Odile, Thanks for being so thorough and for encouraging Steve to participate. I am pulling together some movements and will respond again when I get your pictures. Understanding the condition of your knees is very illuminating and helps me know where to go with a full plan. You are fortunate with the cartilidge loss that you can kneel. Any knee pain other than the tightness during exercise. Look forward to finally sharing some beginning to your recovery. Vickie
P.S. Isn't it great that we have medical doctors who will share on this site? I love it!
Could anybody help me posting photos by PM to Vickie? Do not know how to go about it. Thanks
Odile, I got your pictures and they are perfect for me to move into some direct instructions. I will take some time with this after my clients today and hopefully post completely by tomorrow afternoon. Sorry I don't have time this morning. Thanks so much for the effort, they told me much important information. Vickie
Odile, Thank you again for the perfectly designed pictures. Since I can’t do any muscle testing I am still somewhat limited in an interpretation (notice I didn’t suggest a diagnosis) but, as they say, a picture is worth a thousand words. The immediately obvious issues, relative to your lower extremities, are distinct hypertension in the fascia latae of the left leg along with other internal rotators, and a probable weakness of the right medial gluteal. You have a posterior tilt of your pelvis causing a flat back. Obvious, but not extreme, hypertension of your knees with a consequent constant engagement of your calf muscles, primarily the gastrocnemius, the muscle that causes the roundness we see in the calf, combined with an undervelopment of this muscle. Your foot pronation appears minimal but there is obvious strain on the anterior tibialis muscle which keeps your ankles distressed continually in its effort to keep the joint stable. That is the obvious visual interpretation.
You mentioned that you have a short left leg, corresponding with the most afflicted achilles tendon. It has been my experience that the leg is typically not shorter, as evidenced by the opposite hip being raised, but the tensions are imbalanced causing it to look and perform as though it is. This is a huge factor in your delimna and must be corrected in conjunction with the work to heal the damage to your soft tissue.
Before I proceed allow me to share that I had a similar, yet exact opposite condition, which set me on this path of healing. I spent most of my young adulthood in pain with a short leg and weak ankles and near constant discomforts that eliminated any opportunity to participate in sports. It was by shear good fortune after a very serious car accident that a kinesthetic chiropractor began to assist me in balancing the tensions around my hips and alleviating problems I thought were just a part of living in my body. With that said, I didn’t have the advanced condition you are experience (ahh, youth) so reversal was relatively swift. I got out of my orthodics and avoided surgeries that ex-rays still always inspire a recommendation from the medical profession. While there are things I cannot do I was able to resume a fully active lifestyle and pain free. Did I mention that my leg is not shorter? Again, with that said, you still need to have a reliable doctor in this condition.
I am going to recommend exercises to directly address the obvious conditions to correct your alignments and support the other good work you are doing. I will also recommend some rather unusual techniques for treating your tendons during this period where directly addressing the injured connections would only cause greater suffering and further aggravation to the site; which will only inspire more thickening and more inflammation due to the body’s super-compensation to the problem, we call it scar tissue.
If you have read any other posts you will know that I believe that less is more as you initiate any healing protocol; this applies to nutritional supplements and exercises as well. You have to begin to interact with your body’s intelligence and set the pace and implementation of expanding workload accordingly. The biggest error we can make is to do too much too soon. If you have the consistency and the patience and the trust that you are on a course of healing your outcome can be very successful. Because I always show up to see my clients I can keep tweeking the work to inspire continual progress and evaluate their work. Online we are limited to the fact that you have to stay in the process on your own. Just remember, as your body’s physiology changes so does the application of the work you are doing. Your level of rehabilitation is limited to the amount of work you are willing to continue to do. Many have responded to work we have done on line but the dialogue must be ongoing to continue a positive adaptation to full recovery. As your physiology improves so will the need for changes . . . if you want more change. It’s nature’s law; not mine.
