Blood Flow Restriction Training

Blood Flow Restriction Training: Is it Worth the “Squeeze?”

There are continual innovations in sports medicine.  Whether it’s through biologic injections (PRP, stem cells) or advancements in rehabilitation approaches, the sports medicine community is always looking for the “next best thing” to help athletes recover and perform better.  One such innovation that has gained popularity over the last few years is blood flow restriction training (BFR).  ESPN did a feature on BFR in 2014 and numerous professional athletes have used this and some teams are using it regularly.  Unfortunately, their are numerous interventions in our field that have little scientific evidence for their efficacy (kinesiotape and cupping for example).  However, this is one innovation in the field of sports medicine that has significant scientific support for it’s use.  At SSOR, we’re using it as an adjunct to rehabilitation for our patients.  So what’s the deal with blood flow restriction training?

What is Blood Flow Restriction training?

Blood flow restriction training, also referred to as “occlusion training,” involves the use of a pneumatic device, similar to a blood pressure cuff (or a similar device) to restrict (NOT cut off!) arterial blood flow during exercise.   It feels very similar to how you feel when you get your blood pressure taken, just not as tight.

Why would I do blood flow restriction training?

For some patient populations, like those with advanced knee arthritis, it causes too much pain to lift heavy weight.  One of the principle objectives in rehabilitation is to build strength.  Well, building strength requires higher loads/resistance.  Many patients cannot tolerate higher loading – those with arthritis, the elderly, or those that have loading restrictions.  Blood flow restriction training enables similar gains in strength and muscle hypertrophy (muscle size) with less loading.  Several studies have shown that using BFR with exercise has improved strength and hypertrophy more than those exercises alone (Takarada et al, J Appl Physiol 2000; Takarada et al, Jap J Physiol 2004; Yasuda et al, Metabolism 2006; Abe et al, J Appl Physiol 2006; Abe et al, Med Sci Sports Exerc 2004).   Furthermore, studies have shown that BFR training has improved atrophy after ACL reconstruction (Takarada et al, 2000; Ohta et al, Acta Orthopaedica 2003; Takarada et al, Med Sci Sports Exerc 2000) and even on atrophy after immobilization (Wall et al, Acta Physiol 2014; Kubota et al, Med Sci Sports Exerc 2008; Cook et al, J Appl Physiol 2010).  Finally, other studies have shown that BFR training leads to less tissue damage compared to other traditional means of training (Loenneke et al, 2012).  Traditional strength training may make muscles sore and usually, you need to wait 48 hours before training the same muscle groups again.  With BFR training, because the loads are so low, you can train more often and the lighter loads are not likely to make you sore.

Despite all the support in the literature above, studies by both Giles et al (BJSM 2017) and Bryk et al (Knee Surg Sports Traumatol Arthrosc 2016) found that while BFR did help with pain relief, outcomes like strength improvement, atrophy, and functional testing showed no difference compared to traditional strength training.

How does it work?

Well, this is a complicated answer because it can get really boring talking about the cascade of metabolic changes that occur.  In the absolute simplest terms, BFR helps increase production of muscle building hormones and substances in the blood stream (Takarada et al, J Appl Physiol 2000; Takarada et al, J Physiol 2004; Yasuda et al, Metabolism 2010; Abe et al, J Appl Physiol 2006; Abe et al, Geriatric Phys Ther 2010; Abe et al, MSSE 2004).  Additionally, by limiting blood flow to muscles to muscles that need oxygen-rich blood to function (slow twitch fibers, or Type I fibers), the “fast-twitch” or Type II fibers, have to work harder (and fast twitch fibers aren’t as dependent on oxygen-rich blood like slow twitch fibers are).  Fast twitch fibers are the muscles that produce the most force and are also the ones that we target when trying to get you stronger after an injury.  Usually, it’s the fast twitch fibers that get the weakest and the smallest after injury or surgery.

How do you do Blood Flow Restriction Training?

There are many devices that can be used for BFR training (Delfi, B Strong, Occlusion Cuff are the most common in rehabilitation settings).  Some units cost upwards of $5000 and the most primitive types are knee wraps used in powerlifting/weightlifting.  The more expensive units allow only one person at a time train with BFR, so it is not practical for teams or large groups.  Plus, that can get expensive!!  Fortunately, there are other options.  In a study by Wilson et al in 2013, 12 trained males used knee wraps wrapped to a subjective 7/10 pain.  Ultrasound imaging was used to confirm vascular occlusion, so this is an alternative method that is more budget-friendly.  Using knee wraps, due to their cost and ability to be used with many athletes at once, is known as “practical BFR.”  Another way is to use a BFR cuff around the thigh and find the pedal pulse.  Pressure is increased until the pulse can no longer be palpated.  Then, the clinician will take 60% of the systolic pressure and have the patient train at that intensity (Loenneke et al, J Appl Physiol 2013; Giles et al, BJSM 2017).We find that a majority of our patients fall in the 150-170 mmHg pressure.  Lastly, thigh circumference can also be used as an estimate of pressure to utilize (Loenneke et al, Eur J App Physiol 2012).  With a thigh circumference <45-50 cm, inflate to 120 mmHg; 51-55 cm, inflate to 150 mmHg; 56-59 cm, inflate to 180 mmHg; >60 cm, inflate to 200 mmHg.  Basically, it will take more pressure to occlude a larger limb.

