Pre-Operative Exercises for Knee Surgery

Should You Do Pre-Operative Rehab Before Knee Surgery?

We see many people before knee surgery for what we like to call “prehab,” or rehab exercises to prepare you for surgery.  There is evidence to support better outcomes in those that do physical therapy and/or exercises before knee surgeries like ACL reconstruction or total knee replacement.  Improving range of motion and increasing strength of the quadriceps and supporting hip muscles has been shown to help hasten recovery of both gait and function.  Unfortunately for many of our patients, they have limited insurance visits.  Therefore, we want to maximize the amount of time we can keep them and supervise their progress and assist them in return to activities.  As a result, we often only see people for a visit or two prior to surgery to show them a home program to do until surgery.  So what should we do about pre-operative exercises before knee surgery?

In the case of ACL reconstructions, a  classic 1995 study by Cosgarea et al in the American Journal of Sports Medicine tells us that basically 4 things should be achieved prior to having an ACL reconstruction.  There are other papers supporting pre-operative exercises here, and here, and one paper shows that it predicts function up to two years later.  The pre-operative exercises should achieve the following goals:

  1.  Minimal to no swelling.  You have to get the swelling out of there as much as possible.  The swelling is the principal reason why you should wait to have surgery – the knee is already “angry” from the injury and to make it more angry by operating can cause more pain and possibly more dysfunction from stiffness post-operatively.  Depending on the severity of the injury, there may be a point where you’ve maximized how much you’ll actually get out of it.  Ice, as much rest as possible, elevation, and compression are all ways to reduce swelling.
  2. Get at least 120° of knee flexion.  It’s hard to know for sure how much this actually is unless a physical therapist measures you, but basically get as much bending as possible.  Research has shown that if you achieve 120° of knee flexion pre-op, your risk of knee stiffness, known as arthrofibrosis, is much less.  Riding an exercise bike, deep water jogging in the pool, or heel slides (Figure 1) are all good ways to do this.
  3. Get your leg as straight as possible.  Much like knee bending, you want your knee to be as straight as possible.  If you have a meniscus tear or an ACL tear, the tear may restrict this and extension could be very very painful.  Do the best you can to get it straight.  Heel hangs are a great way to do this (Figure 2).
  4. Maximize your quadriceps function by being able to do a straight leg raise.  A straight leg raise (Figure 3) is a fundamental exercise post-op because if you can do it, you’ll be able to walk without a brace and you have “minimum” quad function.  You have to be picky with this though – it can’t be a “bent knee raise.”  We’re really particular about this exercise at SSOR, so check with us if you aren’t sure.  If you try and do one and can’t keep your knee straight, quad sets (Figure 4) are a good place to start. Roll a towel up and place it under your knee and just push the back of your knee into the towel roll.  A physical therapist can also put you on a muscle stimulator to help facilitate this.

Pre-Operative Exercises before Total Knee Replacement

Truthfully, the above are great guidelines for any knee surgery.   In the case of exercises before total knee replacement surgery, the evidence supports doing pre-operative exercises for those having a total knee replacement.  As this systematic review shows, pre-operative exercises may also reduce costs and length of hospital stay. However, there is evidence saying pre-operative exercises are not effective, but in our experience, improved motion and strength prior to surgery leaves you with a better starting point after your total knee replacement.   In addition to the goals stated above for pre-operative ACL surgery, other exercises may include hip strengthening, stretching, and balance activities.  The three main issues long-term after total knee replacement are declining quadriceps strength, loss of motion, and decreasing balance.  Those three items are heavily emphasized at SSOR both pre- and post-op to maximize function.

If you’re on track to have ACL reconstruction or a total knee replacement, it would be a privilege to partner with you in your care.  Give us a call if you need exercises before knee surgery to help maximize your outcome post-operatively and put yourself in the best position to succeed.  We have locations in Overland Park and Prairie Village to serve you.

Figure 1: Heel slides with sheet for range of motion

 

 

Figure 2: Heel Hangs

 

 

Figure 3: Straight Leg Raise

 

 

