This article is not going to be an end all article on how to solve knee pain and injury. Rather there are categories of knee injuries that all need different attention depending on what has been injured. From there we can determine what the best course of action that needs to be taken for each individual because everyone is a bit different.

This article is going to be relatively brief on each because there are many topics I will have to cover. I expect that if you have any questions they should be addressed to your orthopedic doctor or physical therapist. Searching the Internet or asking people on the web for more information is at your own risk.

Disclaimer: Any information contained herein is not professional medical or physical therapy advice. Always consult your doctor or physical therapist before using such information.

Where the pain is occurring during movement is generally a good indicator of what may be wrong, and differential signs and symptoms can be used to further delineate what is wrong in most cases.

Image courtesy of Adam Inc. (though extremely modified)

Despite the generalized locations of what you think is injured compared to the chart sometimes the physiological issue or pain bleeds off into other areas. Also, there may be multiple pathologies in a certain area since there are a lot of different muscles, ligaments, tendons, etc. running through the area(s). I cannot say for sure (again, this is the Internet after all) that if you have a pain in a specific area that it corresponds to the conditions. Thus, for a sure diagnosis you should definitely see an orthopedic doctor or physical therapist on these issues.

Additionally, the pathology of knee injuries is very important. Often times for many of the types of non-impact knee injuries there are also mobility or flexibility issues at the ankles and hips. The knee sits smack dab in the middle of the two longest bones in the body, the femur and tibia. Given this alignment any issues in the ankles and hips that create any odd forces are distributed along the kinetic chain into the knees. Since the bones are so long any of the torques (Torque = Force * Distance) at the adjacent joints are magnified significantly which means that something as small as a bit of tightness in the ankles or hips can lead to a significant change in torques at the knee which may exacerbate or even create a pathology.

The knee is between the longest bones in the body // Photo from http://kitssportschiro.com

If there is a loss of range of motion at some joints, the other joints or tissues will have to take up the slack. This leads to many types of overuse or compensation injuries.

This means that in addition to any potential rehabilitation there needs to be an assessment of the whole lower body up to the back to ensure that things are moving correctly especially with recurring knee injuries. If you know you are tight or have a lack of mobility in certain planes this may also be your wake up call to eliminate tight areas. You may be surprised how much improving areas like the feet, ankles, hips, and back will improve your knee problems.

Notes:
1. If the pain is on the back of the knee then see the back of the knee section.
2. If the pain is over a particular muscle and not a tendon/ligament/connective tissue or deeper structure then see the muscle strains section.
3. If you suspect your injury does not fall into any of these categories then see the other pathologies section.

Given that you now know this head over to your particular section to see if we can possibly figure out what is going on with your particular pain and dysfunction.

Table of Contents
I. Introduction
II. Categories of knee injuries
III. Quadriceps tendonitis
IV. Patellar issues
V. Patellar tendonitis
VI. Tibial tuberosity issues
VII. Knee capsule / plica / medial collateral ligament
VIII. Pes anserinus issues
IX. Fibular head / biceps femoris / Lateral collateral ligament
X. Iliotibial Band issues
XI. ACL issues
XII. Meniscus issues (lateral and medial)
XIII. Muscle strains
XIV. The back of the knee
XV. Other pathologies
XVI. Conclusions

If you suspect you have an injury that does not fall into any of the categories above see a medical professional immediately. Also, if you have an injury which presents debilitating pain or presents possible insidious neurological symptoms such as sensory or motor deficits see a medical professional immediately. Motor deficits are critical enough that you may want to go to the ER ASAP.

Image from http://orthoinfo.aaos.org

If you are quad dominant from sitting a lot with marginal activity (feel quads burning a lot while running, lifting, etc.) then this could be an issue that needs to be dealt with. Strengthening and activation work for the posterior chain and learning how to squat correctly will help a lot in the correction of this.

This is exacerbated more in women because they have a greater Q-angle which puts more torque on the knee. If you would like to read more about this you can see Shoes, Sitting, and Lower Body Dysfunctions which talks about this issue more in depth.

Photo from http://www.doctorkolstad.com/

Treatment

Thankfully, we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.kneeguru.co.uk/

Around the patellar there are a myriad of structures. If the pain is around the quadriceps tendon insertion and patellar tendon origin then it may be related to those two overuse injuries respectively.

If the pain is slightly under the apex (bottom of the patella) that may be an issue with the infrapatellar fat pad.

If the pain is over the patella that may indicate overuse to one of the bursas in the area such as the pre-patellar bursa seen in the picture above, or just below the kneecap with a bursa such as the infrapatellar bursa (commonly referred to as clergyman’s knee).

Patellofemoral syndrome and/or chondromalacia patella is the other common cause of pain localized around the patella. These two often go together because they are somewhat coupled in the pathological etiology.

The knee is a delicate balance between forces that pull the patella laterally and medially, and it is just so happens that the muscles that pull it laterally tend to get more emphasized by poor biomechanics (e.g. inward collapsing knees during running, squatting, etc.) and are larger from the start. Vastus lateralis is bigger than the vastus medialis/vastue medial obliquus.

Now, what happens is that when the patella is start pulled more laterally is it starts rubbing on the lateral articular surface of the femur more and starts wearing down the cartilage both on the patalla and femur. This process starts softening and breaking down the cartilage (chondro = cartilage & malacia = softening) and will eventually cause a lot of pain and inflammation.

The reason why it does appear right away when this occurs is because cartilage has no sensory/pain fibers located within it. So only when it gets to a higher level of damage by wearing through a lot of cartilage and inflammation does your body start to feel the effects. This also means that there must be significant time taken to correct biomechanics because usually these are ingrained pretty well before the pain starts occurring so good care must be taken to teach proper technique especially with females who experience this issue.

Treatment

Typically, bursitis and fat pad irritation can be treated with typical RICE protocol, massage, and anti-inflammatories if necessary.

For the fat pad irritation if it is making the knee unstable taping can be an effective protocol to ensure that any mobility or exercise does not aggravate it any further.

Generally, for any impact injury to this area it should definitely be checked out by a doctor to make sure there is not any issues with the patella itself though.

With patellofemoral syndrome/chondromalacia patella there are multiple things we need to focus on. First, bringing down the pain and inflammation is paramount. Like the bursitis this can be done with the typical RICE protocol, massage, and anti-inflammatories if necessary.

Secondly, there must be loosening/strengthening of particular muscle groups. We want to strengthen the vastus medialis, vastus medialis obliquus, hamstrings, and glutes. We want to massage, trigger point, foam roll, tennis ball, etc. to loosen the vastus lateralis, rectus femoris, IT band, calves, hip flexors, etc.

Thirdly, we need to make sure there is enough range of motion at the ankles and hips. We want to especially gain more dorsiflexion in the ankles with calf stretches, and we would like to gain more hip extension by stretching the hip flexors as well as mobilizing hip internal and external rotation.

Many of the specific stretching/strengthening exercises can be found here.

Lastly, we need to teach proper biomechanics by deemphasizing the anterior chain by sitting back more in squats, teaching proper running technique, etc.

In addition, the knees must NOT be allowed to collapse in during any exercise that is taught. This is paramount. One of the best ways to do this is to cue to spread the floor with the feet during squatting, lunging, etc. if the knees want to collapse inwards. If this is ineffective, a band can be placed to pull the knees inwards to force the the person to think about forcing the knees outwards during the movement.

Since the glutes are one of the potent external rotators of the hip they should be evaluated for weakness/inactivation especially if there is a lot of sitting during the day. Once you get them active not only will it help correct the technique, but it will make you significantly stronger as well.

Photo from http://www.arthealthcare.com/

If you are quad dominant from sitting a lot with marginal activity (feel quads burning a lot while running, lifting, etc.) then this could be an issue that needs to be dealt with. Strengthening and activation work for the posterior chain and learning how to squat correctly will help a lot in the correction of this.

This is exacerbated more in women because they have a greater Q-angle which puts more torque on the knee. If you would like to read more about this you can see Shoes, Sitting, and Lower Body Dysfunctions which talks about this issue more in depth.

Photo from http://www.doctorkolstad.com/

Treatment

Thankfully, we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photos from http://www.boostphysio.com/ and http://4.bp.blogspot.com/

As can be seen above this can be easily diagnosed by X-ray, and it will physically manifest as bumps on the shins that will be sore to the touch.

Treatment

Typical doctor recommended treatment is the RICE protocol. Activity should be limited to non-painful activities lest it be aggravated.

Like said in the above sections on tendonitis it is important to do soft tissue work to help loosen up the quads to exert less stress through to the tibial tuberosity. In this respect, foam rolling, massage, and light stretching should help significantly with the RICE protocol.

Posterior chain and proper biomechanics during running, squatting, lifting, etc. activities should also be examined to make sure that more stress is not being put on that area. However, generally this type of injury is more self limiting than the tendonitis issues.