Because of lighter loads, the athlete/patient will do more repetitions.  Normally, you do 30 repetitions the first set, then follow with 3 consecutive sets of 15 repetitions.  Take a minute between each set.  You don’t want the cuff/wraps on for any longer than 15 minutes.  This does make exercise difficult to complete and make no mistake, it’s not comfortable!  However, you should complete the 75 repetitions, or be really close to it.  The wrap/cuff is too tight if you have numbness in the leg or can’t complete the prescribed repetitions.

Knee wraps normally used for wrapping knees for weight lifting can be used for “practical BFR.”

This doesn’t sound safe.  Is BFR safe?

There’s always a few things to keep in mind.  If you have varicose veins, are pregnant, have high blood pressure or cardiac disease, or have a current deep vein thrombosis (DVT) or a history of one, you should consult with your doctor.  Other studies have been done on safety (Nakajima et al, Int J KAATSU Training Res 2006; Heitkamp et al, J Sports Med Phys Fitness 2015) and minimal to no negative have occurred and those effects were transient (brief numbness, petechiae on the skin).  There have been reported case studies showing adverse effects (Noto et al, Internal Med 2017), but improper training methods were used, occluding for an hour every day.  Surgical tourniquets are inflated for roughly two hours with a complication rate of 0.04% (Odinson & Finsen, JBJS Br 2006), so 15 minutes is far less than that.  So, BFR is definitely safe if used correctly.

Blood flow restriction training may help you and enhance your recovery after injury or surgery.  At SSOR, we utilize BFR training on specific patient populations.  Not sure if it’s for you?  That’s OK, we can talk about it!  Fact is, traditional methods of training work just fine – this is just another means to an end.  It would be a privilege to serve you and partner with you in your care.  Give us a call!


Patellar Instability: My “Kneecap” Goes Out!

Rehab For Patellar Instability

Patellar instability can be a debilitating and frankly, a terrifying condition to deal with because you have no idea when or how the patella will “move out of place.”  When it does, it can be painful and crippling.  Patellar instability encompasses a few different scenarios.  Patellar dislocation is when the patella or “kneecap” moves out of place and stays there.  Sometimes a person can move their knee and it will pop back into place and other times, people need the hands of a skilled medical provider to help it reduce.  Patellar subluxation is when the patella slips out but comes back into place immediately.   Still, others can have patellar instability from a shallow trochlear groove (the groove in the thigh bone that the patella sits in) that enables it to move out of place easily, and some have loose soft tissue around the patella which makes it easy to be unstable.  Patellar instability may be a result of multiple dislocation or subluxation events that over time stretches your tissues to the point that they’re like “Silly Putty.”  At SSOR, we understand how to address this conservatively but also how to help you should you need surgery.

Picture of Normal, Subluxed, and Dislocated Patella

Picture of Normal, Subluxed, and Dislocated Patella

What are the symptoms of patellar instability?

People with patellar instability typically have a history of an injury where the patella “went out of place.” Once that happens, the tissues around the knee get stretched out and therefore make it easy for this to happen.  Symptoms of patellar instability include but are not limited to: aching in the knee or the feeling of the inability to get comfortable, the feeling of “popping” with activities of daily living, pain squatting/going down stairs, and feelings of apprehension when doing functional activities for fear that it will go out of place.  Sometimes people with patellar instability also have systemic hypermobility, whereby they are “loosey goosey” throughout their body.

Do I need to have surgery?

Not necessarily.  You should always try conservative measures first, and that starts with physical therapy.  You should try structured physical therapy and home exercises for at least 6 weeks.  The only time you should consider surgery is if rehab failed (but make sure it’s the right rehab! We’ll talk about that below), or if there is gross instability in that it goes out all the time.  For example, people that still dislocate/sublux rolling over in bed, walking, or sitting on the toilet after physical therapy should consider having surgery to stabilize the knee. There are many different procedures that can be done and these should be explored with your orthopedic surgeon.  Most commonly, people have a medial patellofemoral ligament reconstruction to help restore stability to the patella.

Will a brace help?

Bracing can help a little for patellar instability, particularly during activity, but it can’t be the only intervention.  We are not aware of any controlled studies saying that these lead to a better outcome.  You should ask for/get a buttress brace or a patellar stabilization orthosis.  There are many different kinds on the market.  Sometimes, braces serve only to give you peace of mind that you have some compression and support around your knee.

