue length and pliability and its ability to accept force and load. This allows the body to do more work with less strain overall. Methods like foam rolling, gua sha and massage can improve arterial and vascular endothelial function, or the flow of blood and lymph through the tissues. Self-myofascial release allows for consistent and cost-effective management. Athletes of all levels most commonly use a foam roller or ball of varying density.

Despite being versed on the benefits, Betsy has trouble incorporating soft tissue work. “I love working on strength and cardio work,” she laughs, “but often under prioritize mobility in my own physical fitness. I know how valuable mobility work is, yet I struggle to incorporate it into my routine.” As part of our Athlete Within Challenge, Betsy agreed to spend 10 minutes foam rolling everyday for two weeks. Here’s how it went:

As with any new habit, the most challenging part about for Betsy was adherence. “I started out really strong for the first week but then the weekend hit and falling out of my daily routine made it more challenging to stay diligent,” she says. Sound familiar?

In order to stay consistent, Betsy found three different techniques to be most helpful: routine, external accountability, and increased accessibility. “I found using an alarm worked really well. I set an alarm for 9:15 every night to remind me.” (As an added benefit, myofascial release can also help to improve parasympathetic nervous system activity, allowing us to mentally and physically calm down so our bodies can regenerate. Soft tissue work in the evening can set you up for a great night’s sleep!)

Betsy shared her goals with her fiancé, finding that having “someone to hold me accountable, who knew to remind me if I hadn’t done it for the day” helped to keep her on track. The last thing she found to be helpful? Relocating her foam roller. “I ended up putting it next to the tv,” says Webb, “so that when I would sit down to watch tv at night I would see the roller and be reminded to use it.”

So is it worth the time? After the two weeks were up Betsy’s body was thanking her. “Foam rolling is something I know I should do more of, especially for my thoracic spine, but never was able to get into a routine." Like so many of our patients, Betsy saw tremendous benefit from going back to the basics: “After the first week I felt good but not too much different, but a full two weeks really started to make a difference in how I felt from a mobility standpoint.” The true payoff for myofascial release work is in the consistency. Studies have yet to show if any of these improvements in flexibility and tissue quality have longterm effects once treatment is stopped. “I fully intend to maintain this behavior. As I saw with the two weeks, the longer I remained consistent the better I felt,” states Webb.

Our vote? Yes to myofascial release!

Looking for Dr. Betsy Webb? As of July 1st, she will be practicing in the Chicago Area!

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Self-Limiting Pitfalls

Elite performance requires us to be vulnerable. It is essential to have an honest view of our skill set to grow and improve. Working with a coach, or using tools like biofeedback technology can give a clear picture. In the clinic, we use a variety of motion and force capture to enhance the assessment process. Outside of the clinic, wearable technology can track heart rate, speed, and sleep metrics to give you a more complete picture of your performance.

But, ultimately, it’s how we interpret that information that matters. Use the self-assessment below and see if you fall into any of these 4 protective strategies that may be limiting your potential:

1. Self-Handicapping:

Intentionally limiting your effort to give yourself an “out.” If you didn’t really try your best, then the results don’t matter.

2. Feedback Avoidance:

Bubble alert! By only surrounding yourself with people who flatter you, you are distort you outlook.

3. Self-Serving Bias:

Only taking credit for success, and not failure. When you win, its because of your hard work and natural talent, but if your fail it could be the refs, the weather, the astrological calendar…

4. Downward Social Comparison:

Rather than look at how everyone performed, you only compare yourself to those who did worse to protect your ego. Maybe you only scored twice, but he didn’t score at all.

Being mindful of these common mental traps helps us build awareness of the role our mind plays in performance.

Adapted from @stevemagness, author of Peak Performance

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How Can I Heal?

This week, Dr. Heather McGill shared in conversation with Crina Okumus on her podcast How Can I Heal. The two discussed Heather’s vision for how to build robust, durable athletes through three healthy habits. Read more about Okumus and her podcast below:

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THIS PODCAST IS A WEEKLY CONVERSATIONS WITH PEOPLE THAT I ADMIRE TO IMPROVE YOUR OWN LIFE FOR THE BETTER.

Subscribe on Apple Podcasts

To give you a little background about me. I have an experience for more than 15 years in the fashion industry, running my company successfully selling in more than 40 countries and being highly profitable. 

One day, I received a call that my father died in a car accident and my whole life completely changed. I started to ask myself who am I and why I am here? The process of healing took more than five years, during which I was also facing my inner calling to move away from fashion and figure out what is next for me.It was certainly not an easy journey and I thought that I will never figure out what I will do for the rest of my life. But one day, I chose to listen to my heart and let it guide me to my future.

And with that decision, everything started moving in the right direction. 

The biggest insight I had during this time was that I could not change the world. I'm too small for that. But I can certainly change myself and the people around me who would be inspired by my story. And that’s when I decided to start a series of interviews with people that I love and who have made a big change in my life. 

So I hope you will join me in my journey and find inspiration in the stories of known personalities but also those of normal people. And please share your own journey with me and let's make a little change and make this world more beautiful. It’s up to us to make this change happen.