Photos from http://www.ortho.com.sg/ and http://www.floridaortho.com/

The knee capsule and plica band can be easily aggravated given improper biomechanics or scar tissue around the area from surgery. This is why the pictures above are of plica and not the TCL/MCL because most type of pain here is likely not going to be of the ligament but rather the capsule and plica especially if there is a lot of cutting/torquing movements and bigger Q-angle.

Treatment

So if the injury is suspecting MCL see an orthopedic doctor.

Since the knee capsule and plica are more connective tissue typical modalities are aimed at reducing the aggravating inflammation. Thus, RICE, NSAIDs, and non-painful mobility and mobilization of the muscles around the area are generally prescribed. Also, other modalities to decrease inflammation such as iontophoresis or phonophoresis can be used, and as a last resort there is surgery.

Photos from http://www.jointventurespt.com/ and http://kneespecialistsurgeon.com

To check to see if there is an issue with tendonitis or the pes anserine bursa this area can be palpated for pain, soreness, and sensitivity.

To check if it is the right area it should be approximately below the MCL and band of plica that sit directly medially along the knee joint. Additionally, if you are sitting and push your heel into the ground and feel for the semitendinosus tendon along the inside of the leg and follow it then it should and insert on the tibia in the position seen above.

Pes anserine tendonitis or bursitis can exist for a variety of reasons. From what I have seen it tends to occur there is improper biomechanical patterns and general overuse.

The most common pathologies I have seen this occur in is if there are the issue of collapsing knees (knees collapsing inwards) during movements such as squatting and running. Likewise, if there is hip internal rotation immobility or a foot pathology such as flat feet where the feet start to “toe out” or duck walk this may start to cause issues with the pes anserine (as well as many other pathologies in this article).

Treatment

Like the rest of the bursitis and tendonitis issues the typical treatment lies with RICE protocol, massage, and anti-inflammatories if necessary. Stretching, heat, and massage may be used on the muscles that make up the tendons to help loosen them up to take pressure off of the bursas and/or tendons to help improve healing.

If it is tendonitis we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.anytimehealth.com/

Like the MCL, the LCL is often rarely injured without a significant impact or twisting injury so if you suspect as such you should see a doctor. If you are sitting you can check it’s integrity by sitting in cross leg position. Then feel underneath the knee for the bump that protrudes on the femur and the fibular head which should be below it. The ropey connective tissue that bridges between them is the LCL.

The fibular head should move in 3 planes when you flex and extend your ankle. If it does not move well then there may be an issue there if there is any type of pain in that area. When you dorsiflex the fibular head should move up, forward, and rotate outwards. The opposite should occur when you plantar flex.

To check the biceps femoris tendon you should put your knee at a 90 degree angle and locate the fibular head on the outside of the leg. If you dig your heel into the ground you should feel the biceps femoris tendon become taught and you can palpate if the area is painful, tender, or swollen.

In regards to the biceps femoris tendon like the pes anserine tendons it can also suffer from bursitis and tendonitis so if the issues are along that tendon as it runs into the fibular head then you probably know what it is.

Treatment

If the issue deals with the LCL or the fibular head not moving correctly then see an orthopedic doctor or physical therapist. Usually if the fibular head is not articular correctly it is a multijoint issue dealing with the foot, ankle, knee, and possibly the hip/SI joint/low back as well. When one thing gets gummed up so to speak other joints/connective tissues/muscles have to take up the slack. Thus, get it looked at by a professional.

If it is tendonitis we have an article On Tendonitis for how to deal with both acute and chronic tendonitis injuries.

Remember, if the injury is acute then the treatment(s) that are most effective are RICE protocol, mobility work, light stretching, massage to the muscle, and potentially anti-inflammatories.

If the injury is more chronic then a protocol that work best are mobility, stretching, heat, friction massage to the tendon, massage to loosen up the muscles, and eccentric exercise. Eccentric exercise is one of the only proven non-invasive methods for rehabilitation of chronic tendonitis. This is the most important factor of a chronic tendonitis regime. See the above tendonitis link for more on this.

Learning how to squat correctly by engaging the posterior chain (glutes, hamstrings, etc.) will help significantly take stress off of this type of injury. So that is definitely one of the things that can be focused on aside from other modality treatment. Exercise should be focused on sitting back on the heels and not coming up onto the toes because that puts more stress on the anterior chain.

Photo from http://www.itendonitis.com/

It’s etiology is very similar to that of patellofemoral syndrome where improper biomechanics, muscle imbalances, or anatomical issues can lead to its development. The various muscles that connect into the IT band do various things. The tensor facsiae latae assists in hip flexion, internal rotation, and abduction; the gluteus maximus is a prime mover of hip extension, abduction, and internal rotation.

Also, what is less known is that a majority of the vastus lateralis sits directly under the IT band itself as it extends fairly far up the lateral side of the leg. That means if the fascia between the IT band and vastus lateralis is tight for whatever reason being it overuse or immobility then that can also affect correct function of the IT band.

If these muscles get tight, overused, build up with scar tissue, etc. it can put a lot of tension on the rest of the IT band. In addition, the improper biomechanics like collapsing knees will also force a lot of stress onto the IT band because it is one of the only forces that prevents the knees from collapsing inwards besides the vastus lateralis and the LCL. Now you can see why patellofemoral syndrome (via vastus lateralis overdevelopment) is a similar issue to IT band issues especially with poor biomechanics.

Treatment

The treatment is very similar to the patellofemoral issues since connective tissue and articular cartilage have low blood supplies they need many things to help correct these issues.

First, bringing down the pain and inflammation is paramount. This can be done with the typical RICE protocol, massage, and anti-inflammatories if necessary.

Secondly, there must be loosening/strengthening of particular muscle groups. We want to strengthen the vastus medialis, vastus medialis obliquus, hamstrings, and glutes. We want to massage, trigger point, foam roll, tennis ball, etc. to loosen the vastus lateralis, rectus femoris, IT band, calves, hip flexors, etc.

Thirdly, we need to make sure there is enough range of motion at the ankles and hips. We want to especially gain more dorsiflexion in the ankles with calf stretches, and we would like to gain more hip extension by stretching the hip flexors as well as mobilizing hip internal and external rotation. In addition, in the case of IT band we need to stretch out the glutes and TFL.

Many of the specific stretching/strengthening exercises can be found here.

Lastly, we need to teach proper biomechanics by deemphasizing the anterior chain by sitting back more in squats, teaching proper running technique, etc.

In addition, the knees must NOT be allowed to collapse in during any exercise that is taught. This is paramount. One of the best ways to do this is to cue to spread the floor with the feet during squatting, lunging, etc. if the knees want to collapse inwards. If this is ineffective, a band can be placed to pull the knees inwards to force the the person to think about forcing the knees outwards during the movement.

Since the glutes are one of the potent external rotators of the hip they should be evaluated for weakness/inactivation especially if there is a lot of sitting during the day. Once you get them active not only will it help correct the technique, but it will make you significantly stronger as well.

Photo from http://www.youcanbefit.com/

First, if you suspect that you have an ACL tear you should see your orthopedic doctor to get tested. There are some tests that can be used such as Lachman’s, pivot shift, or anterior drawer tests, but these should be performed by a profession who knows what they are looking for.

Generally, if you have an ACL tear there will be some unmistakable symptoms:

1. Pain within the joint. Usually sharp from an impact or contact injury.
2. Many times a pop can be heard when the injury occurs
3. Usually the knee will swell fairly significantly
4. Instability when walking or running. The knee will feel like it will suddenly give out on you.

Directly after an injury it may be hard to confirm a diagnosis since if there is pain and swelling and general tightness of the muscles it may lead to some false positives.

However, diagnostic imaging is used in almost all circumstances to confirm before surgery is scheduled.

Finally, I must note that meniscus injuries sometimes present like ACL injuries and often happen concurrently with ACL injuries which means it is imperative that you seek proper medical attention instead of trying to self diagnose yourself. You will not be able to treat them yourself anyway which is why you should see an orthopedic doctor especially if your activities of daily life or athletic performance are hindered.

Treatment

If you have an ACL tear and want to get back to athletics you should get the surgery. Talk to your orthopedic surgeon and physical therapist.

You can live a perfectly normal life without an ACL as long as the surrounding musculature of the knee is strengthened properly. A repair is not needed in these cases. In some instances, athletes have been able to play on a torn or partially torn ACL for years without knowing they did drastic damage to their knee because they are strong and the muscles were able to stabilize the knee correctly.

If you have any questions about this type of injury talk to your physical therapist or doctor. Listen to your PT for rehabilitation options.

Photo from http://www.riversideonline.com

However, there are some similarities and a couple differences you can look for that may point towards a meniscus injury as opposed to an ACL.

1. Pain within the joint. Usually sharp from an impact or contact injury.
2. Many times a pop can be heard when the injury occurs
3. Usually the knee will swell fairly significantly. For a meniscus injury this may or may not occur.
4. Instability when walking or running. For a meniscus injury this may or may not occur.