Physical Therapy for Patellar Instability

  1.  First and foremost, a thorough physical examination is required to evaluate you for any anatomical or structural abnormalities that may be exacerbating your condition.  Examples might be excessively flat feet, anteroverted or retroverted hips, or lateral positioning of your tibial tuberosity.  All of these basically change the line of pull of the quadriceps in one way or another and enable the patella to slip out.  You should see an orthopedic surgeon to get X-rays and an MRI to determine extent of bony and soft tissue damage.  Ultimately, this will help predict if physical therapy will be helpful or not.
  2. Strengthening of the quadriceps, gluteals, and hamstrings.  All of these muscles provide structural support to the knee. Whether it’s a first time dislocation or you’ve had multiple episodes, your quadriceps are likely atrophied and very weak.
  3. Balance training.  It is imperative that balance training be done on the lower extremities.  Working on balance training helps keep the knee stabilized during functional activities.  It should start on stable, flat surfaces and progress to more unstable ones.  The idea is that when things happen suddenly during our daily lives, the muscles can respond quickly to stabilize the knee and avoid an episode.
  4. Ice massage for pain.  Works wonders, just try it.
  5. Bracing
  6. Activity modification.  Depending on your recreational interests, they may put you at risk for further complications.   Therefore, you may have to modify or adjust your activities until after physical therapy is complete.  That said, many people are able to play their chosen sport after physical therapy and with the use of a brace.  However, you should be evaluated with functional testing measures, like hop testing, to determine physical readiness for sports.  Testing is of particular importance if you desire to play a cutting/pivoting sport.

If commit to the process of rehab and you’re still having trouble, it’s probably time to go back to your physician and consider surgery.  Fear not, people do quite well following surgery for patellar instability.  Depending on what they have to do in surgery, it may take a little longer to recover fully, but you should be pleased.

Patellar instability doesn’t have to be a continual problem and the reason for your inactivity.  A structured, comprehensive physical therapy program by a sports physical therapy specialist will help you reduce pain and maximize your function after a thorough exam by an orthopedic surgeon.  The experts at SSOR welcome the opportunity to serve you and it would be a privilege to partner with you in your care.

Three Huge Fitness Mistakes You Might Be Making

3 Fitness Mistakes: Are You Guilty?

We see people in physical therapy on a regular basis that get injured when starting well-intentioned fitness programs.  This is a bit of a paradox for us because injured folks are our lifeblood, but so much of these things can be avoided!   The staff at SSOR is committed to helping you help yourself avoid having to come see us, so here’s three avoidable things you might be doing:


1.  Not getting properly screened before starting.  If you’ve been sedentary for a while or are trying a “couch to 5K” plan, it’s a good idea to see your physician to make sure you’re healthy for activity.  Additionally, you should see one of the physical therapists at SSOR to do a musculoskeletal screen of you to make sure nothing is lurking below the surface that will create problems for you down the road. You should be long, strong, mobile, and stable!

2. Starting too fast/too much too soon.  The hot trend these days is do it fast and do it quickly.  However, without a general fitness base, this will inevitably lead to problems.  If you don’t have appropriate joint mobility or have an injury history that may have caused mobility deficits, you’re asking for trouble.  Without proper work capacity/tolerance, fatigue ensues and with fatigue comes poor technique.  Poor technique almost always leads to injury at some point and a visit to the gang at SSOR.  Ramp things up slowly.

3.  Not listening to your body.  May be you’re working really hard and are really short of breath or light-headed.  Your body is telling you to stop, so you should.  If not, at a minimum, reduce how hard you are working or take a break.  Additionally, if you’re having pain with exercise or things during normal daily living start to hurt, it means you may have a problem on your hands.  If that is the case, give the physical therapists at SSOR a buzz and we’d be glad to help get to the root of the problem.

The physical therapists at SSOR are all about solutions, not stop gaps.  We’ll figure out the problem and get you back to doing the things you enjoy doing as soon as possible.  Give us a call, it would be a privilege to serve you and partner with you in your care.

Sciatica: “A Pain in the Butt”

Physical Therapy for Sciatica

Sciatica is an all too common condition that we see on a regular basis here at SSOR.  Also known as “piriformis syndrome”, sciatica is a painful, aggravating diagnosis because it limits your ability to stand and walk and requires specific positions of relief, often sitting or lying down.  People with this condition typically have low back and/or hip pain with associated pain and/or numbness, “buzzing,” or burning in the gluteals that can extend down the leg.  The purpose of this post is to educate you on sciatica and of course, what you can do about it.

What is Sciatica?