With love,
Crina

Flexor Hallucis Longus Tendinopathy: Part II

If the symptoms from the last post sound familiar, it’s important to seek care to prevent the condition from advancing. The good news is FHL tendinopathy does not require imaging for diagnosis. You can see a PT or AT directly- they’ll evaluate and diagnose your condition, and will refer you to a physician as needed.

After assessing your leg, your clinician will be able to ascertain contributing factors that led to the injury and how to address them with an individualized exercise program including neuromuscular re-education and functional training. Neuromuscular re-education helps reprogram the way you move- focusing on specific muscle activation and timing. This strategy takes the whole kinetic chain into consideration, looking for inefficient habits that may seem unrelated to your injury.

For example, many athletes diagnosed with FHL tendinopathy present with excessive pronation- or arch collapsing- a faulty pattern that can contribute to overloading the FHL in running. Strengthening the hip, pelvis and core muscles, combined with improved running mechanics can reduce this problem for the long term!

If you are able to see a clinician in-person, manual therapy may be beneficial to reduce inflammation, muscular tension, and any joint stiffness.  

Until your appointment, follow these recommendations at home:

1. Rest from the aggravating activity - running, dancing, etc.

2. For pain management, try over the counter NSAIDs (ie Advil, Aleve)

3. Use contrast therapy to reduce inflammation:

   • Submerge foot for 10-15’ total following the pattern below:

     • 2-3’ in ice water

     • 2-3’ warm water

     • 2-3’ ice water

     • 2-3’ warm water

     • 2-3’ ice water

4. Self-massage the outer calf by rolling with a tennis ball or something similar on the floor

5. Perform a seated calf stretch with a towel at the toes, being sure to pull the big toe back with the foot

Flexor Hallucis Longus Tendinopathy

Often called “dancers tendonitis” due to its prevalence in classical ballet dancers, FHL tendinopathy actually happens to various athletes whose sports require repetitive push-off and extreme plantar flexion (pointing of the foot), such as sprinters, soccer players, gymnasts, and even swimmers.  

Image Credit

The Flexor Hallucis Longus (FHL) muscle is located in the back of the lower leg, originating from the fibula and traveling behind the Achilles tendon. The FHL tendon then passes the inside of the ankle through the tarsal tunnel, and travels along the instep of the foot, ending at the big toe. Its function is to flex the hallux - or big toe. It also has an important role in controlling mid-foot pronation and supination.

Because of these roles, the FHL functions as a powerful convertor of force from the rear foot to the big toe. However, repetitive pushing off the foot and toes can sometimes lead to irritation. This can be worsened when combined with eversion - or an outward motion of the toes relative to the ankle. Often, young dancers will evert when attempting to achieve greater “turnout”, but this also can be seen in runners as excessive pronation - or “arch collapsing” - most often due to strength deficits in the stabilizers of the limb.

If you’ve irritated this muscle-tendon unit, you may experience pain within the foot or at the back of the ankle depending where along the tendon inflammation has occurred. Some may also experience the big toe “getting stuck” with active movement, or swelling and a crunchy-sensation along the inside of the ankle. Flexing the big toe against resistance, or forcing the foot into a pointed position may also be painful.

While the exact physical cause of FHL injury is under debate, it is believed that the tendon can snag either at the ankle in the tarsal tunnel,  in the mid-foot, or at the sesamoids (two teeny round accessory bones) of the big toe. When combined with repetitive motion, this entrapment of the tendon creates micro-trauma. If left untreated, this can lead to tissue damage. The body's inflammatory response begins to heal these micro-tears, sending more blood and nutrients to the area. This inflammation of the tendon is what is called tendinopathy. 

Restriction of the FHL routinely occurs in three spots:

Image Credit

• Tarsal Tunnel at inside of ankle, star.

• Intersection of FHL with neighboring Flexor Digitorum Longus tendon, triangle.

• Attachment of FHL to the first bone (proximal phalange) of the big toe, square.

To learn more, check out these articles and texts:

1. https://www.sportsmedtoday.com/fhl-tendinopathy-va-132.htm

2. Quirk R. Common foot and ankle injuries in dance. Orthop Clin North Am. 1994 Jan;25(1):123-33.

3. Pagenstert GI, Victor V, Hintermann B. Tendon injuries of the foot and ankle in athletes. Clin Ortho Trauma. 2004; 52(1):11-21.

4. Simpson M, Howard T. Tendinopathies of the foot and ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-1114.

5. https://www.sportsinjurybulletin.com/the-flexor-hallucis-longus/#:~:text=Overuse%20conditions%20in%20the%20FHL,posterior%20or%20postero%2Dmedial%20ankle.

6. Bone Joint Surg. 78A:1491-1500, 1996

7. Am J Sports Med. 1977;5:84-88

8. J Orthop Sports Phys 1983; 5: 204-206

9. Norris R. Common Foot and Ankle Injuries in Dancers. In: Solomon R, Solomon J, Minton S, eds. Preventing Dance Injuries. 2nd ed. Champaign, Ill: Human Kinetics; 2005: 39-51

10. Foot Ankle Int. 2005; 26: 291-303