Figure 4: Quadriceps setting exercise

How to Squat Properly

Learn How to Squat Correctly

If there was one exercise that all people need to perfect is the squat – athletes or not.  We’re not necessarily talking about putting a bar on your back and doing maximal effort squats.  We’re alluding to simply performing sit to stand from a chair, or getting on/off the toilet with proper squat technique.  That said, so many compensatory patterns and muscle substitutions take place from the ankle to the trunk.  This is one of the first things we look at during a physical therapy evaluation, and you may not even know it, but we’re looking the minute we see you in the waiting room.  Watching you get up from the chair is the first clue as to how you are performing this activity.  We almost immediately have an opportunity to help you or your loved one before we’ve even talked!  There are many reasons that poor squat form can occur – lack of mobility in the hips, knees, or ankles or lack of stability in the core region. Figures 1 and 2 show some poor squat form because of these areas.  Figure 1 shows the subject leaning forward, and Figure 2 shows the heels elevated.  In figure 3, the subjects knees are collapsed in and the feet are turned out.  You may have one or all of these regions causing you to not perform a proper squat.   We can help you determine which areas are the sources of your dysfunction.  The purpose of this blog post is to talk about some ways to perform a proper squat movement to not only help improve function, young or old, but for the active patient, provide a foundation for more advanced leg strengthening.  The squat is not only a basic tenet of movement in general, but also part of a strengthening program.  The body weight squat should be perfected prior to adding external resistance.

 

 

Figure 1:  Poor squat form, trunk leaned forward

 

Figure 2: Poor squat, heels off ground

Figure 3: Knees collapsed inward, toes pointed out

Reasons for Poor Squat Form

Are you Figure 1?  If you look more like figure 1 with a forward trunk lean and not so great depth, more than likely you have tight hips and/or core and hip weakness.  Both are easy fixes!

Are you Figure 2? You may have both of Figure 1 deficits, but if your heels are coming up, you may have tight calves or an ankle mobility restriction.  Perhaps you had a previous ankle/foot surgery and your mobility has been affected?  We can figure that out in an evaluation.

 

Are you Figure 3?  If you’re figure 3, more than likely you have some or all of the deficits in figures 1 and 2!

Key Aspects of a Proper Squat

First of all, see Figure 4 for good squat form.  The feet are slightly more than shoulder width apart, the trunk is leaned forward, the head is up, the trunk is parallel with the “shin” bones.  The curve in the low back is maintained.  Many people struggle with achieving these basic points.   Sometimes it’s a MOBILITY problem why we can’t get there.  Perhaps with arthritic aging joints or tightness in muscles from sitting in front of a computer all day, you may not be able to get in that position.  Conversely, you may have a STABILITY problem.  We know this by watching you squat by yourself, then having you repeat it while we hold your hands, supporting you.  If you increase your depth and your form improves, we know that you’re using us for stability.  Therefore, we know our targeted interventions here will focus on hip and core stability training.

Figure 4: Proper Squat Form

 

Exercises to Improve Your Squat

In figure 5, you’ll see the subject holding on to a cable attached to a weighted stack.  Basically, what this provides the subject is some stability as they descend.  Usually, people stop their descent with the squat because any lower, they will fall back.  You can confirm this by getting to the bottom of the squat and then letting go of the cable – if you fall backward, you are the ideal person to need this!  As you get better at this, you can release one hand, try and hold on less, or get to the bottom and pause without holding on.  If you don’t have a cable or are teaching this to a relative at home, any immovable object that the person can hold on to will work.  Exercises to strengthen your core and hip muscles should compliment this activity however.  One of our physical therapists can show you a comprehensive program to address this. Maintaining proper form and posture is paramount when you do this though.

Figure 5: Assisted squat, using a cable

In figure 6, you’ll see the subject’s feet are elevated.   This is actually a way to help someone squat with tight calves or lack of ankle mobility from joint or soft tissue restrictions.  Again, these issues can be addressed in physical therapy.   However, this method is also good because by virtue of shifting weight to the toes, the hips have to go backward – equal and opposite reaction.  As you improve, you can either lower the height your heels are elevated or use nothing at all.  The elevation of the heels effectively acts as a “buffer” or “buys you time” until ankle or soft tissue mobility is restored in physical therapy.  We don’t let people cheat, but this is a way to let you cheat until you have the mobility and control you need.

Figure 6: Assisted squat, heels elevated

Hopefully, these tips help you perform a proper squat.  You can use these tips to teach a child or an elderly relative how to perform a proper squat.  It would be a privilege to partner with you in your care.  Remember, you can see a physical therapist in Kansas without a physician referral.  Give us call!  We have locations in Overland Park and Prairie Village to serve you.

 

“Home Gym” for Senior Citizens

Home Fitness Equipment for Seniors

Mom and/or Dad needs a home gym.  What should I buy?

We had some questions recently about what “home gym” equipment people might get for an elderly parent, grandparent, or relative.  Whether it’s to stay in shape and active or to prevent physical decline, there’s lots of stuff you can get.  Many of the common things that most people use or purchase just aren’t necessary or aren’t safe for older folks though.  Here’s a short list of some things you might consider getting them set up with. Of course, some of this is determined by your space and budget needs.

First of all, it’s important to talk about the main things that affect older adults.  As we age, we tend to get weaker, stiffer/tighter, lose balance, and lose cardiovascular conditioning.  Therefore, our home gym should focus on those things.