The piriformis is a muscle deep in your hip, under your gluteals.  Basically, it runs horizontally across your bottom on both sides.  Directly behind the piriformis is the sciatic nerve.  The sciatic nerve is a thick, broad nerve at this location.  Because they are in such close contact, the piriformis can “rub” on the sciatic nerve, which causes the pain and numbness in the hip and possibly the back of the leg.  That’s why sciatica is often discussed interchangeably with piriformis syndrome.

What Causes Sciatica?

Well, there are a host of potential causes.  If you have a disc bulge or herniation, the pressure on the nerve can cause the pain and/or numbness.  Stenosis, or narrowing of the foramen the nerve exits out of, also puts pressure on the nerve in a similar way.  Muscle tightness and hip weakness can also contribute to sciatica because either of them can alter muscle length and strength and the lack of either strength or flexibility can irritate the piriformis muscle.  Finally, there are a host of people that can get sciatica from trauma, like car accidents or stepping awkwardly off a curb for example.

Exercises for Sciatica

There are several potential treatments for this, but it really depends on the reason you are experiencing symptoms.  Here’s a video link to “home remedies” you can try.  A thorough evaluation by the physical therapists at SSOR will undoubtedly help you find out the true cause of your pain and discomfort.  Activity modification and posture/ergonomics education are two basic but very important parts of treatment.  Often, soft tissue work to the piriformis with a foam roller or lacrosse ball, stretching, and “nerve glides” are three DIY techniques you might try, all shown in the link above.  Manual therapy to loosen a stiff spine and pelvis can be effective as well.  Finally and perhaps most importantly, hip abductor and external rotator strengthening exercises (Figures 1 and 2 below) will help control both the femur and the pelvis to prevent aggravation of the piriformis.  Things like ultrasound and electrical stimulation are completely useless for piriformis syndrome or sciatica, so if your current physical therapist is doing either of them, it’s probably time to find a new physical therapist.

“Clamshell” exercise for hip external rotator strengthening

Sidelying leg raise for gluteus medius strengthening. Lay against the wall and while keeping your heel against the wall, raise your leg up and down.


The physical therapists at SSOR are experts in biomechanical evaluation and assessment. Sciatica is definitely one condition that requires a thorough evaluation by a skilled, experienced physical therapist to find out the true cause of your symptoms and help you reduce pain.  You shouldn’t live in pain.  We have locations in Overland Park and Prairie Village to serve you.  It would be a privilege to partner with you in your care.

Udoka Azubuike: MCL Sprain

Rehab Guidelines for MCL Sprains: KU’s Udoka Azubuike

The Big 12 tournament is underway and KU hoops star Udoka Azubuike suffered a knee medial collateral ligament (MCL) injury in practice recently.  Of course, like any in-season sports injury, the timing is not good.  Looks like he’ll miss the Big 12 tournament.  So what’s the deal with these injuries, and everyone wants to know, will he be ready for the NCAA Tournament?

KU’s Udoka Azubuike


What’s the MCL?

The MCL is a ligament along the medial aspect of the knee.  It’s more of a thickening of the joint capsule, more “sheet-like.”  It is also an extra-articular ligament, or outside the joint.  On the contrary, the infamous anterior cruciate ligament (ACL) is intra-articular, or inside the knee and is more “rope-like.”  There are four knee ligaments that contribute to knee stability, and the MCL helps prevent the knee from “buckling” to the inside.  Here is a comprehensive link on MCL anatomy and function.

Illustration of the medial collateral ligament of the knee.

Illustration of the medial collateral ligament of the knee.

How is it injured?

Most of the time, the MCL is injured from a blow to the outside or lateral aspect of the knee which causes the knee to buckle inward.  However, the MCL can also be torn from an awkward cut or land from a jump.  It can be injured in the mid-substance over the joint line, or off of its bony attachments on the tibia or the femur.  In this case, there are a number of reasons why Udoka Azubuike could have sprained his MCL – could be contact or non-contact.

Possible mechanism for MCL sprains. Here, the knee buckles inward as the athlete makes a cut

Possible mechanism for MCL sprains. Here, the knee buckles inward as the athlete makes a cut

How long do they usually take to heal?

A general rule in sports medicine with MCL injuries is that it is about two weeks of time loss for each grade of tear.  Therefore, with a Grade I tear, expect two weeks out, Grade II four weeks, Grade III tear would be approximately 6 weeks out.  Certainly, this rule is not an absolute as athletes may require more or less time.  Proximal, or femoral attachment MCL sprains, tend to heal a little faster but can stiffen up.  On the contrary, distal or tibial attachment tears tend to heal slower, but typically aren’t as stiff.  All that said, injury history, concomitant injuries, time of season, level of play, and athlete confidence are just a few of several other considerations that affect return to play.  Sounds like the injury to Udoka Azubuike wasn’t too bad, so we’re guessing on the lower end of this general rule.

Why is an MCL sprain a big deal?