So here are a few exercises to get you started on what looks like the origin of your problems. They will look disassociated from the symptom area and should not cause you any distress in terms of increased pain. If any one movement does, this it means we need to refine the way you align for the work or the exercise is contraindicated at this time; that’s the body communicating. Remember that the form of these exercises is really specific, which is why the explanation is so lengthy and it’s easier in words and demonstration. I recommend you read the exercise, then perform the exercise, then read it again while you are feeling the motion. Initially I would like for you to do these once daily. In three days I’d like to know how it is going and then increase the work; what ever that might happen to mean in this case. See, I too am at the mercy of your body’s knowledge.
Here we go:
Shoulder Stretch Deltoid / Rotator Cuff Joint
Lie on the floor on you back, with your feet flat and your knees bent, arms by
your side with the palms down
Your shoulders should be down and your lower back will have a natural
curvature, in some cases keeping your low back off the floor.
Do not allow your back to change position through out the movement.
Lift one arm completely straight up, around, and over the shoulder to lay it
along the side of your head with the palm facing the ceiling.
Keep your arm straight through the elbow and hand and only stretch as far as
the shoulder joint will allow. Never force it or just let the hand fall to the
floor.
In the early stages (or on tense days) your arm may not go to the floor but with
time it will comfortably rotate around.
Hold for 20-45 and then engage your shoulder to lift the arm around
to the starting position.
Check to be sure your torso is flat and relaxed. Repeat on the other side.
Key. Your goal is not to lay your hand on the floor, Your goal is to create enough flexibility capability in the shoulder joint that the arm bone can smoothly complete a 180 degree rotation that results in your hand being on the floor.
The Passive Frog Inner thigh /Adductor muscles / Hip flexors
Lie on the floor with your back relaxed, your knees bent and your feet flat.
Let your knees fall away from your center and press the soles of your feet together stretching
the inner thigh passively.
Bring your feet in toward your torso as your flexibility will allow.
Lie comfortably for 30-60 seconds.
Use your finger tips to give a hoist to the outside of the thigh and bring your knees together.
Key: This exercise can surprise you as the intensity increases in the first couple of workouts while you are learning to completely relax the hip joint. Some days will be easier to hold than others
Never stay longer than you can manage with your breathing and never forget to use you hands
at the end. Don’t worry if one leg is higher than the other. They will find their way.
Hip Stretch (abductor stretch / focus: outer thigh)
Lie on your back with your knees bent and your feet flat.
Open your knees to bring your feet and knees wider that your shoulders.
Relax your hips as they rotate your knees inward, toward one another.
don’t let your hips lift even when one knee rotates inward
more than the other.
Once you are warmed up, open your feet a little wider and repeat.
Continue to open your feet and repeat in small sets until you can no longer
comfortably touch your knees together.
Once you have reached your maximum foot placement move one leg down
toward the floor. Do this by rotating in the hip joint while trying to
keep your back from lifting. When the leg will rotate no further, then
allow just a little lift in your back.
Continue this in small increments until your have reached the floor with your
knee.
With time and practice you will find that you can rotate more in the hip without
compromising the length of your back.
To exit, relax your leg and just rock your hip to the floor which will lift your leg
passively.
Key: You can not rush this exercise. You have to learn to relax in the work to allow the stretch in your leg to happen, so it is counter productive to struggle. You have gone too far into the stretch if you feel discomfort in your knee. In this case either open your knees until the sensation is gone or bring your feet in closer and resume you work. Pain is not gain.
Psoas Lift
Lying on back with knees bent and feet flat on the floor.
Zip up the abdominal wall to firmly stabilize your pelvis.
Extend one knee continuing to keep your center of gravity in the core and avoiding
pressing on the opposite hip.
Rotate the leg from the hip joint to rotate your foot approximately 20 degrees.
Without compromising the stabilized back, lower the heel to the floor and return to start.