Home Gym for Older Relatives

  1. Bike or recumbent stepper. A bike is a great way to keep old joints moving and keep up the cardio without the impact loading of treadmills, upright steppers, ellipticals, etc.  A stepper might be a good idea for a relative with osteoporosis because it allows some weight-bearing to help facilitate bone growth.  There’s lots of refurbished or used equipment out there if budget is a concern.  Choosing an upright or a recumbent or upright bike is a personal preference, but if safety is a concern, recumbent bike is the choice for you.  With all of these, there is a wide array of prices with assorted “bells and whistles.”  Truth be told, most of that stuff just isn’t necessary.  Need an “On” button, some resistance, and a timer.  Good to go!! stepper
  2. Ankle weights and a set of light dumbbells. There are lots of choices of dumbbells and these “space saver” cuff weights.  We suggest getting a set of 1-10 lbs.  Grandma and grandpa have the ability to get stronger just like the rest of us, it just takes more time to do it.  Can’t be afraid to lift an extra pound or two provided they have good form while performing the exercises.  For most exercises, these are better choices than elastic bands are because the resistance with the bands is highest at the end ranges of motion.  At this position, their muscles are at risk for injury. With cuff weights and dumbbells, the resistance is consistent.  However, bands are consistent and are great tools that can be taken anywhere.  Just start with the lightest resistance you can get and work up from there.
  3. A stretch strap. This is an easy way for your older relative to do some stretching without having someone help them.  There are lots of stretching exercises you can find online with this strap. Keep in mind, not all of them are appropriate.  Might want to review these with a physical therapist. Don’t like that idea? Get a video on Yoga poses for older adults or Tai Chi exercises. stretch
  4. A mat if they can get on/off the floor safely OR a table of some kind. Mats are cheap, but getting on/off the floor can be trouble for an older person.  A bed or a couch isn’t a great choice because it’s not a firm surface to push from.  A treatment table used in physical therapy can be about 4-500$, or if you have more money to invest, a mat table is a good choice.  You can get away with a used massage table too.  table

Other “home remedies” to use:

  1. A chair to do squats with.province-active-gardening-chair-squat
  2. Steps to do step-up exercise for leg strengthening.
  3. Can’t afford dumbbells? Cans of soup work pretty well! soup cans
  4. A closed door or a wall to do push-ups from.wall_push_up

It would be a privilege to help your loved one get back on their feet after an injury or to help them avoid physical decline.  We know how to be progressive, but safe at the same time. Give us a call! We have locations in Overland Park and Prairie Village to serve you.

“Must Do’s” After ACL Surgery

ACL Surgery and ACL Rehab

It’s hard to watch a sporting event anymore without seeing or hearing an athlete tore his or her ACL.  U.S. Women’s National soccer player Megan Rapinoe is one of late that tore her ACL.  Rehab after anterior cruciate ligament (ACL) surgery is a long, arduous process that takes several months.   Unfortunately, the internet is a sea of misinformation on what to do/not to do.  It’s littered with various experts, horror stories, and various pundits who all have a different take, which adds to confusion.  Complicating matters further is that everyone seems to want to base outcomes on a professional athlete’s outcomes, or be married to the idea that it has to be a specific time frame, commonly 6 months, prior to return to sport after ACL surgery.  Your ACL rehab should be a collaboration with you, your operating surgeon, and your sports physical therapist.  The purpose of this blog is to emphasize a list of 10 things that must be addressed in your ACL rehab.

ACL tear

Rehab after ACL Surgery:

