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Thank you Dr. SanFilippo

Posted by Ed Davis, DPM on 4/25/05 at 12:59 (173702)

I just noted an ART newsletter in my email. I must assume that you somehow got my name on the ART people's list. Thank you very much.
I hope that you did not have to go through too much work to accomplish that because I had been unsuccesful in getting them to communicate with me in the past. Please let them realize that this site is an 'equal opportunity' site but there is wide readership and a large range of opinions so anyone posting needs to be willing to engage in constructive debate and should not misconstrue that debate as an 'attack' but a continuing educational process. Let the site moderator know if a poster says something innapropriate, keeping in mind that sometimes moderators can 'have their hands full' and cannot always respond to innapropriate messages with adequate speed. Moderators also, as humans, are not perfect and need to make judgement calls that cannot satisfy everyone.
Regards,
Ed

Re: Thank you Dr. SanFilippo

Ralph on 4/25/05 at 16:45 (173713)

Dr. Ed,
Some earlier posts showed the Pods here more skeptical of ART than the posters.

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/25/05 at 18:29 (173718)

Ralph:
It is part of our 'job' to ask the technical questions. Doctors are trained to be professional skeptics. We are given the responsibility to find out how things work, what they do, what the limits are and to separate the facts from the non-facts. Type in 'heel pain' in any search engine and you will get enough potions, gadgets, etc. to make your head spin (mine sure does).

Luckily, we finally have a doctor who provides ART and can answer the questions. Also, our new doctor sounds like he really is knowledgeable about biomechanics which is one of the harder things to explain.

Keep in mind that you will find healthy skepticism and questioning and that which is not. For example, it would probably not be reasonable to ask for a 'double blinded peer reviewed study' before accepting the information. Some will demand it because they will not consider empiric evidence or experiential evidence. Those individuals probably will not get such a study for quite a while unless one has been launched which I do not know about. Interestingly, a lot of medicine being practiced today has never really gone through that process being demanded of newer modalities.
Ed

Re: Thank you Dr. SanFilippo

Robert J. Sanfilippo, DC, CCSP, ART on 4/25/05 at 22:13 (173734)

You are quite welcome Ed. Just like yourself I want people suffering from these conditions to have all the information available to them. ART is a viable treatment and the only way that can happen is if other doctors and people understand what it is about. I'm not worried about hecklers and welcome all credible questions.

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/25/05 at 23:00 (173738)

Rob:

Just as we inquire and question aspects of ART you should feel welcome to critique the plantar fasciitis treatment 'status quo' much of which you will find in the Heel Pain Book. This site is quite large. Besides the book their are archives of posts.

We routinely have people coming onto the site, introducing a new modality but it is not often that we have someone introducing it with your level of knowledge and credibility. We have had some well meaning, enthusiastic ART supporters come to the site in the past. They brought much enthusiasm but could not describe the mechanism of action of ART, it limitations, applications, etc. Some confusion existed as to whether ART should or should not be classified as a form of massage since it has similarities to deep tissue work and myofascial release. Please clarify the differences and how ART should be classified or should it be in a class unto itself. It appears to be a form of myofascial release that influences tissue quality. Tissue quality is really the big issue, as I see it in 'intractable' plantar fasciitis. We have had limited means of influencing tissue quality until ESWT came along. You will note a long history of debate and even a section on ESWT on this site. Dr. Z, a pioneer in ESWT use can show you a 6 year uphill acceptance 'battle' for that modality.
Ed
Ed

Re: Thank you Dr. SanFilippo

Dr. Z on 4/25/05 at 23:39 (173743)

Dr. Rob,
I have a question. What role does your gait analysis have when determining which parts of the kinetic you address ART with. How often do you find that you are only treating the plantar fascia area and not other areas of the lower extremity.
How long have you been using ART. How long has ART been used in the USA
One question has turned into more then one question. Here is another question how do you address a soft tissue ankle equinus and what are your results. I have many friends that are very successful Chirpractor physicians and every time I bring up ART to them they tell me its just another name for manipulation and deep massage. What is the difference ?

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/26/05 at 15:51 (173776)

Dr. Z and Dr. Rob:
All good questions. Everyone will benefit from Dr. Rob's responses.
Then it is a matter of reminding posters to look at the archives of posts to bring up the information.
Ed

Re: Thank you Dr. SanFilippo

Robert J. Sanfilippo, DC, CCSP, ART on 4/26/05 at 16:09 (173779)

When I have some time I will read through the heel pain book and I appreciate the offer. I guess you can classify ART as a form of massage but I'd classify it more like myofascial release. ART is used to mobilize or break up scarred(fibrotic) structures such as muscle, ligaments, tendons, and fascia. Myofascial release generally uses ischemic compression to alleviate the 'trigger points.' ART uses palpation to located the lesion, then pinning it so to speak, then having the patient or doctor move the structure actively. This action movement will break up the lesion under the doctors finger, thus freeing the structure in question. ART is also an assessment technique and follows specific protocols of treatment. ART also treats peripheral nerve entrapments which can be entrapped by muscles and fascia. So based on that I would definitely classify ART by itself.

As an ART provider we believe that repetitive/cumulative trauma to a structure will cause fibroblastic proliferation which in turn causes the laying down of collagen/scar tissue. When scar tissue is laid down without the appropriate stressors, it will be laid down in a random pattern which will cause the alteration of function, then adaptation and then pain. So with ART we use our fingers to assess the scar tissue or entrapment and look to free up the structures so function can be restored. I hope this sheds some light on the ART technique.

Re: Thank you Dr. SanFilippo

Robert J. Sanfilippo, DC, CCSP, ART on 4/26/05 at 16:26 (173782)

Well, I use both postural analysis and gait analysis. I first look at their neutral posture when standing. I observe them from the front, back, and side. I'm looking for a high iliac crest, hyperlordosis of the lumbar spine, leg length discrepancy, Q angle, foot and ankle stance, genu varus, genu valgus, muscle tone.

