I recently filled out a written Q&A for Dr. Kelsey Armstrong, who is a Podiatrist in Raleigh, NC. Dr. Armstrong recently became exposed to some of my messages and asked me to expand on some things for his Website. What I just sent off to Dr. Amstrong is below.
1) Tell us a little about yourself and why you chose to become a physical therapist?
I think like many of us in our profession, I began as an athlete playing ice hockey and baseball through high school. I enjoyed weight training, and I found it very cool to be strong. I used typical young bodybuilding approaches and had success at that time. Going into college, I played baseball, but I knew that was done after college. To stay in sports, I eschewed being an orthopedic surgeon since even though I was very good at carrying or moving large objects, I wasn’t very good at putting them together. So I became set on being a Certified Athletic Trainer and go on to graduate school. My undergrad had the same Premed program for the ATC program, so that also gave me all the prereqs for physical therapy school. My advisor said I could still do everything I wanted to do as an ATC even if I went to PT school, and it would make me more marketable and have a good backup plan as well. So I graduated undergrad in ’96, got my ATC in ’97, MSPT in ’99, and DPT in January of 2010.
In the summer of ’98, I was working as a PT aide, and one of the referring physicians asked the owner of the PT office if they knew any ATCs interested in working with a minor league basketball team coming to the area. I got that job while still in PT school, and after graduating, the connections from that minor league job got me to the New Jersey Nets for the ’99-00 season. From 2000-03, I was a Head Athletic Trainer in the IBL and NBDL, which also included responsibilities of Strength Coach, Equipment Manager, and Travel Secretary. In ’03, I got back to the NBA with the Philadelphia 76ers as Game Day Athletic Trainer and Rehab Consultant. At that point, the 76ers did not have a Strength Coach, so given my build I think the players found some confidence lifting with my guidance. That earned me Head Strength Coach and Assistant Athletic Trainer for the 76ers through 2006. After not getting renewed in Philadelphia, I moved to my home area in NJ where I became Director of Sports Performance and Physical Therapy @ CentraState Sports Performance, which is a hospital-owned sports training center where we trained and rehabbed folks as PTs, Personal Trainers, and Strength & Conditioning Coaches all as one entity. Currently, my job title is Lead Physical Therapist for Marine Corps Special Operations Command (MARSOC). At Camp Lejeune, NC, I am responsible for contributing and managing programming for both rehab and general physical preparedness for the PERRES program, which is MARSOC’s Performance and Resiliency Program.
2)Your knowledge of the human body goes beyond any physical therapist that I know. What drives you to this level of understanding?
I’m not sure there is a becoming or humble way to answer this question. Learning, integrating, and clinically growing all will lead me to both the status and quality I want to achieve and more importantly, a level of provision and service to the folks that trust me with their body. I don’t want to be good at what I do. I don’t even want to be the best I can be. I strive to be the best to ever live. While that is likely an unattainable goal, if that is indeed the goal, then the best I can be and good are automatic. I just want to be the equivalent of every great athlete and historical figure put together.
I guess I blame and credit my parents and coaches and mentors that have held my hand for the past 34 some years. And also the confidence that the folks that trust me with training and education have had a huge impact on my continued development.
3) Tell how devastating to the body is limited motion of the big toe joint (hallux limitus)? And what is your usual protocol for treatment?
To begin the explanation globally, the body’s appropriate mobility is set up to allow stability to drive propulsion. Propulsion is the ultimate goal in any of its forms, such as locomotion, pushing, pulling, squatting, stepping, etc. Like most primitive movement patterns, the mission is thoroughly ingrained in our neural programs of the CNS. So regardless of the quality of our mobility and stability, the CNS will usually succeed in driving propulsion or locomotion in this case. Win if you can. Lose if you must. But always cheat. That is the CNS’s way.
So like with many other ingrained movements patterns, the brain will find a way, and it doesn’t always care if the pattern is mechanically efficient. It only cares if it is neurologically efficient. Neurological efficiency equates to motor learning and associated feedback. If there is success in the ultimate goal, going back to this case of forward locomotion, the brain registers efficiency, quality, and begins to cement that pattern in the brain.