As an elite basketball player, Udoka Azubuike is frequently jumping, landing, cutting and changing direction, let alone getting hit from opponents on the outside of the knee.  Given that the MCL provides medial stability to the knee and helps prevent “buckling” of the knee, it’s critical for him that this ligament is doing its job.  Therefore, he needs stability of the knee during these manuevers.  Without it, he could be at risk for a more serious injury, like an ACL tear.  Typically, you want to avoid surgically repairing an MCL unless it’s part of a more severe injury, like a multiple ligament knee injury.  Even then, surgeons usually elect not to fix it and let it heal over time.  After surgery to repair the MCL, the knee stiffens instantaneously and makes rehab a significant challenge.  Best to rehab these injuries at all costs.

Can’t we just brace his knee and play?

Well, it’s not that simple.  No brace can “prevent” any further injury and if there’s any instability or pain, he’ll still deal with that, even if to a lesser extent than no brace.  Certainly, they can help athletes feel more confident that “something” is there to support the knee, but it’s not much more than a “security blanket.”  Remember too that athletes have to be mentally okay with wearing a brace too.  Some athletes just can’t play their sport with restrictions.  They’re not used to it and it’s “different.”  Because he’s a basketball player and the how the timing of this injury isn’t good, we’re guessing he’ll wear a brace for a little extra protection and support.  It shouldn’t affect his play at all should he choose to wear one.

Physical Therapy for MCL Sprains

The rehab for MCL sprains depends of course on severity of the sprain.  The more serious the sprain, the slower the process.  In the case of Udoka, they’ll likely be a little more aggressive because it’s not a bad sprain and the timing of the injury makes return to play of prime importance.  His rehab will likely be pain relief and modality driven to control his pain and get him back on the court ASAP.  With an acute, severe sprain, the athlete is likely to need crutches, a brace, and graded range of motion progression.  Progressing range of motion too fast with this injury may cause more pain and impede optimal healing of the ligament.  In general though, here’s a rehab outline:

  1. Control pain. Icing, compressive wrapping, a knee brace, and use of a crutch or crutches will all help reduce pain and promote healing of the ligament.  Another “training room trick” is to put a medial heel wedge in the shoe of the affected knee.  Effectively, the medial wedge may decrease strain on the healing ligament by compressing the medial joint line, even if only a little.  It’s one of those interventions that is by no means a game-changer, but can help.
  2. Low-intensity pulsed ultrasound (LIPUS). There was a time when ultrasound was used for everything. Therefore, its effectiveness has continually been debated and questioned.  Unfortunately, it has been discarded as a useful modality and this is actually one injury where it may help.  However, there are some good studies supporting the use of LIPUS for MCL healing here, here, and here.  Laser therapy is also an option and can be effective for these capsular ligaments near the surface.
  3. Restore range of motion. The use of a bike, pool, or heel slides are all ways that can help an athlete restore their range.  The optimum stimulus for regeneration of ligaments is modified tension in the line of stress, and tons of repetitions at that.  That is precisely why cycling is a great modality for these injuries.  With more severe sprains, a graded range of motion progression may be done to help prevent over-straining of weakened, painful tissue.  Therefore, an athlete may have 30-90° for a couple of days, then open 10° in each direction every day or two after until full range is restored.  In more chronic cases with pain in specific ranges of motion, instrument assisted soft tissue mobilization can help break up scar tissue and facilitate healing.  There is one study using these instruments for this injury from the Journal of Orthopedic and Sports Physical Therapy that supports use of these tools to facilitate healing.  Just because of pain, it is not recommended to use the instruments acutely.  They’re best suited for chronic injuries/chronic phases of healing.

    Tools for instrument assisted soft tissue mobilization.

    Tools for instrument assisted soft tissue mobilization.

  4. Strengthening of the lower extremity. All sagittal movements (moving forward) should be painless prior to initiation of lateral and rotational movements.  Lunges, step ups, squats, and leg press are just a few exercises that can be utilized. Of course, strengthening the hips should be a part of a comprehensive program for this injury.  One word of caution – hamstring curls can be painful with this injury.  Proceed carefully.  Once straight-ahead movements are tolerated, progressing to lateral and rotational movements should follow.  In Udoka’s case, they won’t be too worried about how much weight he’s pushing – they’ll just be concerned about his ability to perform on the court.
  5. Graded progression of return to sports activities. Forward jogging can commence once range of motion is restored and the athlete has passed strength testing.  Speed will be gradually increased.  45° cuts, shuffling, and 90° cuts would follow, then the athlete would progress to more field or court-based sport-specific drills.  A good progression is non-contact individual drills non-contact team drills, contact drills, then full release to activities.  Udoka may have some discomfort as they expedite the healing process, but as long as he can perform on the court, this phase of rehab will be a quick one!!

