Dr Stoxen:   Now, the objective findings for the orthopedic tests and radiographic findings I'm going to go over now.  I'd like to bring up Larry.  Larry could you come on up here, please.  And Larry is miked, because we're going to put Larry in some pain here.  Larry did I mention that to you, Larry?
Larry (patient) :    No.

Dr Stoxen:     Ok, come on down here, Larry.  Okay.  I have just met Larry.  He works here at the conference.  Okay, lay back there.  Larry is a big guy.  What sport do you play?
Larry (patient) :    football

Dr Stoxen:    First of all, I'm going to do my consultation.  Larry, do you feel tired?

Larry (patient) :    Yes

Dr Stoxen:     Do you have any lower back pain?

Larry (patient) :    lower back

Dr Stoxen:    The principal pain that you have today is what?

Larry (patient) :    Just lower back pain.

Dr Stoxen:     Lower back pain.  Okay.  And how long have you had it?

Larry (patient) :    Years

Dr Stoxen:     For years.  Have you lifted something that caused the lower back pain?

Larry (patient) :    weights

Dr Stoxen:     Weights, but not recently, right?

Larry (patient) :    yes.

Dr Stoxen:    Just there.  Larry do youhave any pain in your knees?

Larry (patient) :    sometimes

Dr Stoxen:     Okay, sometimes. And are you having it mostly in the morning?

Larry (patient) :    yes

Dr Stoxen:    Now how ab out your ankles? 

Larry (patient) :    yes

Dr Stoxen:     What about your ankles?

Larry (patient) :    they hurt.

Dr Stoxen:     They hurt. And also your feet.

Larry (patient) :    ah, yes.

Dr Stoxen:     Your feet hurt.  Do you have any cramping?

Larry (patient) :    on the bottoms.

Dr Stoxen:     How perfect can you get, right?  Okay, now Larry, when you had this cramping, when you had these pains in your ankles, did you have an ankle sprain recently? 

Larry (patient) :    No.

Dr Stoxen:     Did you have a knee sprain?

Larry (patient) :    No

Dr Stoxen:     No type of trauma.  How long have you had the ankle problems?

Larry (patient) :    uh, since highschool.

Dr Stoxen:     Since high school. How old are you now?

Larry (patient) :    37

Dr Stoxen:     So what, 19 years?

Larry (patient) :    18 years

Dr Stoxen:     18-19 years.  That's a long time. Now first of all what we're going to do here is we're going to evaluate Larry.  Now I'm not going to evaluate all of his muscles, just the ones that are indicators that are the ones that are going to find positive on the patient.  So I'm going to lift his leg up here.  Larry, I want you to hold this up real strong for me.

Larry (patient) :    ahh

Dr Stoxen:     Okay, he's got big muscles.  He's a very strong guy.  He has big legs.  Okay, hold that tight for me.

Dr Stoxen:     Okay, he's got big muscles.  He's a very strong guy.  He has big legs.  Okay, hold that tight for me.

Dr Stoxen:     Okay, good. Okay, now what I'm going to dos is I'm going to check his balance muscles.  Those are the gluteus metius.  Good.  now I'm going ot hold his leg lateral to his other leg and not lifting it up and he's not allowed to bring it this way and I'll hold it straight lateral.  He's not allowed to rotate his foot, because if he does, then he's incorporating the quadriceps muscles.  what we're testing is the lateral compartment of his hip.  Okay, push up.  Go.  Okay, now push to the sides again.  Okay.  He's pushing as hard as he can.  Larry, push as hard as you can.  Okay.  I used two fingers pressure on his lateral hip and he has no strength in his hip.  And I know for a fact that he has no    in the abductor compartment of his hip.  Push out as hard as you can.  Okay.  Absolutely no strength/ alright, you don't feel any good strength, right?

Larry (patient) :    Right

Dr Stoxen:     Now the next thing I'm going to do, doctors, is I'm going to check the rest of the musculature.  Sometimes, the patient is really strong, and they're going to be able to fool me, but not if I'm going to use my palpatory skills.  Sometimes the patient will be able to overcome my power just because they have 38” thighs and they can squat about 800 or 900 p[ounds.  Now what I'm going to dohere as just for a tester for Larry.  I pretty much have Larry's situation figured outhere.  I'm going to press right here.  Larry do you feel any pain there? 

Larry (patient) :    slight.

Dr Stoxen:     Okay.  How about right there?

Larry (patient) :    a little bit more.             

Dr Stoxen:     Actually I'm pressing on the center of the quadricepabout 1/3 of the way down.  Center of the quadricep.  Any pain there?