Your intention should be focused on the psoas, lower abdominal region/ groin area.
Key: Do not allow your hip to dip as you move your leg up and down to train the abdominals to support the work.
Periformais Stretches
Yoga Position
On all fours
Cross your left knee over your right knee and let it rest on the floor
Begin to stretch out your left leg which will stretch the right hip.
Slowly lower your elbows to the floor, increasing the stretch.
As the stretch happens, let your left leg stretch out even more.
Stay on one leg for 45-60 seconds.
Flex your left ankle and push yourself back to an all fours position.
Repeat on with the right leg.
Cross Crunches
Lie on your back with your knee’s bent and your feet flat
Hands behind your head but do not pull on your neck, just lay your head in your
hands.
Squeeze your abdominal muscles to curl your shoulders in toward your hips.
Bring your knees perpendicular to your hips with your shins parallel to the floor.
Rotate your right elbow toward your left leg as you bring your left knee toward the right
shoulder. You will be crunching up to bring your elbow on the outside of your
knee.
This will create a lifting motion in your rib cage and an internal rotation in the
hip.
Now from that high position, rotate back through the center and take your left
elbow high and toward the right knee.
Do not rest between each side.
As you go through the motions begin to stretch out the leg opposite of the bent
knee.
Keep your feet high in the beginning, slowly moving to a fully stretched leg.
Only stretch out your leg to the degree that you feel no discomfort or weakness
in the low back.
Key: This movement should be slow and deliberate use caution not to engage your back to create the action. It may take a couple of weeks to be able to rotate your knees appropriately and to stretch the opposite leg to full extension. That is appropriate in developing the complementary functions.
Torso Twist (Spinal Torque & Lengthener / Pectoralis & Hip Stretch)
Lie on the floor with your back comfortably and completely elongated.
Begin with your knees bent, feet flat, and your arms stretched out perpendicular to your
shoulders and your palms to the ceiling.
Lift your feet, one at a time, off the floor to bring your thighs perpendicular to the floor.
Keeping head straight and shoulders stationary, lift one hip to drop your knees off to the
opposite side feeling the back twist and stretch.
As the tension builds be aware of the opposing shoulder trying to lift off the floor.
Just as it begins to lift allow the bottom leg to continue to the floor but only slowly allow
the top leg to lower to an appropriately comfortable position.
As you hold this position and it becomes more comfortable, slowly allow the leg to twist
over more by lifting the hip and bringing the knees in line.
Key: Do not force this movement. It will improve weekly.
Bridge Lower Back Relaxer / Neutralizer
Lie on the floor with your knees bent and your feet flat.
Zip your abdominal wall, place your navel on your spine and distribute your weight
evenly on your heels. Tighten your buttocks (glutes) and lift your back off the
floor slowly in one motion to make a straight angle from the knees to the shoulders.
Hold for 10 seconds
Bend at the flexors and lower your back smoothly toward your heels until you reach the
floor. You will be arching slightly
This will bring your shoulders up to your ears if you relax into the stretch.
Now tighten the lats and pull both shoulders low on the floor toward the hips.
Feel how long your back and your neck feel.
Key: Create an opposing force against the torso during the lift and against the hips as you lower. Be purposeful and consistent. Visualization is a must for this exercise as may be a slower motion.
Central (Medius and Minimal glute) Squat
Stand with your feet just wider than shoulder width apart and your toes only
slightly pointed outward.
Keep your weight in your heels and slowly lower your hips back, keeping
your upper torso as vertical as possible.
Concentrate on creating the action from the top and sides of your hips. Imagine
your hands are on your hips as you look down the fairway.
Do not push up through your knees and keep your motion slow enough to feel
your focus.
You will add a single dumbbell after your get good at feeling the movement in
the desired area and know you are not in your knees.
Standing Quad Stretch
Standard form with your feet together.
Bend one knee and reach down with the hand on the same side and grasp at the
ankle.
