Cuboid Syndrome : pain on the outside part of the foot

What is cuboid syndrome?

Symptoms: Pain on the lateral (outside) part of the foot.  There is often no associated accident or injury to this area, though sometimes twisting one's ankle can exacerbate it.  Often it develops slowly and for no apparent reason.  It will usually feel worse when standing on the affected foot. Walking is also usually painful.  Wearing shoes that are tight around the forefoot can become unpleasant. 

Cause: It is theorized that the syndrome occurs when the foot pronates excessively, causing a misalignment of the cuboid bone.  Personal experience suggests that this is partly true. My most observation is that most commonly the affected side is the foot that is too far midline.  People rarely stand perfectly symmetrical.  Usually one foot is more medial. Or to say it another way, is that the foot is more underneath you. This usually results in excessive pronation, as well as more forces being absorbed by the affected foot in standing, walking and running.  Athletic activity increases one's chances of  getting cuboid syndrome. 

Diagnosis: Examination may reveal some swelling.  Cuboid pain and tenderness to palpation is typical. X-rays will often show nothing, as alignment is not always discernable.  Absence of fracture is a good indication. Whereas misalignment is the primary pain mechanism, radiological imaging is not often necessary for diagnosis. Considering the cost of soft tissue imaging techniques like MRI and CT scans, it makes more sense to attempt therapy before even considering these expensive options. 

Treatment: manual manipulation is extremely effective when performed by a skilled professional. Multiple treatments is usually necessary.  Total number of treatments is dependent upon how long the patient has had cuboid syndrome. 

Dr. Schafer's note:  As I previously stated, cuboid syndrome is usually due to asymmetrical stance and gait. When one foot is more medial (midline), not only is the foot misaligned, but so is the knee, hip, pelvis and spine.  Long term success depends on re-alignment of the whole system.  Chiropractic manual adjustments techniques are extremely helpful, as well as core exercises. Yes-core exercises are better than foot exercises for long term success. 

Does everyone need a chiropractor?

While on a recent vacation to Ireland, we toured the Guinness factory in Dublin.  Near the end of the tour there was lots of old Guinness advertisements, and some artwork from local artists. I found one piece of art both striking and thought provoking: "A woman needs a man like a fish needs a bicycle".  Apparently it was a phrase found in graffiti on the streets of Dublin, and a local artist liked it so much he made it into this display.  The phrase is also used in a song by the (Irish) band U2 in the song "Tryin' to throw your arms around the world". I am sure there a some women who would agree with this, and some who would disagree. But I think the main point is that for some fish, uhm, I mean women, this is certainly true. There is no universal truth one way or the other. 

This made me wonder.  Does everyone need a chiropractor? Is it a universal truth that everyone needs to be adjusted on a scheduled basis all of the time?  I know there are plenty of chiropractors that will respond with an emphatic "yes!" But to say that (as a universal truth) would ignore the millions of people who have never been to a chiropractor, and seem to be in good health regardless. This does NOT MEAN NO ONE needs a chiropractor.  I have seen too many patients who were treated poorly by the medical system, or have tried every physical therapy exercise known to man, or have ignored the pain for years with opioids which they can no longer take.  And without regularly scheduled adjustments, their pain would quickly overwhelm them to the point of debilitation.  Some of these patients have had significant trauma for which there is no surgical "fix".  And some of them just have a genetic predisposition for musculoskeletal pain. Many of them have jobs which keep them sedentary, and this alone is the biggest contributing factor for their painful syndromes. 

 If you have a chiropractor that keeps you out of pain, by all means, continue treatment.  If you only need to be adjusted by a chiropractor periodically, that's great! Get treated "as needed".  When a new patient walks into my clinic, my goal is to figure out why they are hurting, not to figure out how to make them a patient for life.  I am not in the business of trying to convince a fish that they need to be riding a bike. But if you ask me this fish looks she wants to. 

  

How I Cured My Plantar Fasciitis Without Doing Any Foot Exercises.

 

About 10 years ago I completed my first marathon. It was a great experience. After the race,I took some time off from training, as many people do.  A few weeks later, I felt it was time to do something again.  I did not need to do marathon distances, but I figured my body could handle 5-10 miles at a time.  After doing this distance 2-3 times a week, I noticed some pain in my right arch and heel.  This made no sense to me.  It was apparently plantar fasciitis. But...why now?

The first thing to check was my shoes.  I had the same brand and model as I did when I was in training, but new.  I had purchased another pair of the exact same shoes. So that was not the problem.

