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!

Tommy John Rehab

Rehab After Tommy John Surgery

With the year round playing of baseball, there has been a meteoric rise in ulnar collateral ligament (UCL) reconstructions in the elbows of baseball players, commonly known as “Tommy John” surgery.  Sadly, there is no off-season anymore.  Kids throw all summer, play fall ball where they throw more, then when the snow hits, they go inside and continue to throw until it warms up again, then the process is repeated.  There has been a sevenfold increase in elbow surgeries since 2000, according to the American Sports Medicine Institute.  So much can be done to prevent them, but if the rehab is done right after surgery, they shouldn’t happen again.  So what’s the story with this injury, surgery, and eventually, Tommy John rehab?

Hall of Fame pitcher Tommy John

 

The Ulnar Collateral Ligament (UCL): The “Tommy John Ligament”

The baseball pitch is the fastest recorded human motion, and elbow extension velocity during the throw has been found to be between 2200-5000°/second.   As a comparison, the underhand softball throw is about 680°/second, and the tennis serve is about 1750°/second.  The ulnar collateral ligament (UCL) in the elbow is a tiny ligament that largely has to control motion at the elbow during the throwing motion, resisting over 50% of the forces that “gap” the elbow during the throwing motion.  The UCL is torn as a result of repetitive overload, leading to microtears, and eventually rupture.  In a young athlete with open growth plates, the bone can separate at the growth plates, causing further injury.  Basically, the ligament takes the bone with it.  This is analogous to pulling weeds – the weeds come out, but often a chunk of dirt comes with it.  In fact, adults tend to rupture the ligament in the middle of the ligament because the bones they attach to are fused or closed at the growth plates.  In skeletally immature kids, they tend to tear at the bony attachment because it’s the weakest link because growth plates haven’t closed yet.  Once it ruptures, the athlete needs what is commonly called the “Tommy John” surgery, performed first in 1975 on major league pitcher Tommy John.  His surgery was successful and has carried his name ever since.

 

General Guidelines for Tommy John Rehab

Tommy John rehab is a long process that will require patience and persistence.  First of all, the orthopedic surgeon will set guidelines for range of motion restrictions to ensure that the graft heals appropriately and doesn’t get stretched too soon.  There is no need to be aggressive in this initial phase as the graft can fail if the stretched too soon.  Strict adherence to these guidelines is imperative.  A successful surgery can fail if the athlete is too aggressive.  It is not a race to get motion back.  If the athlete does what they’re supposed to do, the motion will come to them in due time.  Restoration of range of motion (ROM) is done in a gradual fashion. Typically, the athlete is in a splint for the first week or so and then gentle ROM exercises commence in a prescribed ROM.

The first 6 weeks or so of Tommy John rehab are relatively boring, which is on purpose to allow healing to occur.  In these initial phases up to 6 weeks, wrist exercises, gripping exercises, and isometric exercises for the biceps/triceps are done.  In addition, given that athletes largely are the ones having this surgery,  cardiovascular conditioning is addressed with riding an exercise bike.  Not only that, but maintaining leg strength and hip mobility can take place during this time.  Over 50% of the pitch comes from the legs.  Mobile but stable hips are critical for the athlete after Tommy John surgery.

Once the athlete hits the 6 week point, progressive strengthening of the rotator cuff, scapular stabilizers, and the wrist/elbow can take place.  An elbow is only as strong as the parts it attaches to.  Therefore, a strong, stable shoulder along with strong hip/core muscles inevitably help reduce strain on the reconstructed ligament.

During these later phases, there are other important components that should take place with Tommy John rehab.  Many times, bad habits done over time lead to the surgery in the first place, so it’s important to look at the pitching mechanics.  For the most part, the mechanics we tend to address are the arm path from the glove, arm slot position, stride distance, knee flexion angle, and trunk position.  A thorough review of proper mechanics can be found here.

As discussed previously, these later phases are the ideal time to improve hip mobility and stability.  Throwers need hip mobility to execute proper stride distance and studies have shown that hip/shoulder separation is needed not only for better performance, but also for injury prevention.

Another often missed but critical aspect of Tommy John rehab is spinal mobility.  In a time of texting/sitting at a computer/playing video games, posture has gotten increasingly bad and subsequently, spines have gotten very stiff.  As a result, the scapular muscles aren’t in an optimal position to do their job and injuries result.  In order for the pitch to be performed correctly, the athlete needs an appropriate amount of thoracic extension as well as rotation.  Effectively, spinal mobility allows the body to “wind up” better.   One example of a spine mobility exercise is pictured below.

“Open Book” exercise, starting position. This exercise improves spinal rotation.