Additionally, the meniscal injuries may also present:

5. Occasionally or often the knee will “lock” often when trying to straighten or bend the knee during any type of movement
6. The pain is usually localized towards one of the diagonal directions of the knee. The pain will be inside the joint but it will usually be localized towards the front or back and off to one side or the other. This is because the anterior and posterior horns of both meniscus are the easiest to damage during an impact and/or with a twisting action that messes with the proper articulation of the bone.

If you suspect a meniscus injury please see your orthopedic doctor to get a confirmation and your options depending on the extent of the injury.

Treatment

There are a fairly large amount of different types of meniscus tears and a significant degree in the extent of injuries. Sometimes they can be repaired; sometimes the menisci will have to be removed.

Photo from http://www.foundrysportsmedicine.com/

There are some instances where you may not need arthroscopic surgery and the meniscus can heal itself although they are more rare. Injuries in the “white zone” tend to have no vascularization which means the body cannot repair the injury itself. However, if the injury is in the “red zone” that means the body has some limited degree of blood supply there where it may possibly heal the injury (depending on the extent of the damage).

However, even if the injury is in the red zone if the tear breaks through the rim of the meniscus that may cause significant destabilization of the knee so there may be problems with non-surgical options even if the tear can heal itself.

Again, your best bet is to see an orthopedic doctor and get assessed. They will likely do some tests such as McMurray’s and Appley’s compression test as well as confirm it with medical imaging such as MRI like they would with an ACL.

If you have any questions about this type of injury talk to your physical therapist or doctor. Listen to your PT for rehabilitation options.

If the pain is located in the quadriceps or hamstrings themselves they it is likely you have some form of strain or at least tight muscles/scar tissue/adhesions in the muscle(s).

In the case of muscles strains or pulls unless it is extremely bad where your tissues are turning black and blue and you absolutely need pain killers, you probably do not need to a see a doctor. This is because you will most likely just get a prescription for pain killers and be told to rest.

However, if you are that worried about your injury then do not hesitate to see a doctor or physical therapist. Better safe than sorry.

Treatment

I have already written extensively on muscle strains which will help you get started on the road to recovery.

Photos from http://www.fpnotebook.com and http://www.5skaggs.com

As you can see from the above image there is mostly only ligaments crisscrossing the knee joint, and then muscles running around doing various actions on the knee. The plantaris tends to be inconsequential but the hamstrings, popliteus, and both heads of the gastrocnemius all play multiple roles in the proper function of the knee joint.

Hyperextension injuries are the most common cause of pain on the back of the knee, and if they are severe enough the injury is likely to be the ACL which helps to prevent anterior translation of the tibia on the femur.

Thus, the other most common type of injury is strains of the aforementioned muscles. But if you have any doubts about the diagnosis, see a doctor or physical therapist.

Treatment

If you suspect ligamental damage, again see an orthopedic doctor or physical therapist.

If you suspect a strain I have already written extensively on muscle strains which will help you get started on the road to recovery.

Obviously, for everything I have not covered it is important to get checked out by a qualified professional.

Treatment

Other problem(s) may show up even if you have a diagnosed pathology, so it is important to be under the plan of care of a orthopedic doctor or physical therapist who you can trust to talk about your injuries and any concerns you have about your rehabilitation.

Remember, there are good and bad doctors and good and bad physical therapists. If you don’t have a good one who can answer your questions and provide you with a good rehabilitation program or options then you can always find another.

If you are an athlete specifically you may want to look for doctors and physical therapists who work with sports teams.

I hope this article was helpful in determining any potential knee injuries and what some of the options are about treating such dysfunctions.

Remember however that this is the Internet and even though this article may be right 90% of the time in correctly figuring out a pathology it should not be used as a definitive guide for injury diagnosis and treatment.

You should always talk to your orthopedic doctor or physical therapist for a confirmation on diagnosis and treatment especially if you have any questions regarding a certain pathology and subsequent rehabilitation process.

If you suspect you have an injury that does not fall into any of the categories above see a medical professional immediately. Also, if you have an injury which presents debilitating pain or presents possible insidious neurological symptoms such as sensory or motor deficits see a medical professional immediately. Motor deficits are critical enough that you may want to go to the ER ASAP.

Table of Contents
I. Introduction

This is a big problem because the first page was just an introduction to the main stimuli that cause the problems. Other mechanisms and compensations were discussed on the second page. The third page consisted of correcting movement deficiencies, and the fourth page on specific soft tissue corrections and strengthening/stretching procedures. The fifth was an overall summary that was important if the anatomy was too much too handle.

If any page was the least important to consider it would probably be the first page… but most people just quit reading after the first page. I want people to realize that shoes and sitting cause problems, but not at the expense of knowing the mechanisms of why it happens and how to correct those problems. If you or anyone you know were one of those people I implore you to go back and reread the whole article. It’s long, but its worth it especially if you have these types of problems.

Moving on…

This is going to be a spinoff of that topic focusing specifically on the feet since most people have these types of problems especially with pes planus (aka flat feet / fallen arches) nowadays. Some of the material is going to overlap with the above article, so if you wanted to get a more generalized overview of other movement problems that can occur with flat feet I would suggest looking at the above.

Let’s get started.

An arch is one of the fundamental structures within engineering for supporting weight for good reasons. They are able to take weight that is put on top of them and sustain it. Instead of the weight becoming a shear or torsional forces, arches help to distribute the weight into compressive forces.

Well, it just so happens that all of our bones are built to take compressive forces. For example, that is why all of our long bones like the femur and the tibia are oriented so weight bearing occurs vertically. If we look at the femur below we can see that the compact bone is oriented for sustaining vertical stressors. The neck and head of the femur actually have their own type of architecture built in as well; the trabecular (spongy) bone is oriented in such as way that there are multiple arches which help support the weight of the pelvis and the rest of the upper body on the femoral head and neck during weightbearing so that it doesn’t shear off during loading.

Photo from itmonline.org and blogspot.com respectively.

So as we can see with other bones bones in the body, the bone is strongest with compressive forces. However, when there is an angle necessary such as the neck of the femur, the body (e.g. evolution, God, etc.) compensates by building its own internal arches to support the bone so that shear stresses do not destroy it. Shear (lateral) forces, of course, are the main culprit in fractures.

Interestingly, the foot is comprised of 3 arches.

Photo from munfitnessblog.com

The longitudinal arch is compromised of the medial and lateral arches. And there is also a transverse arch of the foot.

The medial arch consists of the calcaneus, talus, navicular, 3 cuneiform bones, and the first 3 metatarsals. In laymans terms it runs on your foot from the heel to the ball of the foot where the first 3 toes are on the big toe side.

The lateral arch consists of the calcaneus, cuboid, and the last two metatarsals. This would be from the heel to the ball of the foot where the ring and pinky toes are.

The transverse arches are comprised of the specific orientation of the tarsal and metatarsal bones. They form a concave C shape underneath which can be seen in the next two photos.

Photos from pilates-pro.com and chestofbooks.com

All of these structures come together to form a stable base of support for the foot during weightbearing.

Photo from craftofpiano.com

Thus, we can think of the 3 arches combined as an oval dome structure; it is structurally sound built to take the forces that we put on them.

On the deep plantar (sole) aspect of the foot there are 3 main ligaments that hold the tarsal bones together in the arch. These ligaments, the spring ligament, long plantar ligament, and short plantar ligament all span the bottom of the arch right underneath where the ankle exerts its weight. As you can see below, the long plantar is more confined to the lateral arch, the short plantar is somewhat in the middle between the lateral and medial arches, and the spring ligament works more to support the medial arch.

Photo from dartmouth.edu

Ligaments tend to function as more of “last line of defense” in supporting a joint structure. For example, everyone knows about the ACL in the knee which prevents anterior displacement of the tibia (relative to the femur). If we rupture that ligament, the knee becomes severely destabilized and likely requires surgery. We will talk about this a bit more later though in the context of the foot.

As we can also see from the above picture, there are tendons from muscles in the deep shin and calf areas namely the peroneus (fibularis) longus and tibialis posterior tendons which wrap around the foot and criss-cross and attach to the metatarsals. If you couldn’t guess by now these muscles are integral as support structures; we can think of them as suspender cables that help to hold up a suspension bridge.

Now, we have only looked at the deepest part of the foot. Let’s quickly cover the rest of the muscles that help support the foot. Besides the deepest layer that serves as “last resort support” there are also *4* layers of muscles on the plantar aspect of the foot not including the plantar aponeurosis (e.g. plantar fascia).

In order from the plantar aponeurosis moving deeper into the foot we have:

Photos courtesy of this site. Visit it for a more in depth anatomy lesson.

I’m not going to delineate all of the specific muscles of the foot and their functions. However, we will conclude that all of these muscles have different functions on the bottom of the foot just like our hands have many muscles in them for grip and dexterity. These muscles are made for stabilizing and reinforcing the arch of the foot itself to hold it together and make sure it functions well to whatever walking, jogging, sprinting task we use them for.