Allow your knee to move forward of your torso as you stand erect in your posture.
Continue to lift your torso until your shoulders are level.
Slowly contract your quadricep and bring it back into line with the opposite knee.
Hold.
To end, bend at the waist to take all tension off the leg and the torso.
Slowly lower your leg and repeat on the other side.
Key: Do not stretch your leg and arch your back from the upright position. Even though this stretches the thigh it is not as profound as moving the leg from an aligned torso.
Standing Hamstring Stretch Back of the leg
Standard form facing any type of stable platform of at least 18 inches in height.
Lift one foot and place the heel of the foot securely on the edge of the platform so that
the foot can pivot to serve the stretch.
Stand on your support leg with your knee fully extended but not locked and your foot
only slightly rotated out.
Do not allow the knee to bend nor lock-out throughout the movement
Rotating off the hip, lower your straight back over your leg as if you are placing your
chin on your toes. Stretch your hamstrings just until the knee tries to bend.
This will feel more like pushing your hip back than leaning forward. Hold.
Round your back and let your nose come more down toward the shin. Hold.
Bend your stretched leg and stand back to ready to repeat on the other side.
Key: Think more of dropping the hip away from your foot than of leaning over and you will find that you keep the joints and muscles at their most full length.
Hold off on this one until the next time we communicate but I wanted you to read it.
Calf Raises
Stand on the floor with your feet flat and in a neutral position.
Slowly lift onto your toes to your fullest range of motion.
Gently roll into the toes more, allowing your knees to bend but keeping your
back straight and vertical over your heel.
Lift fully out of this position.
Slowly return your heels to the floor
Repeat.
Key: Don’t let your back arch and don’t over extend your knees. The action is inspired by the ability to roll into your toes.
Those are the exercises that you should do once a day in the beginning. The second recommendation I will place here is very unusual for me. I believe in the ultrasound techniques that increase blood flow to the tendon area. I have no relationship with a retailer but know that they can be purchased on line at a reasonable rate. If someone tells you that this is bad advice then I will tell you that I have seen really good results and the very first day I did my apprentice work in a rehab facility, without taking my first class, I was directed to administer this treatment on a patient. It is an adjunct to rehab not a replacement but very effective on tissue that is sensitive to work at this early stage.
So we have begun. You can be in complete control of this process. Please maintain good medical support and stay in contact as we refine the process. I will be happy to be in it with you.
Here is my feedback after performing the exercises you recommended to me:
I feel my calves more relaxed and I really appreciate. Some exercises I did not fully understand and I would need some clarifications:
1 Hip stretch: Do I need to stretch passively as in passive frog? When I stretch actively, I feel a bit of pain in the right hip.
2 Standing Quad stretch: You say "bend one Knee" Is it bend or lift or both may be. I don't quite understand your key. At the end, do I let my knee go backward or just let it in alignment with the other knee?
3 Calves raises: You say gently roll into the toes. The movement is up and down to the heel from the toes. I guess there is no rotary movement?
4 Do I continue the exercises given to me by my PT, stretching the achilles tendons?
Last week I visited my rhumatologist for a checkup. The peri-tendinitis is back and he gave me anti inflammatory tablets. He proposed cortisone, to which I refused. We talked about ultrasound therapy, and he recommended to me a maximum of 10 to 15 sessions, at the rate of 3 per week. He said not more because after 15 sessions Ultra sound is no more effective. I felt discouraged because I had high hopes in this therapy that you mentioned that I could use every day on a long term basis. He said that we still dont know exactly how ultra sound really acts on the tendons...What do you think?
I misssed some of these posts. Sorry I haven't responded sooner.
You have orthotics. Some people need them, some don't. Some who have them can do without them once they are healed. Since I can't see you, I can't tell you if you need them or not. As long as you are in pain, you need to wear them all the time. If you don't, you are re-injuring yourself. If its hot out, find a sandal you can put the orthotics in.