“Open Book,” ending position. Contact between the trunk and foam roll is maintained.

 

In general, athletes begin an interval throwing program around 4-6 months after surgery.  This varies however due to surgeon preferences and the athlete’s injury history.  It is a graded progression of throwing from flat ground over short distances to eventually throwing off the mound.  It can take a few months to work through this program, but it is vital that the thrower stick to the guidelines while at the same time continuing with their exercises for shoulder maintenance.  The analogy here is that it can take months to train for a marathon – a person training for a marathon doesn’t run 26 miles the first day.   It is the same idea for throwers – the progressive overload from the interval throwing program ensures that the body gradually adjusts to increasing stresses with minimal risk of further injury.

Return to sport after Tommy John surgery is anywhere from 8-9 months to well over a year, depending on many factors including surgeon preference, the athlete’s injury history, and the level of competition they are returning to.  With all that said, it is imperative that the athlete continue to perform many of their Tommy John rehab exercises regularly to reduce the risk of future injury.

There are some great resources available for parents and athletes, in addition to the American Sports Medicine Institute listed above.  PitchSmart is an informative site dedicated to giving up to date information on injury prevention and pitch counts.  Another very good site is Elite Baseball Performance.  Some of the better minds in baseball have collaborated to give evidence-based recommendations on injury prevention, rehabilitation, and performance.

Can This Injury Be Prevented?

There are some clear cut things that athletes, coaches, and parents can do to avoid this injury.  First and foremost, research suggests that you should not throw more than 8 months out of the year.  Risk of injury is 5x higher if you throw more than 8 months out of the year.  Secondly, adhering to pitch count recommendations advocated by the American Sports Medicine Institute is important.  As stated above, this injury is largely an overuse one, so “saving your bullets” will help.  Next, giving the arm “tender loving care” will help.  Icing after games, stretching the back of the shoulder (which tends to get tight from throwing), foam rolling, rotator cuff and scapular strengthening, and spine mobility exercises performed as part of a regular routine will help keep the arm healthy.  Lastly, listening to your body is imperative.  Athletes should not have elbow or shoulder pain when they throw.  If they do, they should be evaluated by a physical therapist, athletic trainer, or orthopedic doctor.

Our team of skilled sports physical therapists can help you throughout your Tommy John rehab.  We understand the injury, the surgery, and how to get you back to sports.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

 

ACL Rehab Must Have’s

7 Things You Gotta Have for ACL Rehab

We see lots of people with anterior cruciate ligament (ACL) reconstructions.  ACL rehab after 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 committed 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.  So what are the key things you need to have for ACL rehab?

Keys to ACL Rehab

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.

Heel hangs. Prop your heel on a rolled towel and let the knee “hang” to get straight.

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 stimulator.  Multiple studies have shown that a muscle stimulator on the quads helps subjects improve gait and quad functioning than those that don’t.

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.

Heel slides to improve knee bending using a bed sheet.

Use a crutch/es 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 our 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.

Focus on single leg 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.  Furthermore, they even unload their leg two years after surgery when landing from a box to floor jump.  So, even though you think you’re symmetrically distributing weight, you are really not.  Therefore, you should focus your ACL rehab on single leg movements for most of your rehab.  We’re not saying “don’t do squats” but we are saying that you’ll likely cheat anyway, so make that involved side work doing single leg activities. (And by the way, we really emphasize eccentric training of the quads to help get those babies stronger and they won’t give you that anterior knee pain that many people get after patellar tendon grafts, but you’ll have to come see us to learn more about that!).

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 throughout your ACL rehab process.

Don’t forget about the hamstrings!  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 the Nordic hamstring curl as part of your ACL rehab.

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 part of your rehab.  Why on earth would you only do balance work on one leg?  Usually, deficits that may have caused your ACL tear are present bilaterally.  Therefore, what you do on one, do on the other.

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 before you aggressively stretch.

Stretch for the quadriceps muscles.

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 have your strength tested and 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.  We promise, our functional testing algoithm is thorough and specific.  You will always know where you are in the continuum of recovery.

Of course, there’s a lot more detail and nuances that we didn’t discuss here, but these are non-negotiable.   We see lots of people after ACL surgery that need rehab after.  We speak to PT’s all over the U.S on how to rehab these the right way – our experts are “right in your backyard” so give us a call!  It would be a privilege to partner with you in your care.

 

Do Inversion Tables Work?

Are Inversion Tables Effective for Back Pain?

Note: This blog was written by one of our physical therapy students on rotation with us as part of his training.  Thank you to KU Med physical therapy student Tanner Vinson for this informative blog.  We get asked a lot about inversion tables around here.  It’s a good topic to talk about! 