The ligaments on the plantar aspect of the foot serve to function as girders underneath to limit collapsing of the arch under compression. When a downward force it applied to the arch of the foot, the plantar surface of the tarsals and metatarsals start to spread apart; the ligaments which do not stretch very much help to stop this from occurring.

The muscles themselves form the core of what supports the arch. As we saw above, there are two tendons that come down like suspenders from the lower leg area (fibularis longus, tibialis posterior) and criss-criss underneath providing lots of support. In addition to these muscles, there are two other posterior leg compartment muscles (flexor hallucis longus [FHL] and flexor digitorum longus [FDL]) which run with the posterior tibialis behind the medial malleolus which shoot out to the big toe [FHL] and the 2-5th digits [FDL] respectively which also give some support the bony architecture of the foot. The tendons of those two muscles are located in the 2nd layer of the foot.

Photo also courtesy of the great anatomy site the above 5 images are at.

Most of the rest of the muscles start from the calcaneal/talus area (heel/ankle) area and run to the metatarsals or phalanges of the foot. They also provide support to compression of the foot from weight above, and also help with the mobility of our distal toe joints during walking activities.

As we stated earlier the most important thing to note is that the arch has its own form of support. The bones form the architecture, and the muscles support it with ligaments as reinforcing beams to provide a last line of defense in case of muscular failure.

The plantar fascia has it’s own role in tensioning relationships called the Windlass mechanism, but primary support with non-dorsiflexion of the toes is done through all of the muscles and ligaments as stated above.

We will discuss why can become a problem in the next section.

If there is a lack of arch development (1) especially in childhood, or (2) if you had arches and they slowly are disappearing then you likely have a dysfunction. This is especially so if we notice valgus features within the hip and knees – e.g. knees collapsing inwards during movements – or have bought into the delusion of wearing excessively padded shoes or orthotics.

Pes planus is a disease of civilization. Much like there are many physiological problems that are created by industrial food processing and sleep dysfunctions from artificial light, there are also movement dysfunctions born out of civilizations.

Let’s review what we learned about movement problems from Shoes, Sitting, and Lower Body Dysfunctions.

Shoes tends to cause the problems of:

• Tight calves resulting in loss of 10-20 degrees of dorsi-flexion range of motion (ROM) in the calves.
• Inactivation of the muscles on the bottom of the foot and the ankle stabilizers.
• Decreased proprioception of the lower limbs.

Why is this?

Shoes are essentially air casts for the feet. What happens when we put a cast on our arm for a broken bone?

Our body is a use-it-or-lose-it system. It does not like devoting energy to things that it deems useless. Thus,

I. When we are immobile our bodies sense that we do not need that particular body part so it starts shortening the muscles through feedback control of gamma motor neurons. Gamma motor neurons regulate muscle spindle sensitivity and start to tighten intrafusal muscle fibers. Muscle spindles are embedded in the intrafusal muscle fibers and regulate length-tension of muscles through the stretch reflex; thus, tightening the gamma motor neurons makes the muscle more resistant to stretch. Hence, the tightness and loss of range of motion in the calves.

II. Likewise, atrophy of the muscles starts to occur which start to weaken all of the intrinsic muscles of the foot and calves. Muscle tissue is expensive to build and maintain for the body, so when we do not use it our body starts to metabolize it to use for energy. Hence, the inactivation and weakening of the ankle stabilizers and intrinsic (all 4 layers) foot muscles.

III. Additionally, since we are not using these muscles the body starts to decrease emphasis of the particular afferent/sensory and proprioceptive/kinesthetic ascending pathways to the central nervous system (spinothalamic, spinocerebellar, and dorsal column medial lemniscal tracts) which in turn decrease output of descending control to both unconcious (medial reticulospinal and lateral vestibulospinal tracts, intermediate hemisphere of cerebellum, possibly lateral cerebellum too) and conscious (lateral corticospinal tract) pathways. The unconscious control is mainly focused on postural and balance corrections, and the conscious tracts facilitate voluntary motion.

Note: I included specific tracts if you wanted to look them up.

The more padding in the shoes, the worse the problem becomes. The padding in the shoe becomes the “support” for the arch; thus the body says to itself it does not need the muscles in the shin/calves and feet anymore and those three big problems occur.

Let’s follow what happens to its logical progression.

• We wear shoes, especially those with padding
• The body senses lack of movement and information from sensory structures
• Thus, the body starts tightening up muscles reducing range of motion, atrophying the muscles, and decreasing foot awareness and control.
• Atrophy of the muscles lead start leading to greater stresses on the ligaments.
• The ligaments start stretching.
• As the ligaments start stretching, the arch starts collapsing
• In many cases, this starts to put pressure on other structures that have nerve fibers. One of the primary places this occurs is the plantar fascia.

The mechanism is pretty straight forward, and that’s the way it happens.

For example, fault biomechanics at the hips and knees through too much sitting can lead to valgus alterations in lumbar, hip, knee, and ankles joints. These changes can tilt the weight foot more onto the medial arch which can be enough to start collapsing in many cases.

Similarly, traumas or impacts can play a factor as well. For instance, one prominent example is the sacroiliac (SI) joint. Sometimes an impact to the leg from an awkward landing or car accident or non-impact scenario can rotate the SI joint out of place. When one side slips or gets stuck in a particular orientation, the loss of mobility at the joint leads to alterations in normal biomechanics of nearby joints. This can cause things further up the chain such as neck or scapular pain, lumbar scoliosis, sciatica, hip and knee pains, etc. mainly through leg length discrepancy. The slipped side usually has the leg become shorter than the other leg (because the SI joint on that side slips downward which tilts the pelvis towards that side making the affected side’s leg shorter).

Photos from sportsinjurybulletin.com and chiropractic-help.com respectively.

I have written some on SI joint dysfunction, but if you suspect this is a problem I would definitely go to a chiropractor or physical therapist who is good with lumbopelvic evaluations to get yourself checked out. You may be able to check yourself with the long sit test – legs will be uneven lying on the back e.g. pelvis oriented upwards, but when you sit up they will be even because the slip doesn’t manifest when the pelvis is oriented forwards.

Even if these issues are fixed you may still have problems later if the issue has been there months or years,so don’t close out your browser on this article yet as you may still need help in this area.

High arches aren’t really a disease of civilization because they aren’t as common, and don’t exist from the same incorrect biomechanical faults as flat feet.

If you have pain from high arches it would be a good idea to get it evaluated by a professional to at least rule out neurological issues.

As we talked about if there are some varus issues (See Shoes, Sitting, and Lower Body Dysfunctions for a longer explanation), it is certainly possible that this problem may stem from bow leggedness or duck walking. It could also just be a postural issue stemming from previous pain incidents or from excessive external rotation of the hip.

If this is a problem take a look at your leg biomechanics. When you run, walk up stairs, squat, and do any other activities are your joints aligned correctly? Are your knees tracking properly over the toes? Are the knees oriented forwards? Is weight properly distributed on the feet or more laterally based on the edge of the foot?

If you can spot issues that may be causing pain, and likely with this condition many inversion sprains then there may be some corrections that you need to do. See pages 3 and 4 specifically of Shoes, Sitting, and Lower Body Dysfunctions for this.

As previously discussed the plantar fascia is involved with the Windlass mechanism. When the toes are dorsiflexed in walking, jogging, etc. it tensions the whole foot through the calcaneus which gives the achilles (and thus the rest of the posterior chain) and stable platform from which it can propel the body forwards. In normal movement, however, there is not constant tensioning on the plantar aponeurosis constantly lest it get easily overused and microtear easier. When compared with the above paragraph I hope you can see the distinction between this mechanism and the normal supports.

Plantar fasciitis pain is not always straight forward. For example, here is a common distribution of the pain patterns. As you can see most often the plantar aponeurosis is aggravated at the heel where it originates from, but pain can be anywhere along the plantar aponeurosis all the way up to the feet.

Photo from yogatuneup.com

Obviously, if you have any variation of lower arches or pes planus, it is more likely that plantar fasciitis is going to show up. Also, very tight calves also puts a large strain on the plantar fascia because they pull the calcaneus from the superiorly which lengthens the arch (through the tensegrity model – here’s one such study).

The prehabilitation and rehabilitation will be grouped together later with the flat feet.

Likewise, remember we showed that the fibularis longus tendon and the tibialis posterior tendon criss-crossed underneath the foot? Well, if the arch is collapsing additional stress is being placed on these tendons. But let’s not forget that shoes also start to tighten up the muscles of the lower leg including these two muscles because of lack of significant use. Therefore, we have the perfect recipe for tendonitis – muscles that are too tight are pulling on the tendon that is already being stretched.

The general areas of pain for these are seen below:

Photos from footclinic.co.uk and joint-pain-solutions.com respectively

As you can see the pain distributions can be moving into the foot from either side or in the lower leg area, but most of the pain is centralized to the tendon area which runs close to the the medial and lateral malleoli respectively because the tendon shealths don’t get a lot of blood flow there.