Once sports activities are painless and the athlete’s confidence is restored, return to play should be considered.  Regarding bracing with these injuries, it’s really a personal preference of the athlete.  Offensive/defensive linemen might consider wearing it due to bodies crashing into each other and lots of lateral, contact movements.  Unfortunately, these braces sometimes make athletes a target for insidious actions by opponents.  We’ll see – Udoka might wear a brace for some extra support, especially if he’s still having some discomfort or confidence issues with his knee.  The biggest things to consider are 1) can he protect? and 2) can he perform?

If you suffer an MCL sprain or any other knee injury for that matter, look no further than the expert physical therapists at SSOR to help you.  Remember, you don’t need a physician referral to see a physical therapist in Kansas.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park & Prairie Village to serve you.

Exercises for Achilles Tendinitis

Treatment for Achilles Tendinitis

We have an active, results-oriented population here at SSOR.  As a result, we see many patients who are battling “tendinopathies,” a catch-all term for pathology and pain in tendons.  One of those regions we see a lot that affects people across the lifespan is Achilles tendinopathy.  The general public commonly refers to it as “Achilles tendinitis.”  Achilles tendinitis can be painful, debilitating, and significantly restrict your ability to perform activities of daily living as well as recreational activities.  So what’s the deal with achilles tendinitis?

What are the causes of Achilles tendinitis?

Like most injuries, there are intrinsic causes that center around your body structure and there are extrinsic causes that center around training methodologies or training environments.  Intrinsically, flat feet can stress the Achilles because it creates an angulation of the heel and alters the pull of the Achilles.  Previous injury can cause Achilles tendinitis from residual strength deficits.  People that are excessively flexible or very tight can also be susceptible to Achilles tendinitis.  These are just a few of the common intrinsic causes, but many more exist.

Extrinsic causes basically center around training errors.  The biggest one is doing too much too soon and not properly progressing exercise, like running or training for races.  Another extrinsic cause is the training surface.  Concrete is not very forgiving.   You should run on school tracks, trails, or blacktop to ease the shock on the Achilles.  Shoe wear can contribute.  Therefore, make sure you purchase supportive, comfortable shoes, not because of the logo on the shoe.  Finally, believe it or not, some powerful antibiotics have been implicated in Achilles tendinitis because they are believed to kill tenocytes, which are tendon cells.   You should talk to your doctor if you’ve been ill recently and were on an antibiotic and then started having trouble after.

What are the symptoms of Achilles tendinitis?

The first thing that needs to be done is to diagnose it accurately – it could be tendinitis or tendinosis.  Dull, poorly localized, achy pain that is more chronic is likely a tendinosis.  Truthfully, it’s better to use the term “tendinopathy” when talking about this injury because if it’s treated as an “itis” when it’s as “osis,” the outcomes can change.  Tendinosis is a more degenerative, non-inflammatory condition and should be treated a little differently than a tendinitis.  Tendinitis is sharp, localized pain that is usually of recent onset.  Tendinitis is an inflammatory condition while tendinosis is not.  Anti-inflammatory medications like Ibuprofen won’t help a tendinosis at all, nor will ice very much.  However, ice and anti-inflammatories can help reduce pain with tendinitis.  Typically, pain surfaces either during or after activity and usually resolves with rest.  Pain may be where the Achilles attaches on the heel or in the Achilles itself.  It will hurt to go up and down stairs as well as during the activity that likely caused it.  People with Achilles troubles tend to hurt more in the morning, feel better as the day progresses, then hurt at the end of the day.  You may also have a limp when you walk as well.

 Exercises for Achilles tendinitis

There are several things you can do to treat Achilles tendinitis.  Ensuring you have properly fitting shoes and if necessary, orthotics is a good start.  A slight heel lift in your shoe can reduce strain on the Achilles as well and is a cost effective intervention.  Basically, put this in the shoe of the involved leg and see if that helps when you do your activity.  Stretching exercises for the calves is very important and you should stretch both your gastrocnemius and the soleus.  Stretches should be held for 30 seconds.  See figures 1 and 2 for these stretches.

Recent evidence has supported the use of isometric exercises to help with tendon pain.  This video specifically shows how to do this for the Achilles. Eccentric exercises have also been shown to be effective for Achilles tendinitis.  That said, there is a very specific way they should be done and you should see a physical therapist or athletic trainer to learn how.  Here is a well-written blog on progressing these exercises.  Finally, similar to any lower extremity injury, gluteal strengthening is imperative because strong glutes stabilize the pelvis and everything attaches to the pelvis.  Those big muscles in your hips act as shock absorbers so that skinny Achilles doesn’t have to work so hard.  It may not make a lot of sense, but gluteal strengthening should be an integral part of rehabilitation for Achilles tendinitis.

Figure 1: Gastrocnemius stretch. Keep your knee straight, heel on the ground, and bend the front knee towards the wall until you feel a stretch in the Achilles. Do not let your heel raise from the ground.

Figure 2: Soleus Stretch. Bend the back knee, keeping the heel on the floor.