  1.  Get your knee as straight as possible as soon as possible.  This is critical for proper muscle function as well as normal walking, and for you athletes, running eventually.  Studies have found as little as a 3° loss of extension adversely affects function, so make sure this is a priority.  Furthermore, Paulos et al showed us in the 80’s in a study in the American Journal of Sports Medicine that scar tissue can form in the joint if you don’t get it straight quickly.
  2. Get your quad muscle working.  In order to walk, it is imperative that your quads work correctly.  These are the muscles on the front of your thigh.   These are the muscles you contract when you stretch in the morning and extend your knees.  As soon as you are able after surgery, you should start “setting” the muscle with brief contractions to get it firing. Think of it almost like a heart beating.  A nice tool to help with this is a muscle stimulation.  Multiple studies have shown that muscle stimulation on the quads helps subjects improve gait and quad functioning than those that don’t.
  3. Maximize your bending as much as your physician allows.  Try not to let that knee get too stiff.  Doing either heel slides, sitting at the edge of the bed, or using a bike for range of motion only are some ways you could do it.  Your doctor may get you a Continuous Passive Motion (CPM) machine but studies show it is not required.
  4. Use crutches until you are walking completely normal!  This one is huge.  Amazingly, many physicians tell people to ditch the crutches and then watch them walk out of the office limping.  This may be my biggest pet peeve with physicians.  All eliminating the crutches does is keep your knee swollen, inhibit your quad, and delay your recovery.  Even if you don’t need two crutches, use one on the opposite side of the surgery (yes, the OPPOSITE side) or even a cane until you are walking completely normal.  Trust us – you’ll thank us later.
  5. Focus on single-leg emphasized training.  Several studies have shown that after ACL reconstruction, subjects unconsciously unload their involved leg up to a year after surgery doing squats on both legs (Neitzel et al, Clin Biomech 2002).  Furthermore, they even unload their leg two years after surgery when landing from a box to floor jump (Paterno et al, JOSPT; Chmielewski et al, JOSPT).  So, even though you think you’re symmetrically distributing weight, you are really not.  Therefore, you should focus your training on single leg movements for most of your rehab.  Lunges, step ups, step downs, leg press, and single leg squats should be the focus of your training.  Once you transition to plyometrics/jumping activities, the focus there should also be on single leg movements.  Eventually, to maximize strength, you’ll need to transition to double-leg activities, but only after your sports physical therapist has determined your readiness.
  6.  You must get your thigh muscle mass no more than 1 cm difference than your non-injured leg.  Many people who have chronic trouble with their involved leg long after surgery is often due to not getting their quad mass back.  Persistent pain, swelling, and dysfunction ultimately affect their function.  Many physical therapists fail to actually measure thigh mass throughout the course of rehab.  An analogy is having no shocks on a car, or having half inflated tires.  What do you think would happen with either of these scenarios?  The car would break down faster and have problems.  Well, your knee is no different.  This may take a year or so after surgery to get back, but someone should keep checking.
  7. What you do in front, you need to do in back.  In real estate circles, people talk about “curb appeal.”  Make the house look nice in front – new paint, trimmed bushes, a nice freshly cut lawn.  Then you look at the backyard.  May be a disaster.  The focus on making the thigh muscle bigger neglects the critical hamstrings.  For the recovering athlete with an ACL reconstruction, your hamstrings are your best friend.  They are the “brakes” that limit the risk of the ACL being torn.  Therefore, make sure you do lots of stiff leg deadlifts, exercise ball bridges, ball curls, leg curls, and eccentric hamstring lowers.
  8. You have two legs, balance training needs to be on both legs.  Humans are a bipedal species – we walk and run on both feet.  Balance after an ACL reconstruction is impaired and needs to be a focus of your rehab.  Further, once you have one ACL tear, you are at risk to do the other.  Why on earth would you only do balance work on one leg?  The other one will get jealous for one, and two, why would you possibly set up your “good” one to be a “bad” one and risk a tear in it by not working on balance for that leg too. Therefore, what you do on one, do on the other.  Speaking of balance, if the only balance exercise you do is throwing a ball at a mini-trampoline while standing on unstable surfaces, it’s time to look for a new physical therapist.
  9. Get your heel to your butt!   This is critical for people that want to play sports again.  When you run, your heel needs to get all the way to your glutes to sprint correctly.  Many athletes get their “active” range of motion back (what they can do), but lack the “passive” range.  The passive range is the “extra” range when you pull.  This is illustrated when you stretch your quads.  If you lift your heel up to try and touch your glute, it can’t get all the way up.   That’s the active range.  When you grab your foot and pull it up to your glute, that’s the passive part – the “leftover” slack.  You have to have that to run right.  If not, you won’t be as fast, and you’re at risk for hamstring strains.  There are many techniques to get this back, and it’s more than just cranking on it till it gets there.   You should wait several months (about 4 months post-op) before you aggressively stretch.
  10. Make sure you get tested before you get “cleared.”  The biggest mistake doctors make is telling patients they’re “cleared” without explaining the difference between being “medically” cleared and “physically” cleared.  Unfortunately, it puts the idea in the patient’s head that he’s good to go.  The doctor clears you medically.  They tell you that your new ACL is healed and you have no infections or any reason to stop training/progressing.  However, physical readiness is totally different.  It shocks me how many people get “cleared” to practice/play when no one has ever watched them cut, sprint, or jump on one leg.  At a very minimum, you should perform a series of single leg functional tests to make sure that your involved leg is at least 90% of your uninvolved one before getting released.  Once you do that, then you are “physically” cleared to begin return to play progressions.

Rehab after an ACL surgery is a long process that requires perseverance, dedication, and a lot of hard work.  Maybe more than you have ever done.  While many factors contribute to the outcome and this list is not exhaustive, the things mentioned in this blog should help you maximize your outcome.

It would be a privilege to serve you and partner with you in your care after ACL surgery.  The physical therapists at SSOR have the most comprehensive and thorough treatments and return to play assessments in the Kansas City metro.  Give us a call, we welcome the opportunity to show you! We have offices in Overland Park and Prairie Village to serve you.