Typically, peroneal/fibularis longus tendonitis is more seen in people with higher arches / supinated feet (as the foot wants to invert more); however, it’s possible to see it occur with more flat feet as it can get unnecessarily short and tight as the foot pronates excessively.

Tibialis posterior tendonitis is usually more seen in people with flat feet as that is the tendon that is going to take the brunt of the stress, especially in plantar flexion to help support the arch besides the plantar fascia if the muscles are atrophying.

Achilles tendonitis is something I didn’t want to particularly group the plantar fasciitis grouping; however, the issue with this problem is is variable whether the actual cause is due to overuse or problems with pes planus. Typical pes planus can exacerbate the condition significantly because the foot everts and the force vector on the achilles tendon gets distorted sideways alterating the torque to a more oblique pull. This increases the potential for tendonitis and rupture so keep this in mind if you have flat feet. If this is an issue follow similar tendonitis protocol as above.

Photo from risely.com.ae and eorthopod.com

Shin splints, like achilles tendonitis, tend to result from overuse. They can, however, be exacerbated by poor biomechanis of flat feet and especially if the person is a heel strike runner (which by the way is an incorrect way to run). Typically what happens during heel-toe running is that most people get lazy in the stride and allow the foot to slap down while they run. Excessive eccentric loading of the muscle can aggravate both the tendon, the muscle itself, or the origin of the muscle located on the bone.

Photos from latrobe.edu.au and sportlink.co.uk respectively.

As you can see if the tendon is aggravate it can distally radiate pain from the top of the foot all the way to where it inserts down near the big toe and also cause big toe pain. Likewise, aggravation of the muscle can cause pain above the ankle, and the pulling of the muscle on its origin on the upper 2/3rds of the tibia can cause stress fracturing to occur within the tibia itself.

Posterior shin splints can occur as well, but we already talked about that with the tibialis posterior. However, we didn’t talk about the pain that can occur deep inside the calf area on the tibia and fibula from the an overworked muscle and the stress fracturing of those bones. As with the above shin splints take care of them in the same manner!

Suffice to say that both collapsed arches, and supinated feet can cause these for different reason. The most common cause of this is due to ill fitting footwear though. Many older women and men have this problem because of the pointed shoes that were too small back in the day which forced the toes into an inward configuration. Suffice to say this is not good either.

Some cases would fall under diseases of civilization such as some forms of metatarsalgia that may result from hypermobility from the atrophied muscles and stretched out ligaments of collapsing arches.

However, other injuries such as turf toe (typically strain/avulsion of tendon of flexor hallus longus) can sometimes be aggravated by flat feet, but most of the time occur mostly with physical activity and cutting movements such that if you cut out the activity and rehabilitate it properly it will be resolved.

Diabetic neuropathy and gout – especially with extremities – are two examples that have more to do with nutritional diseases of civilization due to poor eating habits leading to excessive inflammation or metabolic insufficiencies. These problems are typically not rooted in the extremities where they exist and rather can be made better systemically. However, in general, mobility to get blood flowing and make sure the limbs are working well is recommended.

I don’t offer any medical advice on these blogs but if you are having problems with diabetes and gout, and it’s causing issues with extremities you had better get your diet and sleep in order. I recommend The Paleolitic diet, at least 8+ hours of sleep if possible, in combination with supplementation of fish oil and daily exercise. Eliminate the inflammation and you’re well on your way to hopefully reversing some of these problems.

Regarding potential fractures and other athletic problems. My stance has and always will be if the pain does not decrease within a week of total rest you should definitely make an appointment with an orthopedic doctor. Make your appointment the within a couple days of having pain as you will usually have to wait a week or two to get into the doctor. If your problem has resolved through proper prehabilitation or rehabilitation then cancel your appointment; if it hasn’t then go to your appointment!

There’s no point in delaying medical treatment if you need it, and if the problem can get worse. By no means is this article supposed to be a diagnosis and treatment option for anything. It is just supposed to be educational. This definitely bears repeating later.

Shoes, Sitting, and Lower Body Dysfunctions did a good job of covering the “evil” of shoes.

Shoes that offer support are not what we are looking for – they are the things that cause the problem in the first place. Just check out this study of people in India. The people who wore shoes had higher rates of flat feet and more laxity in their ligaments. Not only that barefoot was least likely to have flat feet, sandals had higher rates, and closed toed shoes had the highest rates. Hmmm, who woulda thought that?

One of the studies I referenced in Shoes, Sitting, and Lower Body Dysfunctions was a study that the military did on fitting shoes to particular foot type. Injury rates didn’t change versus those who didn’t have their feet fitted to particular shoe types.

Many other studies were done comparing barefoot versus shod running. Torques increased and altered biomechanics persisted coupled with the decreased proprioception for those with shod compared to the barefoot conditions. Universally, we want to stay away from shoes to solve any type of problem we have.

Again, check out the link above. I don’t make this stuff up.

In general, orthotics and their derivatives disgust me. Again, like padded shoes they’re supposed to offer people with flat feet or high arches “support” but in reality we’re just reinforcing the poor patterns that already exist that cause the problem to begin with. You don’t offer more support to muscles that are already weak and ligaments that are already lax. You strengthen them. With foot exercises and going barefoot.

The whole shoe industry and orthotics are an extension of what the pharmaceutical companies are to modern medicine. These companies are trying to turn big profits. I’m sure that many people in those companies mean well, but if we look at the literature it shows that most of these things are ineffective compared to natural solutions.

For example, this study in children showed no significant outcomes in pain reduction or an increase in function.

Yes, your drug may help with heart disease, but it ain’t fixing the problem. Yes, orthotics may temporary relieve your foot pain, but it ain’t fixing the problem. You know what fixes the problem? Getting enough sleep, eating correctly, and exercising. Proper mobility and rehabilitation work for the latter.

Now, there are certain instances where orthotics can be used effectively. For example, if say you are in the military and have foot pain and you absolutely need to keep exercising and orthotics help with that. The same may be true if you have a job that requires you to be on your feet a lot. HOWEVER, remember that orthotics do not fix the problem; make absolutely sure you are concurrently rehabilitating your feet during this so eventually you can get off orthotics.

In most any type of situation with foot pain it is much better to try physical therapy or other rehabilitation methods first before saying screw it and get the “quick fix” of orthotics. Most people that do this don’t bother to rehab after their pain has gone away, and they will be stuck buying these things inevitably forever.

This is not conducive to health. It’s the easy fix. It’s the lap band (on the stomach) instead of eating right and exercising. And speaking of lap bands if they people don’t correct their eating and lack of exercising habits they can still balloon up to the same weight again. That tends to be what happens with orthotics and recurring pain too.

Here are the links specifically for the helpful sections:
The feet
The lower leg

Of the techniques mentioned in the above links I prefer use of sand or other instability factors the best. Foot exercises with foot gymnastics/dexterity work as well, but it’s just easier to use sand as it does the work for you and all you have to do is walk or play around in it as long as it’s not painful. Plus, it’s a good excuse to go on a vacation, right?

Any type of balance work focus on using the musculature of the place you need balance at. For example, what’s the point of using our arms to balance on one leg when its our feet that are our weak link? Put your arms behind your back, don’t let your torso move, and only allow the feet and lower leg muscles to work. That’s what we are aiming for and that is therefore what we should do.

The key for any of this rehabilitation work is to get the tight muscles loosened up, and mobilize as many of the joints as you can. Get your toes, metatarsals, ankles, etc. moving. Get those muscles working and stronger, get the sensory units firing signals up to your brain.

If the arch is in the process of collapsing or recently collapsed it may be possible to save it or reform it. Our tissues are are fairly good in their plasticity that they have the capacity to change.

If you are having issues is pain soft tissue work and non-painful mobility work is extremely important. One of the major factors in eliminating pain is the gate control theory of pain. The gate control theory of pain shows us how to help dull down the pain so the body can heal itself better.

Gate control theory of pain. Photo from health.howstuffworks.com

All of the fibers under ‘gate control’ are sensory afferents from the skin, muscles, ligaments, and joints. The large fibers specifically are the ones that travel fastest – alpha and beta fibers – in humans these are golgi tendon organs and muscle spindles. The small fibers tend to be smaller afferents responsible for nociceptive (pain) input including delta and C fibers.

The theory goes that stimulation of the large alpha and beta fibers can interfere and help dull the body’s sense of pain from the smaller delta and C fibers. What stimulates alpha and beta fibers? That’s right: soft tissue work and movement.

Soft tissue work gets into the muscles and surrounding tissues and stimulates alpha and beta fibers (and also through CNS feedback gets gamma fibers to loosen or knocks out hypoxic trigger points) thus getting tension off the muscles. Good stuff.