Then one day I just happened to be at a "fun run" event at a local running shoe store.  This was a good opportunity to see video of my running form. They had the high speed video camera set up right by the treadmill.  I suspected it would reveal how my foot was striking the ground the wrong way. Maybe the foot was pronating too much.  Or maybe it was turned out, or turned in too much.  

So I recorded my stride, and what I saw was completely unexpected.    Every step with the right foot was on the far right edge of the tread. Every step with the left foot was directly in the middle of the tread.  Now I know that when I was on the treadmill, I was centering myself in the middle.  I know that my head and chest were centered in relationship to the console.  And yet the video showed something different. 

Initially this made no sense. But then I realized that it wasn't HOW my foot was striking the tread, it was WHERE. The far lateral position of my foot relative to my torso was causing the plantar fasciitis. The foot needing to create movement from a less than optimal position, and so it had to work much harder to achieve it.

I then surmised that the time I had taken off from all exercise had weakened my core muscles.  While it was smart to take some time away from running, I should have continued with some sort of core training.  Because I did not, the core was too weak to keep my hips and pelvis level. When my pelvis tilted, the left foot went midline and the right foot went too far laterally. 

So I did what I should have done the first time.  As I took time off from running, I worked on strengthening my core.  And I was treated by another chiropractor to help realign my pelvis. A few weeks later, I again started running again.  No plantar fasciitis.  

So to reiterate:

 I DID NOT DO ANY FOOT EXERCISES TO CORRECT MY PLANTAR FASCIITIS! 

The best doctors and therapists know that where the pain is and where the problem is are often two different areas.  I can only imagine that if someone like me had gone to a foot and ankle specialist or podiatrist, they would have never found the true cause of my condition.  If the clinician never looks past the area of pain, it is impossible to see the big picture.  I am sure some foot and ankle stretches would have helped, but I am also certain  that I would have never recovered so quickly without looking to the core. 

If you are interested in some examples of core exercises click here for a link to my Youtube page.  Everyone needs to work their core muscles. Call us for an appointment if you are interested in starting a new core routine. (616) 301-3000.

Heavy Breathing for Injury Prevention?

Most people don’t get hurt from a lack of core strength. They do get hurt from a lack of core coordination.

What is core coordination, you ask? 

Core coordination is when muscles fire in the right patterns with the right timing so as to stabilize the torso and spine. This is because MUSCLES NEVER WORK IN ISOLATION.  Muscles always work together in integrated systems. When systems fail, the dysfunction creates pain through overuse of certain muscles. But these patterns also need to coordinate with your breathing.

Why, you ask?

Well, breathing is kinda necessary.  And just about ALL of the core muscles ARE ALSO muscles involved with active breathing.  That is to say breathing when NOT at rest.  Look up "accessory muscles of respiration", and you will see what I mean.

According to Physiopedia, "The accessory expiratory muscles are the abdominal muscles: rectus abdominis, external oblique, internal oblique, and transversus abdominis."

So forcefully breathing out turns out to be a great way to activate all of the major core muscles.

Also, the accessory muscles to inspiration (aka inhalation) are:

sternocledomastoid, scalenes,  serratus anterior, pectoralis major and pectoralis minor, trapezius, latissimus dorsi, erector spinae, iliocostalis, quadratus lumborum, serratus posterior superior, serratus posterior inferior, levatores costarum, transversus thoracis, and subclavius.

So are all of these muscles "core"?

That really depends on your definition of core. Various sources will cite many different muscles as being part of the core.  There is much grey area here. My opinion is that a core muscle is any muscle that takes part in stabilizing the spine in one of the six major planes of motion. To be clear, there are two planes of motion for each of the planes seen here:

The case can be made that just about all of the accessory muscles of inspiration are also core muscles.

So how does one incorporate heavy breathing into their exercise routine?  The best way to do that is to exercise to exhaustion.  Not to the point of collapse, of course, but until you are "out of breath".  Just about any cardio exercise will do.  Any movement that elevates your breath rate and volume.

This would go a long way in explaining why distance runners seem to always benefit from a weekly "sprint" workout.  Core activation improves running efficiency and reduces injuries. But you don't have to be a runner to do this.  You could challenge yourself to do a "sprint" on the elliptical, or stationary bicycle, or rowing machine.  Doing this weekly is best.

Start with a mild warmup for 5-10 minutes.  Then go as fast as you can for 1 min.  Then recover and catch your breath. This may take 1-3 minutes.  Then repeat two more times.  You can start with 3 one minute "sprints" and work your way up to as many as you want.  Just keep in mind that if can do this for more than 8 sprints you are probably not going as fast as you can. Keeping up that intensity for many repetitions is just not possible.

Whereas this is certainly an intense workout, it does not take very long.  I recommend incorporating stretches to be done afterward.  The increased intensity may otherwise create soreness in muscles that you never knew you had.