Jimmy Graham Injury Rehab

Patellar Tendon Rupture Rehabilitation

Seattle Seahawks Tight End Jimmy Graham ruptured his patellar tendon a couple of weeks ago.  This is a tough injury for any athlete.  It’s a season-ending one, much like an ACL or Achilles rupture is.  Athletes can definitely return from this, but the rehab process is a long one.  So what will Jimmy Graham’s rehab look like?

Jimmy Graham

Function of the Patellar Tendon

The quadriceps muscles converge to form the patellar tendon and it attaches on the tibial tuberosity below the knee.  Basically, the quad muscles lost their anchor. Without that, the knee cannot function. It really is as simple as that.

Patella-Tendon-Rupture

How long is the recovery?

This can take 6-8 months for sure to recover from, especially for an athlete at that level.  The two most significant limiting factors after this surgery are that the range of motion (ROM) is restricted for the first 6 weeks to allow the repair to heal and the other is regaining the quadriceps strength lost from the injury and subsequent period of protected mobilization.  You just cannot run, jump, cut or frankly, walk or ambulate the stairs without strong quadriceps.   Because of the strength and power needed, especially for him, this injury can take a really long time to get the strength back to perform at a high level.

repair

Rehab after the Jimmy Graham Injury

Usually, ROM is restricted for the first 6 weeks or so.  People are often locked in extension for a week or so, then a graded progression of ROM is allowed – 30°, then 60°, then 90° by 6 weeks post-op.  During this time, the patient should have soft tissue work done on the lower body, strengthening of the hips and lower legs, and for athletes, cardiovascular activity can be accomplished with an arm bike.  Quadriceps strengthening can be initiated with some basic exercises and can be enhanced by muscle stimulation to the quadriceps.  Numerous studies have advocated the use of muscle stimulation after knee surgery to facilitate quadriceps strength both in the short and long-term.  Unfortunately, the first 6 weeks is a waiting game for healing to take place.   Another concern along those lines is that the incision is rather long as the surgeon has to “open up” the knee.  Therefore, a proper healing environment has to be facilitated, but patients will also need extensive soft tissue work to break up any scar tissue from the incision.

Once the patient gets the “green light” from the doctor to begin strengthening, the process really kicks into high gear.  Weight-bearing exercises like squats, step ups, and leg press are initiated. Again, these are initiated in graded ranges so as to not stress the repair too much.  Loading increases over time.  Progress is measured by standardized strength testing as well as measurement of the muscle mass.  We like to tell our patients that their “tires need full inflation” before we release them to sports.  If the quadriceps muscles are smaller, athletes are at risk for a host of injuries.  Hopefully, that makes sense.

The other issue after this surgery is getting ROM back, especially end-range flexion.  Most of the time, surgical procedures are the ultimate “catch-22” – you need protected ROM to allow healing, but as a result, patients often battle getting the last bit of ROM due to stiffness/tightness.  Numerous techniques exist to maximize ROM gains, but the bottom line is that you need a physical therapist that provides hands-on treatment to get it.  Ultimately, athletes (and really all patients, but athletes especially), need to be able to get their heel to their glutes.  If not, a whole myriad of issues can surface.

Once adequate strength is restored, impact activities begin.  Athletes need to develop not only power, but neuromuscular control to tolerate landing from jumps as well as cutting during change of direction maneuvers.  Athletes especially have to demonstrate willingness to load the limb during these activities.  An astute sports physical therapist (like the ones at SSOR!) will be meticulous in their evaluation of the performance of these activities to maximize their return-to-play ability.

Will Jimmy Graham come back the same or better after this injury?

We bet he will.  Most athletes have every resource at their disposal to heal and get their bodies right.  It’s just a war of attrition – will he have the resolve to persist and keep working to get back? Only he will decide that.  Like we said above, expect a 6-8 month recover after this one.

SSOR has a goal-oriented population that demands results quickly.  Our staff understands post-operative protocols and more importantly, how to safely yet effectively progress you back to the activities you want to do.  It would be a privilege to partner with you in your care.  Give us a call! We have locations in Prairie Village and Overland Park to serve you.

Can You Do This Critical Movement After Knee Surgery?