Also, non-painful movement uses muscles stimulating the alpha and beta fibers to help create noise to eliminate that pain, and additionally it helps increase blood flow to the area for healing, proprioception/kinesthetic awareness increases, and muscles are being used so they don’t atrophy. Likewise, mobility/flexibility work that doesn’t hurt does similar things.

Reforming an arch?

For adults, feet that have been flat for some period of time may not be able to reform the arch. It MAY be possible with orthotics to reshape an arch (not ones that are fitted to your foot), and proper rehabilitation. However, in general it may not be possible especially if you’ve had the problem for years.

I think we can all be happy though that the body is remarkably adaptive and can cope and be strengthened enough in certain positions to avoid pain altogether even with the deformation of flat feet. Just make sure you do your exercise and rehabilitation!

The arch naturally develops during the time where we are learning to walk well (somewhere in 2-6 years old) because of the stressors placed on our feet aid in this developmental process.

Since children are still growing proper foot strengthening will likely help reform an arch. Anyone up to about the age of 21 with flat feet should be made aware of this. The long bones in your feet are still growing with proper care and strengthening it may be possible to change the foot structure significantly enough to reform an arch.

Fibularis longus tendonitis, tibialias posterior tendonitis, tibialis anterior tendonitis, achilles tendonitis, etc.

Tendonitis issues depend on a lot of factors so beware. I’ll try to educate you as best I can.

Okay, so the initiate phase of tendonitis is inflammatory – there is inflammation and the RICE protocol tends to work best with it. Most of these cases resolve with purely rest. Massage and RICE may help.

After the tendonitis becomes chronic – tendonosis – which tends to occur after about 3-4 weeks of continued exercise aggravating tendonitis OR a period of at least a week or two rest from which the tendonitis does not resolve.

Tendonosis responds better to an opposite protocol namely eccentric exercise, heating instead of ice, and massage to the muscles that are aggravated – not the tendon itself because it is degenerating. If these things do not resolve chronic tendonosis then more drastic measures may be needed, but you can check out alternative stuff in the article posted.

Shin Splints

Shin splints rehabbing typically is very hard to pinpoint. If the tissue is more down in the foot and ankle I would say treat it more like a tendonitis case. If the muscle itself is sore, or the bones of the shins are getting sore then we have a different issue.

If the muscle itself seems to be the biggest cause of pain then rest and let it heal. It’s being overworked. Massage can help via the gate control theory above but don’t overdo it. Light mobility work will help. After the muscle itself heals over usually a weeks time, we can start to strengthen it by doing toe raises or loading weight onto the toe and doing toe raises. One of my favorites is to put weight into a backpack and sit on a countertop/ledge and do toe raises with the backpack hanging off the foot.

If the pain is more bony is nature that tends to mean stress fracturing. Unfortunately, for this condition rest is the solution. DO NOT TAKE NSAIDs FOR THE PAIN. While the NSAIDs help with inhibiting the pain, they also inhibit inflammatory pathways that are critical for healing and proliferation of the bone to increase cortical bone density. If you are taking NSAIDs for your pain and have this issue stop immediately. It’s counterproductive to your healing rates, and will make your rehab take that much longer.

Very light mobility work to get blood flowing, and massage tends to be good as well. Direct ice massage tends to be helpful a lot. But the key here is rest.

This was glossed over in the Shoes, Sitting, and Lower Bodies Dysfunction article, so I figure that I should mention it now.

The fact that we are not only wearing shoes a lot more, but also sitting indoors a lot now (and not getting much vitamin D) is frankly disturbing to me and a huge factor in the movement diseases of civilization.

Rickets is not a prominent disease in our culture now due to prevalent food sources, yet things such as osteomalacia, osteopenia, and osteoporosis. The fact is that over 80-90% of people in U.S. are deficient or severely deficient in vitamin D. This is a big problem. Why?

Softening of bones due calcium malabsorption will lead to softening of the bones of the arches of the foot. This can clearly lead to a higher prevalence of flat feet.

Those with darker skin are more at risk, especially in moderate climates because sunlight conversion of 7-dehydrocholesterol from UV to vitamin D precusors occur slower in those with more melanin.

Vitamin D analysis and recommendations are here. Either get out in the sun at least 30-60 minutes per day or take a supplement if you’re indoors a lot like me. It’s not worth being deficient in this vitamin, especially with all of its positive benefits as you’ll see by reading the above link.

Sunscreen, even SPF 8 tends to block almost 80-90% of vitamin D production. So don’t be afraid to let the kids out after school (when the suns not even the highest) to soak up the rays. In fact, we should be encouraging they go outside not just for the vitamin D but for the exercise as well!

It’s funny how everything fits together (and that I’m referencing tons of previous articles).

Rickets. Photo from thachers.org

Hmm, it’s interesting how childhood rickets tends to look like valgus problems which can lead to flat feet in older children. You know, right about the time we put them in school for 7 hours a day and bog them down with homework so that they don’t get out of the house in the sun any…. and take away recess. For younger children it’s varus problems.

NSAIDs and acetaminophen/tylenol: a lesson

I started to touch briefly on this topic in the previous section on shin splints.

NSAIDs while great for pain relief often help slow the healing rates of issues that you are trying to fix with rehab. For example, typical NSAIDs prescribed for pain and inflammation are over the counter such as aspirin and ibuprofen. Things you may typically get with a prescription are stronger such as naproxen.

Image from altair.chonnam.ac.kr

The mechanism of typical NSAIDs is to inhibit the cyclooxygenase pathway of inflammation as seen above (aspirin, indomethacin). This is great because it eliminates the pain by inhibiting the PGE substrates that aggravate the delta and C sensory fibers within the area like we talked about before. However, this is bad because it also inhibits the prostacylins and HHTs which are responsible for drawing in white blood cells and platlets that help clean up the damaged tissues, and release growth factors to move on to the more proliferative phase of healing. Here’s a few studies showing this.

Now, I’m sure we tend to all think of Tylenol/Acetominophen the same as the other NSAIDs, but it is in fact actually not and anti-inflammatory agent. Thus, if you’re having pain with this, it would be recommended to take this over any of the NSAIDs because of healing rates.

This also applies in reverse though. If you suffer a traumatic injury to the ankle such as a sprain and it’s inflammed and swelling up then avoid acetominophen in this case. It’s not going to help with what we need which is the anti-inflammatory factors. We would want to do the RICE protocol, NSAIDs, massage, mobility work, etc. in these cases.

I would try to avoid using NSAIDs for anything related to pain where tissues need to heal if there isn’t excessive inflammation. The cyclooxygenase pathway is a critical step of that inflammatory phase that is needed for any sort of tissue regeneration whether it be muscle, tendons, ligaments, bones, etc. If it hurts bad then use different anti-pain medications like tylenol. It’s only when the inflammation gets so out of control such as with lots of swelling or fever where NSAIDs start to become more useful.

Warmness of the skin area is a good indicator of acceptable levels of inflammation (as prostagladins of the cyclooxygenase are fever inducing), but when there starts to be a lot of redness and swelling/puffyness symptoms it may be time to help cut down on excessive inflammation with NSAIDs. For example, a couple days after workout the muscles are usually warmer because of the inflammation and healing process that is occur; it is unlikely unless there is severe DOMS or rhabdomyolysis that any NSAIDs may be needed for this.

Fish oil is also a good anti-inflammatory if needed, and of course eating right is going to help the most.

These are things are probably not told to you by your doctor or any other healthcare professional (heck, I didn’t even know about NSAIDs vs tylenol until I was taught that in class a few weeks ago). Keep this type of stuff in mind.

Thus, it’s not such a huge stretch to see that women will probably have more issues with flat feet in general with men. We talked about the SI joint a bit earlier, and women are also more at risk for slipping the SI joint there as well with the additional upper body weight (pregnancy, swelling breasts) in addition to the relaxin.

If that wasn’t enough women also wear high heels. Yes, high heels limit ankle mobility and also lead to the problems described in this article from tight calves.

Be aware women. Unfortuantely, some issues are more prevalent with gender. Biomechanical issues and foot issues tend to be one of them.

I would suggest getting minimalist shoes if they are absolutely required for your job or the area is littered with broken glass. Vibrams are highly recommended.

My other conclusions on things that may help with integrating solutions with workouts, barefoot running, some integration with sitting, and other systemic evaluations are in the conclusion of Shoes, Sitting, and Lower Body Dysfunctions.

If you are heel-toe runner you should definitely check out the barefoot running resources, and start trying to learn how to run properly. CHI running and POSE are two different methods that teach proper running technique; however, sprinters and other elite runners (besides very few long distance runners) tend to naturally run with proper mechanics that occur with barefoot.

The key to any of this is to start off slow and build up. The focus in barefoot running should be (1) relaxing meaning we are only using the muscles that should be used, and (2) moving silently which means that our muscles are absorbing all of the impact and less or none of the force is being put on our joints or ligaments.