We are experts in the treatment of tendinopathies.  Our team of physical therapists understand how to evaluate these conditions and how to apply interventions that specifically target your pain and dysfunction.  It would be a privilege to serve you and partner with you in your care.  Give us a call! Remember, you can see a physical therapist in Kansas without a physician referral.




How to Treat Muscle Cramps

Ways to Treat Muscle Cramps

If you lead an active lifestyle like many of our patients here, at some point or another, you probably got muscle cramps.  Maybe you got muscle cramps in your calves, or maybe in your thigh muscles.  These are painful!  If you haven’t, you’ve probably seen athletes on TV who are crippled by muscle cramps and see the athletic training staff feverishly working to resolve them.  We typically see cramps most often in really hot weather when athletes have been sweating profusely for a long period of time.  They lose lots of water and electrolytes and for all intents and purposes, their muscles dry out like a raisin.  Certainly various mechanisms for muscle cramps have been proposed, but what are some easy things you can do to avoid muscle cramps?

How to Reduce Muscle Cramps

1.  Hydrate, hydrate, hydrate.  A good rule of thumb is to weigh yourself before activity and weigh yourself after.  For every pound lost, you should replace that with 2 cups of water each.  Unfortunately, this takes a lot of discipline!

2. Stretch!  Whether it’s your hamstrings, quads, or calves, easy stretching usually helps reduce these.  If that’s not doing the trick, putting some deep pressure on the muscle can help too.  So, pressure with a foam roll or an athletic trainer/friend can put manual pressure on it.   Typically, this is what is done “on the court/field.”

3.  Consider changing clothes at halftime or during a “break” in the action if you’re soaked.  When you are soaking wet from sweat, the wet clothes won’t allow the sweat to evaporate.  So, having an extra pair of socks, underclothing, shirts/jerseys, etc may help.

4.  Have fluid replacement products readily available.  This is where sports drink companies make their money.  They have electrolytes in them to help replace some that are lost from sweating.

5.  If possible, have IV’s available.   IV fluids are the fastest way to re-hydrate.  Obviously, medical professionals need to be present for this to happen, so this might not be an option in your situation.

6.  Avoid alcohol.  Alcohol is a diuretic (makes you pee!), and if you lose water from a night of drinking before practice/game, you will be more susceptible to cramps.  Similar argument can be made for coffee.  Coffee is fine, just make sure you’ve had plenty of water prior to vigorous exercise.

7.  Stay loose and stretch between games.  Cramps seem to show up when athletes have had a long bout of playing followed by rest/no activity, then playing again.  That said, this is also an issue of hydration.  Make sure you re-hydrate between games to compliment your stretching. Foam rolling and using massage sticks can help with this too, both before and after games as well as breaks in the action.

8.  Recover!  This one encompasses many of the ones listed already.  Young athletes especially have crazy schedules nowadays.  Many sports and activities going at once.  If they don’t “fuel the power plant” with fluids and a good diet, they’re at risk for muscle cramps.  Make sure water is readily available and proper nutrients from a balanced diet help in the recovery process.  Certainly, things like massages are helpful too.

9.  Acclimatize your body.  With air conditioning being almost everywhere now, athletes sit inside all summer and then start practicing outside in the August heat and really struggle.  This is not to say that they need to be outside for 8 hours a day running sprints.  It is to says that in the weeks leading up to starting practices, you should be outside in gradual increments to get your body used to the conditions.

Muscle cramps hurt and can pull you out of activity, often at the worst time.  While there is some debate about what causes them and the best way to treat them, there’s some easy things you can do to help reduce the risk of getting them as well as what to do if muscle cramps happen.  If you have chronic trouble with this, you should consider seeing your primary care physician for more advanced testing.

Muscle cramps or not, our team of physical therapists are competent, skilled, and understand how to help you recover from injury.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

Rehab after an Ankle Sprain

Ankle Sprain Rehab

Ankle sprains are very common and occur across all sports and frankly, across all walks of life.  Almost 80% of ankle sprains are of the “inversion” nature.  Inversion is basically the motion when you “roll” your ankle.  We see people that roll their ankle off of a curb or out in the yard as much as we see athletes who land awkwardly from a rebound or struggle to plant correctly in a soccer game.  The expert sports physical therapists at SSOR are here to help you get back quickly and safely from an ankle sprain.  So let’s talk about the how’s and why’s of this injury.

What gets injured?

Depending on the severity of the sprain, the most common ligament injured is the anterior talo-fibular ligament.  With more severe sprains, the calcaneofibular ligament gets sprained as well.   It is worth noting that you can also suffer a “high ankle sprain” or syndesmotic sprain.  These are a little different that your typical rolled ankle and we’ll chat about them in a different post.

What is the cause of ankle sprains?

Most inversion ankle sprains occur when you “roll” the ankle some way, like we described above.  As a result, there is lots of pain and often an inability to walk without a limp.