Larry (patient) :    slight.

Dr Stoxen:     Slight. How about right there?

Larry (patient) :    a lot more.

Dr Stoxen:     A lot more.  I'm working my way laterally toward the tensor fascia lata.  Okay, how about right there?

Larry (patient) :    it hurts.

Dr Stoxen:     A lot.  Okay. Here's the sign you're going to get.  First smoke comes out of his ears, his eyes bug out, that's not hyperthyroidism.  It's a lot of pain.  He's in a lot of pain.  So it's really not difficult for you to figure out that he has this spastic activity in the thigh.  Right there?

Larry (patient) :    oh yes.

Dr Stoxen:     Right there?

Larry (patient) :    yes, yes, yes.

Dr Stoxen:     Now, here's what's happening.  I hate to tell you this, Larry, but it's going to get worse as we go down.

Larry (patient) :    laughter

Dr Stoxen:     Okay. Pain Right there?

Larry (patient) :    yes

Dr Stoxen:     Okay. I know exactly what's going on at this point and I'm going to work my way all the way down to the knee.  Okay.  How about right there?

Larry (patient) :    not as much

Dr Stoxen:     Okay, how about right there?

Larry (patient) :    yes

Dr Stoxen:     Okay.  Pain right there?

Larry (patient) :    yes

Dr Stoxen:     And then all the way down to the knee.  Okay, the next thing I'm going to do is I'm going to check his knees.  Okay, lift up, relax.  I'm going to put my hand on the patellar area and bend it, move back and forth here. And let the troch…. I'm hearing all kinds of cracking in his knee.  Which means he is susceptible to chondromalacia patellar pain as well as the fact that since he has no lateral stability or strength here, he's more susceptible to knee injuries.  Here's what you're going to find.  The patient doesn't understand what's wrong with him.  He has low back pain, and thinks maybe he's getting it from lifting.  It's not happening.  It's happening from all the way down to the foot.  Now, the patient is going to run down the field, he's going to cut to the left and then all of a sudden his knee is going to go out on him.  What he's going to tell you is that he stepped the wrong way.  And that's really not what happened.  He just did not have the strength to make that cut in the lateral compartment of his thigh.  But nobody picked up on it.  See, so he was left out there.  Now we're taking his shoe off here

Larry (patient) :    ugh (pain)

Dr Stoxen:     Okay, now, what I'm going to do is I'm going to take my hands and put them like this fashion because I'm going to reach around the back of his calf.  Any pain.

Larry (patient) :    ugh (pain) – Yes

Dr Stoxen:     And what I'm feeling for is not the gasroc or the solis, I'm looking for is a different kind of muscles, and I call them the pronator supinator cuff. Why do I call them the pronator supinator cuff is you understand the rotator cuff holds the shoulder in the socket so that the primary movers can really push the weight.  That's exactly what the pronator supinator cuff does.  If you could understand the principle of the engineering effect of the suspension bridge, which is like the Golden Gate Bridge, you'll understand this concept.  The posts are like his tibial anfibula, the suspension bridge.  The wires are like the muscles of the pronator supinator cuff. 

What they're going to do is they're going to reach down and they're going to loop around the foot and they'regoing to grab a hold through their insertion different boneso f the foot.   As a result of that, when they loop around through the arch, they're actually used as a supportive mechanism for the arch.  When the patient has poorly constructed shoes, as Larry has here, these are very weak counters.  When I'm talking to the patient, about choosing foot wear, I ask them to choose a footwear like they pick out that some fruit.  We all know how to pick out fruit.  So it's not that difficult.  What you're going to do, is you're going to go in and you're going to squeeze the shoe like that to see if it's strong.  You'll want a leather shoe. 

I do not recommend that my young athletes wear gym shoes all day long – Absolutely not.  The first place you start when you go back home to your practices is with yourselves, and then your children.  You have to look at their footwear, you know why? Because they emulate all these movie stars and these gangster rap singers and the surfer guys.  They're wearing these shoes.  The first thing that they're doing is they're not even tying them.  And they pick the shoes with the real thick material.  This real thick material is really, I mean it's analgous to wearing a sleeping bag around your body all day long.  It's very hot.  So, as a result, they want to open them up, get some air in them.  And you know that when the air gets inside there, it acts as insulation, so the foot actually gets hotter and that's not what we're looking for. 