Key Clinical Milestone After Knee Surgery

We see lots of people after knee surgery at SSOR – knee “scopes,” meniscus repairs, anterior cruciate ligament (ACL) reconstructions, and total knee replacements.  We also see lots of people as the “last resort” physical therapy place due to having persistent trouble after knee surgery and just not getting where they want to be.   Whether they have persistent swelling, pain, weakness, or poor range of motion, people come to us after knee surgery frustrated and searching for answers.  One of the first things we look at and one of our principle post-operative goals is to obtain full knee extension range of motion.  Previous studies have found that even a 3° loss of extension leads to a decline in function (Shelbourne & Gray, AJSM 2009).  It is critical that that the knee gets fully extended after surgery.  First of all, it is needed for proper walking gait.  When you are in the stance phase of gait (all your weight on one leg, the other swinging), the stance leg needs to be straight at that point.  Otherwise, you effectively walk with a shorter knee and you will have a quadriceps muscle that can’t best do its job.  Plus, if you can’t get straight, your quadriceps can’t stabilize your knee enough – it can lead to “buckling” during walking and instability.  The other key problem with lack of extension is that scar tissue can form in the front or anterior part of the knee, known as an infrapatellar contracture syndrome (Paulos et al, AJSM 1987).  If scar tissue forms there, it is very difficult for the knee to function properly.

Once your knee is fully extended, the hard part is getting the quadriceps muscles to work correctly.  Check out this video to learn more about how the quadriceps should work after knee surgery.

It would be a privilege to serve you and partner with you in your care.  Please understand that there IS a difference in quality of physical therapy, just like any other business.  We are confident you will be thrilled with our approach and your outcome.  Give us a call! We have locations in Overland Park and Prairie Village to serve you.

Peyton Manning Injury: Plantar Fascia Rupture

Plantar Fascia Rupture

National news was abuzz recently when Denver Broncos future Hall of Fame quarterback Peyton Manning recently ruptured his plantar fascia.  Now, anytime you hear the word “rupture” in sports, particularly in someone with Peyton Manning’s fame, it leads the headlines.  Fans are nervous and deflated, the “haters” have a collective chuckle or sigh of relief when the nemesis is incapacitated.  So what’s the big deal with plantar fascia ruptures?

Peyton Manning

What’s the plantar fascia?

The plantar fascia is a thick band of tissue that runs from the heel to each of the toes. Basically, it serves to support the arch of the foot and helps stabilize the foot during gait.  Think of it as a spring that runs from the heel to the toes.

Plantar Fascia

What causes the plantar fascia to rupture?

Any athlete that runs or jumps is at risk for a rupture, but any athlete who spends their time on their toes is at risk too (i.e. boxers, dancers).  Athletes with a history of chronic plantar fasciitis are at risk.  Steroid shots have also been implicated as a contributing factor in plantar fascia ruptures.   It is the very essence of a “Catch-22” with steroid shots – they help with pain and dysfunction, but over time, they weaken the tissue, making it susceptible to rupture.  Risk of rupture after steroid injections has been reported in the literature.

What are the symptoms?

Usually, athletes report hearing and feeling a “pop” on the bottom of the foot.  They may even be able to see and/or feel the fascia rolled up in the foot.  Pain, swelling, and the inability to walk are also signs of it.

What are the problems with a plantar fascia rupture?

Some may perceive that if it’s painful and bothersome, a rupture might be a good thing.  Sometimes it is.  In an athlete though, it could be problematic.  The support on the bottom of the foot is lost and stress fractures may result in the metatarsals, particularly on the lateral side as athletes tend to shift weight to the lateral border of the foot.  At a minimum, the arch is flattened and may result in pain or cause other problems, similar to people that have “flat feet.”

Do you have surgery to fix a plantar fascia rupture?

No.  Sounds crazy, but the tear is left “as is.”  Sounds like a big deal, but it’s really not with a custom orthotic and good rehab.

Physical therapy for plantar fascia rupture

Athletes are typically non weight-bearing for a couple of weeks.  After this initial period, athletes usually transition to a boot and then will transition to shoes once they have normal gait and minimal pain by 4-6 weeks.  Because the support of the fascia is missing, it is critical that athletes get custom orthotics to support the foot.  Additionally, intrinsic foot strengthening is needed to strengthen the arch muscles since the fascia is no longer there to support it.  It is recommended that athletes complete a comprehensive program of proximal hip strengthening, soft tissue work to the foot, and progressive return of functional activities.  Pool exercises are also a great adjunct to land-based treatment.

"Toe Curls" used to strengthen the muscles of the arch.

“Toe Curls” used to strengthen the muscles of the arch.

So how long does it take to get back to sports?  Well, a 2004 study in the Am J Sports Med found that in a group of 18 athletes with plantar fascia ruptures, the average time to return to sport was 9 +/- 6 weeks.  Much of that depends on the sport the athlete plays, the level of competition, as well as the size of the athlete.  Hard to predict at this time when Peyton Manning will be back running the Broncos offense.

The physical therapists at SSOR have treated plantar fascia ruptures and know how to get you back to the activities you enjoy.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park and Prairie Village to serve you.