So the first thing to consider with a loss of big toe mobility, if it is not dominant enough to 1) cause enough nociception for failure, or 2) limit a compensatory pattern for success, the dysfunctional pattern will begin to revise and/or cement the motor pattern. And as the mobility loss causes an inefficient pattern, this pattern alters the motor program that can be very challenging to change even when/if mobility is restored. This is more principle-based than specific to the big toe, but the key is to acknowledge that regardless of mobility or stability qualities, an altered motor program will continue unchanged until motor learning is reinstalled with new success and feedback.
Any time a joint system does not explore its full range of motion on some level of regularity, and yes, the joint surfaces will degenerate. The full exploration of as much of the joint surfaces as possible is the “swishing” mechanism that flushes synovial fluid through the joint. Synovial fluid is the motor oil for the joints, and the value of joint mobility AND using it to some degree through appropriate natural and free movement (i.e. yoga) is joint health. A loss of mobility in the big toe, from a joint or soft tissue restriction, will accelerate DJD at this local level.
Next at the regional level, the minimization of plantarflexion can cascade into a number of reactions. Some things don’t have to do as much of what they should do, and others may have to do too much. Regional can be defined in a number of different ways, but in considering regional, we will call that the lower quarter continuing to the hip. There is a litany of issues that can evolve all based on the individuals’ specific stiffness through the chain. Where the final stress is funneled or funneled away from is very specific to the individual. It can be predicted with screening, but not without some individual analysis.
The mid-foot will not have the proprioception to stabilize which can lead to plantar fasciitis or medial arch stress. Deep foot musculature may become long and tight with a lack of reactive stabilization in the mid foot.
Ankle mobility into dorsiflexion may become limited as the stride will reflexively shorten. As a part of an altered motor pattern, the stride length will shorten in an effort to limit hip extension on the stance side. This creates what the CNS perceives as neurological efficiency as now the big toe will not have to extend as much to locomote. With less hip extension, less dorsiflexion is required to establish foot flat. This scenario welcomes the lunacy of wearing heel lifts, Nike Shox, and rocker bottom shoes to accommodate for the biomechanical scenario.
A loss of hip extension mobility in this chain can be straight extension, or it can be expressed through a toe out posture from hip external rotation, which in turn can lead to a loss of mid-foot stability that we mentioned previously.
The potential for anterior knee pain can also result. The sagittal restriction from the toe can translate into further sagittal movement at the knee. If this is accompanied with a dorsiflexion loss, the process of stabilizing the lower quarter can fall onto the bony stability between the femoral heads and the retro-patella. The body again will find a way to gain forward propulsion. The toe can be the initiator, or it can be the reaction, but it all leads to this loss of mobility or stability at the segments that should allow these expressions.
I have discussed before how something like big toe dysfunction can correlate to distant dysfunction of the upper quarter or cervical spine as well. Aside from the specific biomechanics that are addressed in the lower quarter, looking at mobility loss more globally will always relate to an anterior weight shift. It is such as struggle for me to discuss with folks that suggest biomechanics and posture don’t matter. Any loss of mobility, be it from tone, shortening, or joint restriction, will result in an anterior weight shift. Repetitive function with an anterior weight shift yields facilitation and inhibition in a very predictable pattern. Where the foci results is not as predictable as I mentioned before, but in this case, propulsion without big toe extension can result in a resting or compensated upper-crossed syndrome. It can happen anywhere along these same lines.
Limitations that do not register as pain or go unnoticed as dysfunction can also expose limitations in power expressions such as vertical jump as and sprint speed as well.
4) I believe that your view of flat feet is quite on the mark. Please explain your view about flexible flat feet and how you would treat it?
Flexible flat feet get trained. That’s all there is to it. You find the weak link from a corrective standpoint, and you train the system.
If posting or foot-based compensations are required for end-stage function, then by all means, please use them to get the job done. We should not be holding people out of games if a heel lift allows them to play full speed. Sometimes we can even forego training in-season and treat symptoms and then regroup when we have a more amenable schedule.