When we're picking out a shoe, we want a shoe that's a little bit thinner and a little bit stronger material, like real thick leather, maybe 3 ply.  This pair of shoes that I have right here are stiff leather.  I've had them for 2 years. I've had them resoled because they're so solid and I wear them in my office.  And doctors, if you're in your office and you're not wearing a solid shoe, you're going to wonder why you're tired.  I'm tellilng you, that's why you are tired.  When I go back here and check Larry's calf, there is some pain here, right?

Larry (patient) :    yes

Dr Stoxen:     Okay, even more there?

Larry (patient) :    yes.

Larry (patient) :    ooh, yes.

Dr Stoxen:     Okay, I'm working myself laterally from medial to lateral and I'm looking basically for this one right here.

Larry (patient) :    yes.

Dr Stoxen:     Okay, and that one?

Larry (patient) :    yes.

Dr Stoxen:     you know what Larry is going to tell me? Larry is going to say, “Well, Dr. Stoxen you're pushing on my muscles, so they're bound to be sore.”  No, that's not true.  If I push here, Larry, do you have pain?

Larry (patient) :    No.

Dr Stoxen:     Okay, well also we pushed here, remember? Remember, he had no pain here.  I'm pushing hard.  Larry, can you see how white my thumbs are?

Larry (patient) :    yes.

Dr Stoxen:     I'm pushing pretty hard, right?

Larry (patient) :    yes.

Dr Stoxen:     Okay, when I work my way laterally, I'm finding the flexor digitor longus, And that muscle reaches around and grabs the foot and it supports the foot, and that's what we're talking about here.  So, basically, the techniques – let's go through the foot as well.  I'm going to reach down and look at Larry's foot.  First of all, I'm going to check the motion of the foot, different digits, and also just the appearance of it.  His feet are very dry.  You need to visit some of the booths. Get some creams and lotions, Larry.  Now, here is where we have to evaluate the intrinsic muscles of the foot.  Basically, what I'm going to do is I'm going to put my thumb right on the plantar fascitis area.  The attachment which is around where heel spurs form, at the bottom of the heel.  And I'm pushing real hard.  Larry do you feel that?

Larry (patient) :    Yes.

Dr Stoxen:     Is there any pain there?

Larry (patient) :    not as bad

Dr Stoxen:     Not too bad.  Okay, we'll work our way toward the first toe. Right there?

Larry (patient) :    Not that bad.

Dr Stoxen:     Okay.  How about right here?

Larry (patient) :    yes.

Dr Stoxen:     Okay. Now, this joint right here, if you look at it, you can feel your own foot.  You're talking about  (flexing foot).  What I'm looking – I don't know if you can see this, but I'm looking at the palisus muscle, both the abductor and the flexor. 

There's the aductor.  As a result of the collapse, Larry's muscles have been trying to fight it off, but they can't because they're collapsed 24 hours a day. Now, if you can understand this, Larry is laying on his back, but his muscles are collapsed, so that means they're working.  A spasm is a muscle contraction.  So if you could imagine Larry going to bed at 11:00, the purpose of which he is trying to recover from the day to recuperate his energy.  However, at night while he is sleeping, Larry's muscles are working.  So you wonder why Larry wakes in the morning tired.  You're searching for some answers in some vitamin, for some sort of disease process – and I think you should. But, more commonly if you just take a moment to take your thumb and put it in that muscle.  If that muscle is in spasm, that's a very large muscle, especially in the gluteal area.  Now look here, Larry has here evan a bunion forming – now it's abductus valvus???? So, you know that this is chronic and it's also causing him to even possibly having some sort of surgical procedure in the future.  Larry you better get some new shoes.

Larry (patient) :    Okay

Dr Stoxen:     Turn on your side for me.  Now at this point, I;'m going to check his hips. It's not that difficult.  We're right here in the same area.  We're pressing on Larry's hips.  Do you feel some soreness there, Larry?

Larry (patient) :    a little bit.

Dr Stoxen:     Right there?

Larry (patient) :    yes

Dr Stoxen:     Okay, and then right in here.  Okay, those are gluteus metius.  Now, Larry would you do me a favor and take off your other shoe.  I'm not going to check his other leg, because I know that we probably have the same thing.  So we checked the gluteus metius, which is the gluteus metius test.  Will you stand up for me, Larry and face the audience.  Now what happens with this kind of patients is that as a result of the collapse of the arches, and as a result of the presentation that Larry has with the legs, what you're looking at here, is the principal method of treatment for our office is not – and you're going to say, oh Doctor, your'e going to talk about orthotics now.  I never use orthotics. Never, and the reason is because Larry was fine when he was in high school, and he didn't have orthotics, right?  Okay, so why does he need orthotics now? 