Do you need X-rays after an ankle sprain?

Ankle sprains are an injury that get way too many X-rays.  Granted, it’s good to be cautious, but many people sit for hours in an emergency room waiting for an X-ray that many times is unnecessary.  The Ottawa Ankle Rules are a reliable method of determining if an X-ray is necessary.  In general, if you are able to walk, even if it’s a little painful, there is likely not a break.  Plus, there are specific bony spots that are exquisitely point tender that may indicate a fracture.  Try coming to see one of our physical therapists first before you sit in the ER for hours.  It’s great – in Kansas, you can see a physical therapist without a physician referral.

Should I use crutches?

Maybe.  If you are limping around, then you should.  Limping creates more problems and delays proper healing.  You may not need two crutches, one may do the trick.  The key is no limping.  FYI – if you use one crutch, it should go on the OPPOSITE side of your injury! Yes, it’s true.  Confusing?  Think of it this way – the door handle is always far away from the hinges.  Same concept.

Do I need rehab?

You may think we’re a little biased, but this is a resounding YES!  Without rehab, the ligament heals improperly, you won’t have your full strength and balance, and may not even get your full motion back.  Even a few visits to learn the best exercises are a good idea.  The problem is that 70% of people who have an ankle sprain develop chronic ankle instability.  Chronic ankle instability can really limit even daily activities, let alone recreational ones.  People with chronic ankle instability sometimes have trouble rolling their ankle randomly or even walking in the house.

Physical Therapy after an Ankle Sprain

Rehab after an ankle sprain depends on the severity.  Early on, you must control pain and swelling.  Therefore, compressive dressings, ice, rest, and elevation are a good starting point.  As stated above, you may need crutches/crutch/cane to help normalize your gait.  That said, here’s some critical things you need to make sure are addressed in physical therapy:

  1.  Range of motion exercises.  You should start with just dorsiflexion and plantarflexion first (pointing toes down/up).  Once that motion returns, then begin side-to-side.   Doing side to side motion too early may stretch out the healing ligament.
  2. Strengthening exercises for the ankle muscles.
  3. Hip strengthening.  Many physical therapists miss this critical aspect of ankle sprain rehab.  Multiple studies have shown a delay in muscle activation and weakness immediately after an ankle sprain.  You have to do exercises to strengthen the gluteals.
  4. Balance exercises.  Once a ligament is damaged, the proprioceptors on the ligament which tell your brain about balance, are impaired and need to be re-trained.
  5. Manual therapy/mobilizations to the ankle.  There are a few critical mobilizations that your physical therapist should do to restore ankle mobility.  Many fail to do this resulting in long-term deficits and recurrent sprains.
  6. Progression to functional activities.  At SSOR, we have a specific, detailed progression on return to impact and running activities.  Walking pain free is not enough.  You need to be progressed from activities that are front/back, side-to-side or lateral, then twisting motions and you should be taken through a functional testing progression as well to determine physical readiness.

Ankle sprains are painful and can severely restrict functional capabilities.  What is more, not properly treating them increases your risk of re-injury almost by 20x that of those that haven’t had one!  Physical therapy is critical, even for a few visits, after an ankle sprain to help avoid these from happening again.  Let the sports rehab experts at SSOR help you get back on your feet and back to life.  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.

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

SSOR Serves Olathe, KS

Physical Therapy in Olathe, KS

SSOR has earned the confidence of both Overland Park and Prairie Village that we are the physical therapy provider of choice in these communities.  We are privileged to have patients come see us from as far as Topeka, KS and Warrensburg, MO too.  Did you know that we also serve the residents of Olathe, KS too?

SSOR in Overland Park is only about 5 miles from Olathe, KS!


The staff at the Overland Park location has many services including:

Check out what a recent patient from Olathe, KS had to say about her treatment at SSOR:

“This place is awesome !!! They have a highly knowledgeable and friendly staff that is down to earth and genuinely cares about you!

My first experience was working with them two years ago on a herniated disc in my lower back. I had worked with other trainers for about two month previously with no results and I don’t think I would have ever made much progress if I hadn’t came to these guys.

My second experience was with rehabbing a labral tear in my shoulder this spring. I had been discouraged about whether or not I could see any results from consultation from other athletic trainers but, these guys encouraged me, got me back on track, and got me back on to workouts on my own in a very timely manner.

Overall they aren’t going to try to get you to come in more than you need to or hit you with any hidden or extra charges. From my experience they want to get you better and back out as quick as healthily possible.

I give a special thanks to Curtis and the rest of the Staff. Keep doing great work and thanks for all the help.”

-Wyatt Melton, Olathe


It would be a privilege to serve you and partner with you in your care.  Remember, you can see a PT in Kansas without a physician referral.  Give us a call, we welcome the opportunity to help you achieve your goals.