Knee Lubrication Injections

Are Knee Lubrication Injections Worth It?

At SSOR, we have a fairly results-oriented, high-demand patient population that comes through our doors.  Knee arthritis is a common condition as people age and it tends to be accelerated in people who either had surgery or who were avid athletes “back in the day.”  Some patients though are in a difficult position – they have a fair amount of pain and dysfunction, but they aren’t quite old enough yet for a total knee replacement.  Total joint replacements last anywhere from 10-20 years right now, but this depends on a number of factors.  Therefore, many surgeons hesitate to do a total knee replacement on younger patients.  So what options are out there?

Knee Arthritis and Knee Lubricating Injections

The American Medical Society for Sports Medicine  recently released a position statement on “viscosupplementation” for knee arthritis.  Viscosupplementation is just a fancy term for knee lubrication injections for the knee.  Basically, as a knee deteriorates from arthritis, it loses its natural lubrication from the synovial fluid in the joint.  Effectively, the knee “dries out.”  Pain and dysfunction result.  Just like a squeaky wheel, your knee needs “grease” to be most healthy and without pain.  The knee lubrication injections basically help to provide lubrication to the knee.  Normally, you get three injections spread out over time.  These injections basically are just buying you time.

Knee Lubrication Injections

What’s the difference between cortizone injections and knee lubricating injections?

We get asked this a lot.  Of course, we encourage you to talk to your doctor about what option is best for you.  Cortizone injections are basically a powerful steroid that serves to decrease pain and inflammation in the joint.  Again, you typically get up to three spread out over time.  Research has shown that they do help in the short-term, but long-term, they have a negative effect on the joint.  It’s the ultimate “catch-22.”  We usually suggest to our patients that the cortizone shots are a great idea if say, you want to enjoy that beach vacation without hobbling around or being a “party pooper” because your knee hurts too much.  Maybe you have a child getting married in a couple of weeks and you don’t want to limp down the aisle.  In these cases, we say go for the cortizone.  It is not a long-term fix though.  Much like the lubricating injections, they are only delaying what is likely inevitable – a total knee replacement.  We suggest doing the knee lubrication injections and let them last as long as possible, then look to the cortizone down the road.  Ideally, you have as little of the cortizone shots as possible.

Can physical therapy help?

Physical therapy can help – to an extent.  We can’t change the knee arthritis, but we can help with impairments related to it.  For example, if you are stiff in the joint or have tender muscles surrounding the knee, we can do soft tissue work and manual therapy to the joint to help maximize what available motion you can have.  We will also give you exercises to not only strengthen the knee but also the hip muscles.  The hip muscles are critical because they support the knee.  We’ll give you stretches when appropriate and even talk about things for pain management.  You would be surprised all the “little things” you can do to take the edge off of your pain.  Stationary cycling and pool exercise is a great way to stay active and really helps reduce pain and keep what motion you do have.  Of course, weight management helps too.  The more weight you take off, the less stress on your knee.  Ultimately, after taking care of all of these things, committing to a long-term home program is what you need.

It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park and Prairie Village for physical therapy to help you.  Give us a call!

 

Elbow Pain: Are you sure it’s the elbow?

Neck Pain as the source of Elbow Pain

Does this sound like you?  You might be male or female.  You’re probably age 40 or greater.  Probably have a job where you sit at a computer all day.  At the end of the day, you have aches and pains in your neck and shoulder possibly, or just that bloody elbow pain that tends to be achy.  When you’re not sitting for prolonged periods, you usually feel OK.  Maybe repetitive movements start to bother your elbow, but you notice it way more often in the car, the airplane, or at the desk.   As it progresses, you feel it more constantly and the pain becomes more intense.

Elbow Pain

The physical therapists at SSOR are astute at evaluating the true source of our patient’s pain and dysfunction.  One thing that is not only diagnosed incorrectly but also treated inappropriately is elbow pain.  Many patients come in here with one or both elbows hurting and of course, they’re labeled with either tennis elbow or golfer’s elbow.  Maybe they’ve been to physical therapy elsewhere where they got the “cookie cutter” physical therapy – stretching, some exercises, ice, heat, bracing, etc.  Little to no improvements are realized.  Patients go back to the doctor and get more medications, get injections, and still, little relief.  Patients begin to get frustrated and think “am I crazy?”  Sadly, this happens regularly.  So how do you know?

Many times, elbow pain, regardless of it is medial or lateral, often comes from the neck.  The cervical spine has been implicated as a source of elbow pain in studies here, here, and here just to name a few .  An X-ray would show that you may have some arthritic changes in the neck, but a competent physical therapist (just like the PT’s at SSOR!) will pick this up.  Clearly, our competitors are not because we’re seeing people come here at the recommendation of others because they’re just not getting better elsewhere!