Okay, let's just talk about another situation.  Larry comes to my office and he tells me he has back pain, and my doctor told me the reason is that I have scoliosis and I'm 37 years old.  Well Larry, did you have scoliosis when you were 17, 18, 19, 20? No.  well, he had scoliosis then.  See obviously that's not a viable answer to his problem.  What's happened to larry since his calcaneous bone (his heel bone_ has collapsed inward, the tibial will have internal rotation.  Now when you're talking about gait, standing still is different than walking.  When Larry takes a step, he's going to step down with his heel on the lateral aspect of his foot, and then all the bones in his foot are going to roll down to the floor.  I'm going to try to keep this simple.  As a result, if the calcaneous is in a valvous position, the result is the rest of the bones of the foot will collapse. 

The calcaneous maintains stabilized in a position that allows the lower extremities to be on center then the resto f the bones will follow suit.  What you have to understand is my theory is htat if the calcaneous bone is stabilized will allow the foot to become stable in its normal anatomical position as well as all the rest of the bones above it.  So why don't I use orthotics? Because I've found that they don't work.  And I know I'm going to upset a lot of people here, but that's just the way it is. It's something to think about.  You might want to try this as a new technique. 

Now, when you're looking at Larry's presentation, he has tibial torsion, he has internal rotation of the femur and as a result  the external rotators of the hip are going to be stiff and they are going to be weak.  As a result of constant contraction, the muscles get weak.  Because the external rotators and the hips get weak, concluding the gluteus metius, I can lay him on his stomach and I bet if we push down on his leg, I bet we can find the gluteus maximus also to be weak.  The pelvis area goes into an anterior position, causing hyper lordosis of the lower spine and they're more susceptible to disc injuries.  Fact syndrome, irritation of facet joints and disc injuries. 

Now when Dr. Goldman talked about some patients that have come to my office, and they've been recommended surgical procedure doctor, after several, 2-3 consults, we're speaking of taking this patient who already has a disc injury and what we're basically going to do is level off the sacrum.  We're going to do this, not by some form of brace or some sort of attachment to his body, but we're going to do this by bringing back the strength that he originally had and making him the way he was before he had this problem.  In other words, we're going to use the natural muscle strength that's inherent in his body. 

We're going to work with that to strengthen those areas and show him up and make him back to normal.  I don't believe in any type of braces.  I have patients that come to my office, that we'll just consult with them.  Ed, how was your training today? Not too bad, I did a 920 for 3 reps.  Now we're speaking of 920, We're talking about  920 pounds of weight on the back going to a full squat, 2 inches below parallel to the .  . coming back up for three reps.  The biomechanics  has to be absolutely perfect for that to occur, otherwise those weights will come crashing down on the athlete and will kill him. 

So, it is imperative that we have good alignment and good mechanics.  In this situation, we're going to have a hyper lordosis.  Like I said, it's susceptible to lower back injury.  Also, in this situation, you're going to see a little bit of protrusion in the gut, and sometimes a little more than a little bit; and the patient is somewhat inactive, and they're also going to be a little bit over weight.  Now, most of the problems that I said that occur as a result of poorly constructed shoes.  But in larry's situation, we're going to look at one more thing, which I forgot, the other positive test that we're going to find is that Larry's balance is going to be off.  This is called the Trendelenburg Test.  It's usually used for _______, but we're ging to use it for evaluation of Larry's balance and strength.

So, Larry, what I'd like you to do is to just take your leg up like this- as in a sobriety test.  What I'd like you to do is thoracic outlet syndrome stay with your body on the center like that.  We're doing this in the mirror, so Larry can see – come on get your leg up there. Okay, have you been drinking?

Larry (patient) :    No,

Dr Stoxen:     Okay, lift up your leg there for me – all the way up.  Okay, now he's having a tough time.  Are you having a tough time?

Larry (patient) :    yeah.

Dr Stoxen:     Okay. Now what you're going to find is that if you align to the center, Larry's body is going to veer to the opposite side. This is all because of the fact that Larry's hips don't work anymore.  as a result, the load that was handled by the hips has now transferred to the lower back.  That's why the erector spinor muscles are really tight. The entire load that was supposed to be shared between the back and the hips are now only on the back because the hips don't work anymore and the presentation that you see in your waiting room is this…. Okay, Larry have a seat, place your hand on the table and push yourself up.  That's what you're going to see.  They're going to grab a hold of the chair and push themselves up with the chair. 

Thank you, Larry.