If you haven’t read through the whole article (this one or Shoes, Sitting, …) by now you should! Or at least you should read the conclusion if you don’t want to read everything else.

photo from shodless.com

Ah the joys of barefoot running….. and if you notice the other competitors use race flats which are minimalist shoes. Who would’ve thought that’s the most effective way to run, right? Our bodies weren’t made for this for nothing.

I hope everyone learned something. If you like this article please send it to people you know who have these issues or publicize it on your facebook or other sites. We like to get the word out there, but we can’t do it by ourselves. We welcome all feedback or discussion! Thanks for listening.

Tendonitis is an overuse injury. This condition arises when the volume of the workouts exceed your body’s ability to recover. Since our muscles have better blood supplies than our connective tissue (tendons, ligaments, cartilage) and bones, they often are able to adapt to the stressors of exercise placed on them faster. This leaves our connective tissues and bones vulnerable to overuse since they cannot heal as fast. If excessive stress is placed on them, they start to break down and subsequently become inflamed and painful.

There are some alternative applications of how tendonitis develops. For example, for tendonitis of the lateral and medial epicondyles of the elbows there are a lot of muscles that have a common origin (or insertion for other muscles). If the muscles become inflexible and tight then that puts additional stress on the tendon which may not let it heal correctly after exercise. Similarly, our individual muscles have sheaths they slide in against other muscles when they contract. If they are are not moving and sliding correctly it can often recruit multiple muscles that do not need to contract to put additional stress on the tendons as well. This also may not let the tendons heal correctly. The application of prehabilitative and rehabilitative protocols will address all of the above reasons including plain overuse in the next two sections.

Tendonitis starts out as an inflammation injury (-itis is the suffix for any inflammation). If a person continues to work through the injury and pain, it will lead to chronic degeneration. Thus, tendonitis may lead to tendonosis which is characterized by (1) a lack of inflammation, (2) continued degeneration of the tendon, and (3) pain that usually worsens and intensifies.

Once an overuse injury starts to develop, if rest and ice is prescribed right away the body will heal itself because the natural inflammatory processes that arise promote healing. However, if this process is aggravated into a chronic state over weeks and months, then the inflammatory process goes away leading to the chronic degeneration. In these cases, rest and ice may not promote full healing of the injured body part because of the lack of inflammatory healing processes.

There is more details about tendinosis’ etiology and physiology located here.

Common places where tendonitis is easily developed are located at:

• Medial epicondylitis (inner elbow – Golfer’s elbow) which arisea from excessive pulling exercises.
• Lateral epicondylitis (outer elbow – Tennis elbow) which arise excessive hyperextension of the wrist.
• Triceps tendonitis (elbow) which arise from excessive pushing exercises.
• Biceps tendonitis (elbow) which arise from excessive pulling exercises.
• Wrist tendonitis (wrist) which arise from overuse at the computer or in excess flexion/extension of the wrist.
• Patellar tendontis (patella/knee) which arise from overuse in running, plyometrics, or weightlifting.
• Hamstring tendonitis (knee) from overuse in running, plyometrics, or weightlifting.
• Achilles tendonitis (ankle) which arise from overuse in running, plyometrics, or weightlifting.

If you have sore joints or tendons that are starting to become sore, this is your body letting you know that you should back off from exercise. This indicates that those body parts are under excessive volume or repetitive strain that you cannot recover from. Continuing to train through this will lead to chronic overuse which is very difficult to correctly rehabilitate and may be only fixed through surgery. This will also hinder your training significantly, so it is not advisable ever to push through any type of pain.

The goal of this section is to provide you the correct rehabilitative protocol to promote healing for the conditions of mild tendonitis to chronic tendonitis. It is my hope that this protocol can help you, and that you have not aggravated your condition to the point that it requires surgery.

I am going to be writing each rehabilitative procotol in order of importance on what you should be doing including explanations for why each is prescribed.

Section 1
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A. Stay away from painful exercises.

Pain is your body telling you that something is wrong. Listen to your body. Continual aggravation of the injury will make it worse and significantly hinder your training.

B. Rest.

Step 1: 1-2 weeks of total rest should clear up mild forms of tendonitis because the initial inflammation will promote healing. Realize that this does not mean you have to cease workouts altogether but just the exercises of the injured body part.

If the rest is successful, work your way back into exercise slowly starting with 20% volume and adding 10% more each week as it’s very easy to aggravate again. If you feel any twinges of pain or aggravation, immediately back off for the day. It is better to be conservative than to have a chronic condition.

Unfortunately, chronic tendonosis may not respond favorably to pure rest. If your tendonitis does not clear up after 2 weeks of total rest then you probably have the chronic condition. This is to be treated different than just mild tendonitis with rehabilitation exercises to stimulate the inflammatory process (along with massage) to promote healing. The overall elimination of exercises that use this affected area should be followed religious if this is the case.

Section 2
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A. Self massage.

Step 1: Concentrate cross friction massage and myofascial release to first and foremost the tendon, and secondly to immediate local area within 1 inch of affected location.

Step 2: To ensure the surrounding musculature is operating correctly and not causing excess strain at the affected area, continue apply cross friction and myofascial release to the whole area inbetween both joints that surround it. For example, massage all of the muscles between the shoulder to wrist for medial epicondylitis at the elbow; massage all of the muscles between the ankle and hip for patellar tendonitis. Alternative manual massage techniques that may help are ART, graston technique, foam rolling, using a golf/tennis ball to roll the area, etc.

• Aim for 20-30 minutes a day of massage, with most of it in to the tendon and local area. If you find tight muscles with adhesions in the surrounding musculature, focus on those areas as well.
• Time of day does not matter, and it can be broken up into as many session as you desire. I often hit up my soft tissue while I am driving to and from work it is basically “dead” time for anything else.
• For structuring massage according to type it really does not matter. All that matters if that you’re getting into the tissue and helping it reorganize through mobilization plus breaking up any scar tissue or adhesions.

Explanation: The purpose behind massage is to promote blood flow to the area for healing as all tissues need nutrients and waste products carried to and from the area respectively. Also, massage helps improve tissue quality through helping to release and reorganize the tissue through the body’s natural inflammatory processes plus break up any scar tissues or adhesions that may be limiting proper movement of the affected and surrounding area.

Note: If you have tried physical therapy and your therapist did not use significant amounts of manual massage therapy, then they are not good therapists in my opinion. Besides rest and ice (which we will talk about shortly) which most doctors and PTs recommend, the #1 thing that will help you the most is massage and/or self massage.

B. Ice after any use & when sore.

Step 1: Ice 10-15 mins per session for 2-5 times a day. Alternatively, ice can be used every other hour on the hour. Direct ice massage on the skin tends to work the best, but be careful of giving yourself frostbite.

Explanation: Like massage, icing helps limit some pain and excessive inflammation (characterized by edema/swelling) especially immediately after exercise or prehabilitation work. Additionally, icing will promote good blood flow to the area afterwards as the body tries to warm up the area.

Alternatively, heat can be beneficial sometimes. For non-acute overuse injuries it tends to be a bit better a week or two out as your body has had some time to heal. If ice is leaving you stiff and not helping much, you may want to try heat instead.

Section 3
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3a. Light stretching.

Step 1: Light stretching for the agonist muscles connected to the tendon, and strengthening for the antagonistic muscles on the opposite side. For example, for medial epicondylitis at the elbow, you will want to stretch the forearm flexors, and do strengthening work for the forearm extensors. For patellar tendonitis, you want to stretch your quads, and strengthen your hamstrings.

Explanation: The reasoning behind this is twofold. The stretching is aimed at the agonist muscles because they are usually tight and short from overuse which may contribute to excessive strain on the tendon. Also, in many cases there are existing muscle imbalances if there is overuse on one side, so it is important to bring up the strength of the antagonistic muscles. Both of these tend to put more stress on the joints and supporting structures such as the tendons and ligaments, so loosening and correcting the imbalance should help get the tissue to function properly. Also, eccentric nature of stretching creates small microtears which will stimulate the body’s natural inflammatory process for healing.

3b. Light eccentric exercises

Step 1: Start with a very light weight, and work on the eccentric portion of the lift slowly. The eccentric movement should take 5-7 seconds.

Step 2: After it starts improving significantly you can add in concentric work. Be careful not to overdo it as it is very easy to reaggravate. For something like medial epicondylitis you should strengthen everything in the forearm. For example, rice bucket exercises.

• This protocol is mostly for chronic tendonosis cases that are not alleviated with solely rest.
• It is probably best to start with very light weights which is best with open chain exercises such as eccentric flexion wrist curls (medial epicondylitis) or eccentric leg extensions (patellar tendonitis). You can use the other arm/leg to help the other arm/leg up for the concentric phase. The reason for this is because it’s easy to microload with light dumbells or ankle weights or other small incremental weights.
• As you progress, you can move on to more closed chain exercises such as the eccentric of walking down stairs slowly or negative pullups. Close chain exercises tend to use a larger portion of bodyweight, so progressing to them too soon may be detrimental to the healing process if they are too difficult and aggravate the injury.
• Eccentric exercises that are anymore than slightly painful (preferably not painful) will probably be detrimental.