As far as gait analysis, we are observing for aberrant motion. First you have to understand the gait cycle and what is considered normal. We observe the core first which generally includes the hip flexors, hip extensors, hip abductors, hip adductors, abdominals, erector spinae muscles, arms and leg swing. The best way to really understand it is find someone with a normal gait. Then observe someone with a PF, low back pain, hip arthritis, pulled groin which is considered abnormal and you will key in on the abnormal movement patterns. These patterns are indicatons that something is wrong so we then investigate the area with our palpatory skills. Once we find the site, then we treat the area then have them walk again and look for return to normalcy and obviously a decrease in pain or their symptoms.

I've been an certified ART provider since Jan. 2003. I am full body certified with biomechanics. I can't recall when ART was started but I think it has been used between 10-15 years.

When assessing an ankle, I look at the entire kinetic chain. I perform a postural analysis and gait analysis. I observe the ankle and determine if its pronated or supinated. I check the lumbar spine, hip, knee, ankle, and foot for altered mechanics. Then I check the soft tissue structures that I determined to be a problem. I perform my treatment then reevaluate their gait and pain.

Many chiropractors who aren't certified in the technique would say exactlly that. The ART is a very expensive technique to learn and many of them don't want to spend the money. So they coin phrases saying that its similar to ART. If that makes them happy to be it. The technique can be very deep but it is not massage by any stretch of the imagination.

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/26/05 at 19:48 (173793)

Rob:
So, having established that ART is not massage, how would you classify it? Does it belong in a category by itself? Would you consider it a form of myofascial release? If it is a form of myofascial release, then do you feel it superior to other forms of myofascial release and why? Thank you in advance for your answers.
Ed

Re: Thank you Dr. SanFilippo -whoops

Ed Davis, DPM on 4/26/05 at 19:56 (173794)

Rob:
Somehow, when I brought the thread up, I missed one of your responses on the clasification issue. Sorry. I often have only a minute or two when posting during the day but do better posting and reading in the evening when not rushed.
Ed

Re: Thank you Dr. SanFilippo

Robert J. Sanfilippo, DC, CCSP, ART on 4/26/05 at 20:40 (173798)

Ed:

I would classify it as a way to assess and treat fibrotic lesions within soft tissues; which includes muscles, tendons, ligaments, and fascia. Myofascial lesions or trigger points are always found in muscles hence the difference. ART is used to treat myofascial lesions but it encompasses most soft tissue structures including the soft tissues that can actually entrap peripheral nerve roots. Maybe I can give you an example that might clarify things. We are all familiar with carpal tunnel syndrome and the common entrapment is at the carpal tunnel in the wrist. Carpal tunnel syndrome is commonly caused by repetitive movement of the wrist generally associated with activities like excessive mousing. Using ART, we are trained to check the entire median nerve as it exits the cervical spine, then traverses throught the shoulder and into the arm ending at the thenar muscles. So if the median nerve is entrapped at any point from the neck to the thumb it can cause a carpal tunnel like syndrome. Most times the median nerve isn't entrapped at the carpal tunnel. It is usually entrapped at the thenar muscle or at the pronator teres in the upper forearm.
Using myofascial release would only treat trigger points within the muscles while ART allows you to track/palpate the nerve and feel for nerve tension and fibrotic buildup around the nerve root.

So as you can see, ART is used to treat myofascial syndromes but it encompasses so much more than a lesion in a muscle. Not to sound like a poster boy, I feel that ART is the gold standard of soft tissue treatments. One last thing, I also utilize a treatment called the Graston Technique which utilizes stainless steel instruments to mobilize and break up fibrotic tissues. This technique is used for myofascial syndromes but I would never use it to treat a peripheral nerve entrapment. Imagine me strumming a nerve with my stainless steel instriment? That would be a big ouch..... Hope this helps

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/27/05 at 20:40 (173846)

Rob:
Thank you for the extra info.
Podiatrists see a modest amount of tarsal tunnel syndrome and we have had posts by patients treated by ART. How does one release the tissues around the posterior tibial nerve without doing damage or bruising the nerve itself. The course of the nerve does have some variability. Usually, locating the posterior tibial artery gives one a good idea where the nerve is.
Ed

Re: Thank you Dr. SanFilippo

Robert J. Sanfilippo, DC, CCSP, ART on 4/27/05 at 21:15 (173856)

Ed:

We are taught with ART to develop 'tension' on the tissue, not 'compression.' As we all know compression on a nerve is not a fun thing. So this tension is the first thing that is taught in any ART seminar because the master of this palapatory technique is key for the best results.

With regards to the posterior tibial nerve, I palpate the medial malleolus and roll off onto the posterior tibio-calcaneal ligament. I will then move above and below it feeling for the nerve. Many times I will palpate the flexor retinaculum and search for the entrapment there as well. So basically I use my landmarks and I really can't describe a learned palpatory feel of a nerve. Years of palpating and treating them is the only way to fully understand what to feel for. Hope that helps.

Re: Thank you Dr. SanFilippo

John H on 4/29/05 at 11:46 (173920)

Good question ED. That was pointed out to me by an Orthopedic Surgeon when doing a nerve conduction study. He also said I should be very careful with any type of foot massasge as I could do some serious damage depending on where a nerve was compressed.

Re: Thank you Dr. SanFilippo

Ed Davis, DPM on 4/29/05 at 15:55 (173936)

Rob and John:
Patients need to be warned, 'don't try this at home' as the level of skill needed to release the tissues around the nerve while not hurting the nerve must be remarkable.
Ed