EXAMPLE: Lets say you need glasses to see clearly. What would happen to you if you decided you weren't going to wear them for the entire summer, because they made your face sweat more? Most people would have severe headaches after a while, maybe a little nausea, and eventually problems with balance.
Same with orthotics. If they aren't comnfortable, then go back and get them adjusted. If the doctor/therapist can't or won't adjust them, find someone who will.
If it hasn't all ready been mentioned, you need to do Vickies stretches for life (maybe not the same intensity). I've seen research that has shown complete relapse of muscle/tendon flexiblity within 2-4 weeks after quitting the stretching routine. This is really what preventative medicine should be all about, but in our society we are more interested in a cure after the disease occurs.
Odile, Sounds like you really have the spirit of consistency if you are already aware of reduced tension in your calves. It is the best sign that you will run this protocol to a fully successful outcome. Additionally, thanks for staying in the process with me. My private clients have the benefit of my clarifications and instructions and demonstrations when they see me two or three times a week. Remote training puts a good deal of the responsibility on YOU to ask for more help and clarity. It is the only way it really works. I’m not sure why most people who ask questions stop after the initial response to their request for physical assistance but I always appreciate the ones that do.
Here are the clarifications for the exercises, proving that you are really bringing the right attention to detail.
1 Hip stretch: Do I need to stretch passively as in passive frog? When I stretch actively, I feel a bit of pain in the right hip.
The beginning of the exercise is completely passive. Once you begin to rotate your hip to take your knee to the floor you are creating dynamic tension; which is stretching actively. So that is all perfect. However, you don’t want to have sharp, acute, pain in the process but you do want to be very aware of the tension, which can be described often as discomfort. So really we are trying to make a distinction between discomfort and pain. If you allow your back to arch a bit more as you rotate your hip you should be able to create a large motion and eliminate pain. This would be appropriate in the beginning and then over weeks you will find that you can keep your back down more and more as the joint realigns appropriately.
2 Standing Quad stretch: You say "bend one Knee" Is it bend or lift or both may be. I don't quite understand your key. At the end, do I let my knee go backward or just let it in alignment with the other knee?
I can see why you got confused; I’ll revise that immediately. Yes you will bend the knee and hold your ankle directly behind you. You want to be able to stand up straight on your opposite leg. If your shoulders and torso are inflexible you may find that you can’t full lengthen your body. In this case allow your bent knee to move forward but try to keep your thighs together (many people can’t bring their legs together and keep their body straight for a number of weeks). Once you can stand upright with your thighs together and knees aligned begin to push your bent knee back, increasing the intensity in the belly of your quad, the middle of your thigh. Don’t let your pelvis to tilt forward creating an arched back (as in a dramatic yoga pose) when you increase the stretch.
3 Calves raises: You say gently roll into the toes. The movement is up and down to the heel from the toes. I guess there is no rotary movement?
At this point there is no rotary movement, strictly linear, and we are working mostly the gastrocnemius calf muscle. You are presently doing primarily a concentric motion. I am adding a calf eccentric motion at the end of the post. I will want you to continue the original calf exercise and add this new one. Soon we will put them together and then move to the other calf muscle, the soleus.
4 Do I continue the exercises given to me by my PT, stretching the achilles tendons?
I would like to know what you are doing but don’t imagine anything would be contraindicated in conjunction with this work. The biggest risk will be simply ‘over working’ which will definitely create a conflict. Maybe you could send me a list.