Explanation: Eccentric exercises are important because they help induce small amounts of microtearing which is part of the inflammatory process to promote healing. Additionally, in many cases, the musculature at that joint will become unable to properly execute the movement because of compensation for the pain. Thus, it is important especially if the muscles are shaking trying to eccentrically lower the weight to reeducate them to fire correctly.

Section 4
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4. Other methods

Cortisone may be a helpful option as it has shown improvement in conditions such as lateral epicondylitis. Repeated use of corticosteroids may lead to detrimental effects, so make sure if you go in and get a cortisone shot that you are also doing proper rehabilitation work in combination to get the best out of your healing.

Next, many of these other modalities are highly dependent on the person to whether they will help or not. If you have exhausted the options above (as well as physical therapy) then it may be a good idea to try some of the moadlities below in conjunction with the above protocols if you want to avoid surgery.

Joint/tendon/cartilage health supplements:Basically, there’s a lot of stuff that works but your mileage may vary depending on the person. Glucosamine & chondrotin sulfate (together 3:2 ratio), Methylsulfonylmethane (MSM), cissus, S-adenosylmethionine (SAMe), shark fin, etc. are all very good. Have also heard good things about Universal’s Animal Flex. Fish oil (which I will talk about later) is very good too.

Other modalities: Low level laser therapy, platelet rich plasma (PRP), prolotherapy, ultrasound, electric stimulation, autologous blood injection, dry needling, etc.

I’ve seen some good testimonials with the LLLT, PRP, prolotherapy because they’re supposed to help with natural inflammatory healing process, so I would recommend checking out those options first.

Similarly, surgery is the last ditch option because of the potential for infections and the often sub-par ability of humans to do what the body should naturally do itself.

Section 5
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5. NSAIDs/anti-inflammatories/pain relievers.

This is my new stance on this subject, which can be found in the new foot article as well.

NSAIDs while great for pain relief often help slow the healing rates of issues that you are trying to fix with rehab. For example, typical NSAIDs prescribed for pain and inflammation are over the counter such as aspirin and ibuprofen. Things you may typically get with a prescription are stronger such as naproxen.

Image from altair.chonnam.ac.kr

The mechanism of typical NSAIDs is to inhibit the cyclooxygenase pathway of inflammation as seen above (aspirin, indomethacin). This is great because it eliminates the pain by inhibiting the PGE substrates that aggravate the delta and C sensory fibers within the area like we talked about before. However, this is bad because it also inhibits the prostacylins and HHTs which are responsible for drawing in white blood cells and platlets that help clean up the damaged tissues, and release growth factors to move on to the more proliferative phase of healing. Here’s a few studies showing this.

Now, I’m sure we tend to all think of Tylenol/Acetominophen the same as the other NSAIDs, but it is in fact actually not and anti-inflammatory agent. Thus, if you’re having pain with this, it would be recommended to take this over any of the NSAIDs because of healing rates.

This also applies in reverse though. If you suffer a traumatic injury to the ankle such as a sprain and it’s inflammed and swelling up then avoid acetominophen in this case. It’s not going to help with what we need which is the anti-inflammatory factors. We would want to do the RICE protocol, NSAIDs, massage, mobility work, etc. in these cases.

I would try to avoid using NSAIDs for anything related to pain where tissues need to heal. The cyclooxygenase pathway is a critical step of that inflammatory phase that is needed for any sort of tissue regeneration whether it be muscle, tendons, ligaments, bones, etc. If it hurts bad then use different anti-pain medications like tylenol. It’s only when the inflammation gets so out of control such as with lots of swelling or fever where NSAIDs start to become more useful.

Warmness of the skin area is a good indicator of acceptable levels of inflammation (as prostagladins of the cyclooxygenase are fever inducing), but when there starts to be a lot of redness and swelling symptoms it may be time to help cut down on excessive inflammation with NSAIDs. For example, a couple days after workout the muscles are usually warmer because of the inflammation and healing process that is occur; it is unlikely unless there is severe DOMS or rhabdomyolysis that any NSAIDs may be needed for this.

Fish oil is also a good anti-inflammatory if needed, and of course eating right is going to help the most.

These are things are probably not told to you by your doctor or any other healthcare professional (heck, I didn’t even know about NSAIDs vs tylenol until I was taught that in class a few weeks ago). Keep this type of stuff in mind.

Integration with regular workouts is the same. Do your workouts, then the structure suggested above. If the workouts require use of the injured limb and does not aggravate it, then make sure the tissue is sufficiently warmed up before doing anything.

Proper structuring of the modalities listed above is important. Here’s the combination of things that I’ve found work the best.

For massage to the tendon itself:

• Light eccentric exercise (1-2 exercises, 1-2 sets of 15-20 reps)
• Self massage (5-15 minutes)
• Ice if it helps (10-15 minutes)

So for example with something like medial epicondylitis I would do:
1. Negative wrist curls
2. Massage to the wrist flexors and tendons
3. Ice if it helps.

For the muscles:

• Strengthening of the antagonist muscles of the tendon (1-2 exercises, 1-2 sets of 15-20 reps)
• Heat to the muscles to the affected tendon (10-15 minutes)
• Massage to those muscles (10-15 minutes)
• Light stretching focusing on improving range of motion without pain (5-10 minutes)

So for example with something like medial epicondylitis I would do:
1. Extensor wrist curls
2. Heat to the wrist flexors
3. Massage to the wrist flexors
4. Stretching of the flexors with wrist hyperextension

Remember, having an injury or something you need to add in prehabilitative work doesn’t mean that you should rest everything and neglect other training. If you have medial epicondylitis (elbow tendonitis) for example you can still do legs and core work as well as do other skill work for your sport and corrective nature things such as flexibility/mobility.

One of the big things with tendonitis at “stability” joints such as the elbows is that there tends to be a loss of mobility in the wrists and shoulders thus putting more stress on the elbows. The same thing occurs with tendonitis at the knees and losses of mobility at the ankles and hips. Thus, if you have tendonitis at the elbows or knees you should work on improving the flexibility and mobility of the two joints surrounding it.

Chronic tendonitis

Here’s a general rule to distinguish chronic tendonosis from tendonitis:

1. If total rest for 1-2 weeks does not improve pain levels, and
2. If the tendon is stiff and achy after periods of inactivity, or
3. You tried to work through the tendon pain for a period of about 3-4 weeks or more

All of these types of symptoms can indicate that the condition has progressed from tendonitis to tendonosis so be wary of what you were doing.

As we discussed a bit before chronic tendonitis (tendonosis in reality) tends to persist even with rest. With this in mind we need to make alterations to rehabilitative processes.

Since there is no inflammation present in chronic tendonosis we need to create some. Thus, eccentric exercise becomes the most important part of our rehab routine. In addition, ice tends to not help as much for chronic cases; thus, we want to use heat instead.

In tendonosis there is chronic degeneration of the tendon. Thus, we don’t want to massage the tendon itself so much (you can but it needs to be lightly), but we want to focus moreso on releasing the tension on the tendon by hitting trigger points or tight areas in the surrounding musculature, especially the musculature of the affected tendon. ART, myofascial or cross friction techniques work well for this.

Additionally, mobility to get blood flowing and any fairly non-painful movement is good.

Thus, a rehab program for a chronic case would look more like this:

2-3x a week, once per day

• eccentric exercise with the affected muscle/tendon complex 1-3 sets of 20-30 reps

5-6x a week, 1-3 times per day

• 15 minutes heat to both the muscle and tendon
• 5-15 minutes massage or specific soft tissue work to muscle to loosen it up (NOT the tendon)
• Light mobility work focusing on pain free movement
• Another 5-10 minutes of heat to the muscle and tendon if you have time

Ice can also be substituted in if it helps more than the heat, but like I said heat tends to be better for those chronic cases that aren't healing with rest.

As the condition improves, we want to start to work slowly from the isolationalist high repetition exercises into lighter compound movements. From there, you can slowly work back into heavy exercise. The general rule for how fast to go with a chronic case is to take a week for each month you've had that problem. So if you've had this problem for longer than a year expect that it may take upwards of 10-12 weeks to completely rehabilitate yourself back into the heavy weights or high volume that you were used to.

fish oil specifics

Lastly, regarding fish oil – Here’s a list compiled by Jae on one of the sites I visit for cost comparison. Unfortunately, Kirkland brand recently changed their products some so I don’t know if they can be trusted or not.

This is the one that I have been using; however the price recently went up $3. (“LOW052″ coupon at checkout will get you $5 off plus save me some money on my purchases if you want to go that route). Comes out to be around ~9.5 cents per 1g EPA+DHA if you want to try it.

This is a decent combo of glucosamine, chondroitin and MSM.

Thanks for reading. Hope this helps you.

Disclaimer: Any information contained herein is not professional medical or physical therapy advice. Always consult your doctor or physical therapist before using such information. For more details see our full site terms and conditions.