While continually looking for ways to improve my patient’s response to care, I have learned to look for things that stand in the way of improvement. It can be a long list that includes past trauma, lifestyle choices, diet, medications, genetics, attitudes, laziness, and the list goes on.
Experience is an excellent teacher, and as our practices evolve over time, we benefit from the sheer repetition of thousands of patient encounters. Those experiences show us patterns, and gradually, things become more predictable.
When I began my practice, my limited experience often led to frustration when a patient didn’t improve quickly or relapsed over a period. This contrasted with the many patients who responded quickly and seemed to get along without complications. I often wondered what I was doing wrong. As time passed, I realized that I needed to develop some additional skills, and my patients needed to be more accountable for their own results.
Hippocrates is credited with saying, “The patient must combat the disease along with the physician.” Results are not guaranteed; they are earned by patients willing to work alongside the doctor. I found that applied to my patients, but I had to develop some tools to help them.
My early years of patient care consisted of instrument adjusting, electrical muscle stimulation, and moist heat for tight and sore muscles. I quickly added custom flexible orthotics that supported all three arches of the foot to my protocols and saw even better results. As I learned more about improving posture, I started having more “complications” to care for.
Patients occasionally complained that they developed additional symptoms that hadn’t previously bothered them. The common denominator of these complaints seemed to be soft tissue issues. I wasn’t creating soft tissue problems; I was revealing them by helping the patient move through greater ranges of motion. I had to learn how to help my patients adapt to this new level of function.
As our brain and functional neurology knowledge has expanded over the past several decades, we have developed skills and methods to utilize our patients’ neurological capabilities. One of the most profound examples of these capabilities is in the recovery of stroke patients. Paralyzed limbs, facial paralysis, and loss of speech can all be restored because of the neuroplastic nature of the brain and nervous system.
Neuroplasticity is the principle that says the brain can change. New neural networks can be developed, and that can change function. This principle allows us to help patients develop better, more efficient posture and functional movement. It helps a patient go from inefficient, painful gait patterns that stress knees, hips, pelvis, and spine to walking with a smooth, efficient gait and strong posture. It’s a fantastic transformation to witness, but sometimes, there are bumps in the road, and that’s where we need to consider the role of soft tissue structures.
Poor posture, gait, and movement disorders are essentially repetitive-use injuries in progress. We are familiar with the assembly-line worker who does the same movement day after day and develops carpal tunnel syndrome or tendonitis in the wrist or elbow. Traditional treatment is provided on the inflamed or strained tissue, and when it heals or feels better, the person can return to the activity.
“The pedal foundation is one of the most consistent sources of postural and movement-pattern dysfunction.”
In the typical chiropractic patient, repetitive use injuries manifest as low back pain, sacroiliac joint pain, neck pain, and hip, knee, ankle, shoulder, elbow, and wrist pain. Trigger points and/or myofascial dysfunction in the trapezius muscle, levator scapula, supraspinatus, infraspinatus, teres minor, erector spinae, iliocostalis, iliotibial band, quadriceps, tibialis anterior, gastrocnemius, and soleus are also present.
Using a digital postural assessment app to quantify posture is a good start to identifying the basic pattern that the patient has developed. Simple range of motion assessments, both active and passive, and a functional squat test will quickly show asymmetrical movement limitations.
Since the human body is immensely complex, it is sometimes challenging to identify which tissue is the culprit. Considering that the neuroplastic nature of the body creates posture and movement patterns based on repetition, some patterns and soft tissue dysfunction have been around for a long time and are the result of old injuries.
Those injuries resulted in the recruitment of neighboring muscle groups while the injured tissue healed. The result was loss of fine motor control, which led to aberrant gait and movement patterns. Those patterns can persist after the injury is healed and the pain has resolved, creating a variety of extremity and spinal joint stress.
The pedal foundation is one of the most consistent sources of postural and movement-pattern dysfunction. Our feet become our interface with the earth somewhere around age one. They feed information to our cerebral cortex, where motor responses are generated and sent back to the body to keep us upright and able to ambulate to seek food, shelter, and community.
This proprioceptive feedback does a masterful job of adapting to changes in our enviromnent and actual physical differences or asymmetries in the feet. Custom three-arch orthotics, adjusting, soft tissue work, and posture-specific therapeutic exercises have been a successful combination for creating new efficient movement patterns.
Identifying the quality of the foundation is key to determining if the feet are a contributing source to joint and soft tissue dysfunction. In about a minute, 3D laser imaging of the feet will tell you if the feet have been feeding the brain clean, efficient proprioceptive input. If one foot pronates more than the other one, which can be measured with a navicular drop test, a cascade of biomechanical distortions begins to work its way up the kinetic chain, creating rotational changes in the ankles, knees, hips, pelvis, and spine.
Those distortions generate tension in the myofascial system, which can cause soft tissue pain and functional disorders. This sets the stage for more significant injuries, including sprains, strains, pulled muscles, tendonitis, and tendinopathy. Then Wolfe’s law of bone modeling and Davis’s law of soft tissue modeling kick in, and you have the ingredients for bone spurs and joint degeneration.
Addressing the myofascial system in practice can be a little daunting because chiropractors are busy adjusting patients and usually have limited time with them. However, I have found that it isn’t prohibitive from a time perspective, and it isn’t a procedure that is needed every visit. Best of all, the results can be felt immediately.
Instrument-assisted soft tissue mobilization (IASTM) is a popular method for addressing myofascial restrictions. Numerous devices are available, from handheld scraping tools to mechanical percussive tools with myofascial attachments and functional taping systems.
I prefer the mechanical advantage of a percussive tool purely for the time it saves me. The textbook Anatomy Trains is a great resource that explains the superficial myofascial system and how to address it clinically.
Older injuries from muscle strains that created scar tissue, myofascial dysfunction, and trigger points can also be addressed with low-tech mechanical devices. Compressing and lengthening the tissue with roller devices for muscle management improves the muscle tissue’s compliance and immediately enhances flexibility.
Low-level or cold laser therapy has also successfully addressed some of these soft tissue problems. Once the muscle and myofascial have regained their compliance and ability to contract and relax, the joint function begins to improve, and the joint physiology returns to a healthier state.
The aging process is an example of entropy, a gradual decline in posture, balance, mobility, endurance, and the ability to repair and recover. When patients present with the typical pain syndromes that drive them into our office, I try to connect the condition they present with to the process of decline they may be experiencing.
One of the simple messages I relay to patients is that “tight muscles (and fascia) hold bones tightly.” Our ability to detect and treat these nuances improves our patients’ chances of successfully resolving their condition. It increases their chances of aging with better posture, balance, mobility, endurance, and quality of life.
Dr. Brian Jensen is a graduate of Palmer Chiropractic College and owner of Cave Spring Chiropractic in Roanoke, Virginia. He has been practicing for over 35 years. As a Foot Levelers Speakers Bureau member, he travels the country sharing his knowledge and insights. See continuing education seminars with Dr. Jensen and other Foot Levelers Speakers at footlevelers.com/more.