Top 3 Exercises to Avoid at the Gym. Part 3: Preacher Curl

   There have been a few documented cases of biceps muscle rupture while doing the "preacher curl", but that is not the only reason I think it is a poor exercise. As a general rule, one should not "isolate" a specific muscle to develop it. In reality, muscles never work in isolation, so why train them that way? As someone who has been a regular at various gyms and health clubs for 30 years, I have seen one thing to be consistent. In every new gym I go to, there is always the one guy who sits at the preacher curl bench for way too long, doing way too many reps and sets. It has been no surprise to me to see that usually, this person has a scar on one or both shoulders. The scar is usually from a shoulder surgery. As a general rule, I know that getting accurate medical history from a guy in a gym is not likely, so I rarely ask questions about it. But it never surprised me. 

   The whole purpose of putting the arms on such a device is to "stabilize" the elbow joint. But in "stabilizing" the elbow joint, we can expect that the shoulder and back muscles, which usually aid in such stabilization under normal circumstances, will be inactive. This is the perfect example of someone whose main purpose of going to the gym is for visual appearance. Excessive emphasis on the muscles most commonly desired such as chest (pectoralis major), arms (biceps brachii) and stomach (abdominus rectus) is the hallmark of someone more interested in muscular development for the sake of muscular development.  They are not really interested in overall health, strength, or athletic capabilities. 

   Integrating all of these muscles together will help protect one from injury. Only without injury, and with muscular balance, can someone achieve optimal physical capabilities. Isolation for the sake of visual muscle appearance will eventually lead to injury. If you are looking for a replacement exercise, try literally any other biceps exercise, where the elbow is not stabilized on a pad, bench or your knee.

Top 3 Exercises to Avoid at the Gym. Part 2: Lateral Deltoid Raise

The lateral deltoid raise has been around since the beginning of weight training. Which is one of the reasons I don't recommend it. Weight training has its roots in bodybuilding and strongman circus shows. Some of the exercises that come from this era are focused on muscular development for the sake of muscular development. As such the premise is to "isolate" a specific muscle. In terms of function, however, it needs to be stated that MUSCLES NEVER WORK IN ISOLATION.

The above picture, taken from Fitnesstogether.com, shows the exercise performed to 90 degrees, as it is usually performed in the gym. If you are confused, think of this exercise relative to how your shoulder functions. The shoulder joint has the greatest range of motion of any joint in the human body. Given that most of our musculoskeletal aches and pains stem from a lack of movement and inactivity, wouldn't it make sense to use our joints to the greatest degree possible without strain? The rationale for stoppping at shoulder height is based on how much the deltoid muscle is being activated as the weight is lifted. Past 90 degrees, the deltoid muscle activation starts to derease and the trapezius muscle activation starts to increase. But as I stated earler, muscles never work in isolation in real life movements and activities. So why in the world would you train it to? And why not train the trapezius AND the deltoid with one exercise?

To be clear, I am recommending to go all the way up with this exercise, as seen in this photo taken from Muscle and Fitness website. I have no research to point to that suggests that this exercise performed to 90 degrees leads to shoulder injury. But I have seen numerous patients who have had shoulder problems, AND they are currently doing this exercise to 90 degrees, AND they don't want to stop wieght training. In every case, getting the patient to go to a full range of motion lateral raise, with lighter weights, has helped.

Top 3 exercises to avoid at the gym : Part 1

Are you heading back to the gym after a long layoff? You are in good company. It's time to turn our Covid bods into beach bods. Which makes this a good time to review Dr. Schafer's list of most common gym exercises to avoid. Let's dive right in. #1 Seated leg press

To be clear, I am not saying that everyone who goes near this machine will wreck their back permanently. But I have observed it to be a major factor in people who like to weight train, but have periodic problems with their back. It seems like a safe exercise because you are seated. But that is exactly what is wrong with it. This exercise tries to replicate a squatting motion without having the person stand. If you turn the image 45 degrees clockwise and imagine the person has her feet on the floor, you start to get the idea of the problem.

To be lifting any weight withe the spine is this position is less than ideal. This obviously does not resemble a squat. The person invariably rounds their low back in order to perform the lift. This changes the curvature of the lumbar spine to a more flexed position, which is commonly associated with intervertebral disc injury. Also, in this position, the low back muscles are stretched out. They remain in this position during the entire motion. Muscles are known to be stronger when they get shorter. To have them lengthened throughout this movement sets them up for fatigue and failure. Skip this one and do some dumbell deadlifts instead. Stay with lighter weights if you are concerned about straining your back. To be continued....