In the end, the foot is the reaction. If the foot is truly supple, and the Cyriax Evaluation yields nothing remarkable (assuming the assessment is not during a state of previous irritation), it can’t be the foot’s fault. But because the foot has such a pliability, it can compensate from what can be a litany of up the chain dysfunction. When stability is lost through the chain, the brilliant foot can find it through reacting with the floor and stealing its ultimate stability.
Find the corrective strategies that provide the most efficient proprioceptive environment to get the quality to appear. Keep in mind, this is primarily focusing on stability and/or motor control training. We identified that the foot was flexible, so there were no mobility issues. Also consider what looks mobile may not always be mobile. Consider the big toe, mid-foot, subtalar, talo-crural, and even the proximal and distal tib-fib joints. And always consider mobility through the chain before asking for stability.
Getting to 1- and 2-leg level changes to drive the foot is where the training path takes you: Squats, Split Squats, Step-ups, Deadlifts, Jumps, Lands.
5) Barefoot running is the hottest thing right now in the running community and podiatrists’ offices. Tell me what do you think about this “movement” and it proposed goal to reduce running injuries?
I think it is an excellent addition to a corrective or conditioning catalog. Unfortunately though, I am seeing this more in theory than in practice. Just because it is a good thing doesn’t mean it’s a good thing for everybody. If indeed it is deemed a good thing for you, it may just not be a good thing for you……yet.
People like to do. They like to add and complement. No one likes to be told to stop or told that there are things that they can’t do. So in terms of barefoot training, it has a positive attachment, so everybody tries it. But this is without screening or assessment when required. This is a major mistake. Barefoot training is a great tool, but it must be instituted with attention and progression.
When mobility and stability are proper, even the deconstructed sneakers have some level of stability. With a fantastically stable barefoot, there is brilliant proprioception sent up the chain creating fantastic reflexive stabilization elsewhere. Consider the homunculus of the brain, where we see the feet holding larger surface area of the motor cortex than other areas outside of the face and hands. When the foot does the right thing, lots of good things happen in the brain.
Training barefoot in itself may be the access point for proprioception to improve function. Or it may not, and I think this is the more likely senario. Not everybody should be wearing Vibrams just yet, and certainly nobody should be taking them off the shelf and going into big cleans and 10 mile runs.
6) In a similar-related question, what functional problems do you usually see in runners and what can they do about them?
Runners are typically prototypes for Stratified Syndrome, which is concurrent Upper and Lower Crossed Syndromes. These are Vladimir Janda terms as he used these postural presentations to categories movement disorders.
Tight hips and tight ankles dominate because long-distance runners (assuming this is who you mean by “runners”) engage in a plodding pattern of very short amplitude. This short amplitude isn’t the problem per se. The 15,000 steps in a “short run” is the problem in terms of minimal requirement of mobility, so the limited excursion locks in at a soft tissue level and a motor control level. The incredible repetition of running is the deadbolt to the key of the shortened pattern of running. But proper training against the evils of running does not need to be on a rep to rep basis. Training 2-3 times a week with corrective approaches and large amplitude conditioning will easily keep long distance runners away from problems.
Poorly executed or uncoached running can be considered a controlled fall where you let the body drop forward and catch it with the other leg reaching the ground. When the body senses the fall, there is both a biomechanic reaction to facilitate and inhibit muscles of the Upper and Lower Crossed, but we should also consider the Startle Response. What we overtly recognize as running may be recognized as a threat to the body. The brain thinks we are falling and further supports the CNS to go into protective mode, the Upper and Lower Crossed.
7) I am a big proponent of integrating collective knowledge of medical specialties to achieve long-lasting total health to the patient population. How can we realistically achieve this in this present healthcare system?
I think this issue starts and ends with like minds. People have to agree on a system of training and divide up the work. Obviously this also includes this “team” to all be comfortable with how the money is divided up from providing this service.
I think finding like minds is a challenge, but it is far more challenging to find that group of clinicians that can also agree to freely refer and consult and share clients and patients.
The healthcare customer is the most misinformed customer in the market. They are not ignorant or undereducated. I think they really do do their homework. They are just getting poor and subjective information in choosing their clinicians. A key to making it all happen is that when you get these folks into your system, you hit a home run every time, and allow their feedback to others to drive the goals of working with your team.
8. Tell us what exciting things you are presently working on right now?