Back pain is one of the more common conditions we see here at SSOR and it affects people of all ages and activity levels.  A global review of the prevalence of low back pain in the adult general population has shown its point prevalence to be approximately 12%, with a one-month prevalence of 23%, a one-year prevalence of 38%, and a lifetime prevalence of approximately 40% (Manchikanti et al, Neuromodulation 2014). Furthermore, as the population ages over the coming decades, the number of individuals with low back pain is likely to increase substantially.  Arguably, no other condition has as many treatment options that have been proposed over the years.  Medications, chiropractic, holistic care, yoga, pilates, and at the most extreme, surgery.  One other intervention that is rather ubiquitous is inversion tables.  Inversion tables are available for purchase and have even been the subject of late-night infomercials.  Do inversion tables work though?

History of Inversion Tables

Inverting the body to treat physical ailments was first seen being used by Hippocrates, the father of medicine. He theorized that inverting the body would reverse the compressive force effects of gravity. It was not until the 1960s that gravity-facilitated traction was made relevant again by Dr. Richard Martin and (as some of you may remember) again in the early 1980s when Richard Gere was featured using Gravity Boots in “American Gigolo.” Around this time in the 80s, inversion traction devices saw a dramatic increase in demand and have since been the topic of debate in terms of their effectiveness to treat lower back pain and associated symptoms. Nonetheless, these devices have remained relevant for all this time and are still being sold by many retailers today.

 

Conventional Traction versus Inversion Tables

Conventionally, traction in the horizontal (gravity-eliminated) position is being practiced to help treat back pain by many physical therapists. Traction by inversion is advantageous because it does not require another person to administer treatment. On the contrary, conventional traction has the advantage of being administered by a professional that may help in determining the need for traction or what parameters to adhere to.

The research comparing conventional traction to gravity-facilitated traction suggests both have positive effects, but one is not superior to the other. Therefore, we may draw some conclusions from the research of conventional traction techniques in regard to inversion tables.

 

 

What’s the Evidence on Conventional Traction?

Conventional traction alone has NEVER been proven to be effective long term for treating back pain. There is evidence that traction as PART OF a rehabilitation program may help improve quality of life and reduce radiating symptoms (symptoms into the gluteals, legs, or feet) associated with lower back pathology. The research suggests that the effects of traction are relevant in THE SHORT TERM (less than 6 weeks).

 

 

What is the Evidence for Inversion Tables?

It has been proven that the pressure within the discs decreases and the intraforaminal space (where nerves exit the spine) increases with gravity-facilitated traction.

Several studies show decreases in muscle activity of the lumbar spine when using inverted traction. This is relevant in cases involving back spasms.

There are studies that look at the effect gravity-facilitated traction has on single level herniated discs. In these studies, patients using inversion traction were able to return to work or avoid surgery based off of a reduction in painful symptoms.

The current body of research has failed to fully explore the effects of inversion traction. For starters, these studies are small meaning there is a small sample size to draw conclusions from. Secondly, these study designs fail to compare parameters and their effect on outcomes. Some of these parameters lacking in research include duration, frequency, and angle at which to invert for maximum benefit.

In terms of outcomes, the research fails to examine long term results of using inversion tables.

Summary of Inversion Tables

Lumbar traction of any kind has been shown to be effective in reducing short term symptoms associated with lower back pain by creating space between the vertebral joints. Like with any weightbearing joint of the body, muscle imbalances (faulted posture) will result in excessive forces to the vertebral joints that result in degeneration over time. The degeneration of discs can result in disc bulging and narrowing of foramen (hole for nerves exiting the spine) which both may result in radiating symptoms. These symptoms are the symptoms that traction (as well as inversion traction) seems to alleviate.

The joints within the spine are responsible for absorbing and transferring compressive forces. Faulted postures plus compressive forces combined for long periods of time cause the discs to deform, resulting in bulging and degeneration. Traction reduces compressive forces which has been proven to reduce symptoms. The elimination of compressive forces (traction) results in short term results. Given the equation for disc pathology, posture must be addressed to achieve long term results.

 

Treatment for Low Back Pain

If you have not experienced back pain before, it might be best to get a professional opinion first.  In Kansas, you can see a physical therapist without a physician referral, so let one of our staff take a peek at you.  If it’s anything serious, we’ll direct you to the right provider.

All that said, if you want to try inversion tables, keep in mind that individuals with conditions that are affected by increases in blood pressure or intracranial pressure as well as mechanical stresses of joints should seek a professional opinion first. Some of these common conditions include hypertension, glaucoma, and osteoporosis.