In reference to your rhumatologist I need to defer back to the post by the doctors who share on this site. I have seen cortisone used effectively in severe achilles issues but it is never the first line of defense. I am concerned that your doctor would want to use this method again. I also wonder why and how he came up with the idea that the effects of ultrasound would be diminished upon a specific number of sessions. I would agree that the effects are’ felt’ more significantly in the beginning of treatment. But the effectiveness of this method to drive transdermal medication is on-going! I believe you even mentioned that you had some relief from each treatments. You asked my opinion so here it is. Your largest tendon with limited blood supply will be positively impacted by increasing the blood flow, getting the topical treatment directly on the injury, and relief from chronic pain and inflammation and a definite path toward healing. I am not against anti-inflammatory medications, although I prefer natural products, but when you take the pharmaceutical you are basically affecting your whole body. I like to know I can apply my anti-inflammatory agent directly to the source of the symptom. I know a runner that has benefited from use of ultrasound for many years. I agree that it would be expensive to purchase ongoing treatment which is why I slightly broke one of my rules of coming close to endorsing products. I learned about the benefits of this treatment, before I became a fitness tutor, after a very serious car accident. The physical therapist used ultrasound on my shoulders which had always been a recurrent problem in my life and were affected by the injuries specific to the accident. I can thank her for telling me that when the insurance ran out I could treat myself. We’ll I didn’t act on it and but it was the beginning of the work I do now everyday. I slowly but consistently corrected the origin of my problems. Years later I watched the relief a client experienced from pain and the subsequent enormous financial burden to obtain the benefits of the treatments. That’s when I went to work to see if there was an alternative and I learned that you could buy your own machine. That’s the long answer. I believe in ultrasound, that’s the short answer.
Now for another piece of the puzzle. The previous post regarding orthodics by our generous podiatrist are right on, no surprise there. You had already indicated that you were beginning to wear your heel cup orthodics daily but they need to be worn in every shoe. Heels won’t be in your future for some time, thank goodness they don’t make high heel golf shoes. I have not previously addressed your knee issues (loss of cartilage) but it is a definite piece of the puzzle and helped me to put together your exercises. Now, the good doctor mentioned that orthodics need to be adjusted from time to time. Basically they are compensating for a problem, I think we agree. As you do this work to correct the alignment problems, the orthodics could become a problem on their own. Remember they are designed to support and compensate for a specific measure of foot pressure. As you move the agreements between your torso, hips and feet they will need to be adjusted to support the new positive adaptations; making it so important to have a trusted and supportive resource. Orthodics may still be necessary in the long run because some of your condition could be permanent. Fear not, I have a great deal of permanent alignment issues but I suffer no pain. I wore orthodics for many years and now am free of them but if I thought they were necessary I would use them. Of the six clients who came to me in orthodics I have four that have been able to loose them and two that are still in some version of them and three other clients I referred to be measured for them’; I love good science. You won’t know where you fit in this formula for some time. For now . . . use what you have both in terms of orthodics and medical support and your own desire to reverse the origin of your symptoms.
Remember my earlier post where I said the natural process is long term. I was being honest. I encourage you not to become discouraged and celebrate even the smallest successes you experience. You are very holistic and I am not convinced your doctor is. And in Forrest Gump –ese . . . “That’s all I have to say about that”.
Till next time here’s your next step . . . literally. Vik
Declining Stairs
Stand at the top of a flight of stairs with hand rails on both sides, and use them.
Turn your back on the stairs so that you will be descending backwards.
Place the bridge of both feet (where the arch begins, big toe to little toe) at the edge of the step.
Slowly lower your heels keeping your weight over your heels (don’t lean forward).
Hold this stretched position for 20 seconds.
Bend one knee and lift your foot a few inches without letting your weight shift your hip over the other foot.
Bend your opposite knee as you deliberately place your foot down to the middle of the next step.
As your foot touches the step, roll from the bridge to the heel and repeat on the other foot.
Alternate your descending foot on each step
Work up from four steps to fifteen steps over a two week period.
Key: Keep your upper body alignment secure and check to be sure your abdominal muscles are engaged. If you don’t have stairs find a single location where you can allow your calves to stretch and then step down then just step back up and repeat. The stretch should not become so significant as to create pain but the stretch is profound.
Hybrid Mode