Achy Elbow Pain – What’s Causing It?

Elbow pain from the elbow – may be point tender or have general achiness around the elbow, but usally nowhere else.  Pain with specific activities – gripping coffee cups, lifting purses or briefcases, grabbing door handles, achiness from typing, or if you’re a golfer, along the inside of the elbow with golfing.

Elbow pain from the neck – typically achy, might be intermittent or constant. May have pain that radiates from the neck and shoulders down to the elbow.  May have associated numbness or tingling from the elbow to the hand.  Not a typical pattern, but you tend to be worse in prolonged positions.  The end of the work day is usually the worst.  You tend to feel best in the morning.  You should also be highly suspicious of neck being the source if BOTH elbows hurt.  Nobody gets bilateral tennis elbow (exception being maybe motorcyclists who have to grip handlebars with both hands!).  Be on alert for this!  Rare to have the same problem on both sides and have the elbows be the source.

How do you treat elbow pain from the neck?

After we determine it’s the neck, we’ll do things like postural exercises, stretching of the front shoulder, spinal mobility, strengthening of the back muscles, and specific manual therapy techniques to improve soft tissue and nerve mobility.  Amazingly, our approach gets people’s elbow pain better – often without ever touching the elbow.  Numerous studies here, here, here, here, and here have all shown treating the neck helps with elbow pain.

We put ourselves out there – we tell our patients that they should expect results quickly.  If we’re right about our evaluation finding the neck as the source, you’ll be markedly better within a couple of weeks.  You should expect this from good physical therapy.  You should see positive trends quickly and not go endlessly for months on end with no end in sight, regardless of your condition.  This approach is wasteful of both your time and money.

It would be a privilege to serve you and partner with you in your care.  Remember, you can see a physical therapist in Kansas without a physician referral.  Give us a call – we’re confident we can help you!  We have physical therapy locations to serve you in Prairie Village and Overland Park.

Morton’s Neuroma

Treatment for Morton’s Neuroma

 

Funny how we physical therapists don’t see something for a while, then we get a run on something.  Morton’s neuroma is a painful condition that affects the foot.  It can cause sharp pain, burning, and aching in between the toes.  People that have it struggle to wear shoes for work and even have pain walking.  It can get worse over time and the pain can become constant.  What is the best way to treat Morton’s Neuroma?

What is Morton’s Neuroma?

Morton’s neuroma is inflammation of the neurovascular bundle between the metatarsals, or foot bones.  There is not a lot of space between your foot bones and the vessels and nerves that supply the region are squeezed in there.  As a result of wearing narrow shoes, high heels, or just tight shoes can cause swelling of that bundle and eventually cause a fair amount of pain.

mortons_neuroma

What are the symptoms of Morton’s neuroma?

Typically, people complain of sharp, often burning pain between the toes.  Some people report numbness too.  Sometimes, patients report that it feels like there is a marble or a pea in the area.  Pain is typically worse with walking and activity and feels better at rest or walking barefoot or with flip-flops as both of these conditions allow the foot to spread out.  You may be able to “self-diagnose” it if you’re not sure by just squeezing the foot together.  If that’s really painful, you may be dealing with Morton’s neuroma.

How do you treat Morton’s neuroma?

Like most things, there are a few ways to address Morton’s neuroma.  Often, the first thing people do is get a steroid injection.  Some studies have supported this.  One study said it can help up to three months and another recent study also supported their efficacy.  Some research has suggested that the size of the neuroma may indicate if the injection will work or not.

Physical therapy for Morton’s neuroma can help too.  Education on shoe wear is a good place to start.  Avoid wearing high heels or “pointy” shoes as the toe box is very narrow.  Rest your feet when possible or wear slippers in between bouts of having to wear dress shoes.  Stretches for the calf muscles, strengthening of the foot intrinsic muscles, and soft tissue mobilization to the plantar aspect of the foot can help.  It is also recommended that you try a metatarsal pad to help create space between those toes.  They can be purchased online or at any medical product store.  Things like ultrasound don’t help too much and have little evidence to support it.

Soft tissue mobilization of the foot with a lacrosse ball. Roll the ball back and forth over tender areas.

Soft tissue mobilization of the foot with a lacrosse ball. Roll the ball back and forth over tender areas.

If these “home remedies” don’t work, you should consider seeing a physical therapist for an evaluation.   They may steer you to a physician for an X-ray or a potential injection if warranted.

It would be a privilege to serve you and partner with you in your care.  We have physical therapy locations in Overland Park and Prairie Village to serve you.  Give us a call!

By the way, who the heck is Morton?

We don’t know.  Some guy named Morton discovered it.  Fun facts though – Steven Tyler had surgery for it, and even one of the “Golden Girls” had it too!  So don’t feel alone!