If you have an inversion table or know someone that does and you choose to use it, it is likely that you do not need to be fully inverted. This means that you do not need to be completely upside down. Most angles in research are between 30-60 degrees from horizontal. This will help minimize increases in intracranial pressure and increase tolerance to inversion.

Although the parameters are not well defined in research, it’s a safe rule of thumb to perform inversion traction for short bouts (less than five minutes) a couple of times.

While inversion tables may help with pain and symptoms, they are not a long-term solution for low back pain.  The only long-term solution for low back pain is exercise, postural improvements (standing desks versus sitting all day, for example), and practicing good body mechanics/ergonomics.  If you need some direction, it would be a privilege to serve you and partner with you in your care.  Give us a call!

References

The effects of inversion traction on spinal column configuration, heart rate, blood pressure, and perceived discomfort. https://www.ncbi.nlm.nih.gov/pubmed/18802266

Traction for low back pain. http://www.cochrane.org/CD003010/BACK_traction-for-low-back-pain

Effects of Gravity-Facilitated Traction on Intervertebral Dimensions of the Lumbar Spine. https://www.researchgate.net/publication/23267651_Effects_of_Gravity-Facilitated_Traction_on_Intervertebral_Dimensions_of_the_Lumbar_Spine

The effect of inversion traction on pain sensation, lumbar flexibility and trunk muscles strength in patients with chronic low back pain. https://www.researchgate.net/publication/264742284_The_effect_of_inversion_traction_on_pain_sensation_lumbar_flexibility_and_trunk_muscles_strength_in_patients_with_chronic_low_back_pain

Inverted Spinal Traction. https://www.ncbi.nlm.nih.gov/pubmed/687049

The Efficacy of Traction for Back Pain: A Systematic Review of Randomized Controlled Trials. https://www.researchgate.net/publication/9033349_The_Efficacy_of_Traction_for_Back_Pain_A_Systematic_Review_of_Randomized_Controlled_Trials

A comparison of inverted spinal traction and conventional traction in the treatment of lumbar disc herniations. https://www.researchgate.net/publication/232054773_A_comparison_of_inverted_spinal_traction_and_conventional_traction_in_the_treatment_of_lumbar_disc_herniations

Effectiveness of lumbar traction with routine conservative treatment in acute herniated disc syndrome. https://www.researchgate.net/publication/7677298_Effectiveness_of_lumbar_traction_with_routine_conservative_treatment_in_acute_herniated_disc_syndrome

Analysis of electromyographic activities of the lumbar erector spinae caused by inversion traction. https://www.researchgate.net/publication/301708034_Analysis_of_electromyographic_activities_of_the_lumbar_erector_spinae_caused_by_inversion_traction

Rehab after a Separated Shoulder

Exercises for a Separated Shoulder

We have an active, goal-oriented population here at SSOR and of course, our folks get injured doing activities they love, but also during normal daily life.  One injury that we see from time to time is a separated shoulder.  A separated shoulder is a painful injury and can significantly restrict use of your arm for even simple things like reaching for a glass or washing your hair.  For many people, these injuries can be managed non-operatively, but in more severe cases, surgical reconstruction is needed.  So what’s the deal with separated shoulders?

What is a Separated Shoulder?

A separated shoulder is a disruption of the ligaments that connect your clavicle (“collar bone”) to the scapula (“shoulder blade”).  The joint of those two bones is called the Acromioclavicular (AC) joint, and this is the joint that is “separated” when you suffer this injury.

What are the causes of a separated shoulder?

Shoulder separations are normally a contact injury in sports (tackling, hitting the boards in ice hockey, skiers falling on their shoulder) or for “regular Joe’s,” falling directly on the shoulder can cause a separated shoulder, as in a fall from a ladder.  These injuries are typically higher velocity/higher impact injuries.

What’s the difference between this and a “Dislocated Shoulder?”

These two terms are often used interchangeably and they are vastly different.  A shoulder dislocation is an actual dislocation of the shoulder joint, the Glenohumeral joint.  Here, the humeral head is no longer in contact with the glenoid fossa that it sits on.  Put another way, imagine a golf ball sliding off the golf tee.  As you can see from the picture, this is a very different injury with an entirely different rehab process.

Physical Therapy for a Separated Shoulder

Normally, a person who has this injury needs an X-ray and potentially an MRI to determine how severe the injury is.  There are different grades of AC injuries.  Most are managed non-operatively, but in more severe cases, a reconstruction of the AC joint is warranted.  Once physical therapy begins, a progressive program of range of motion exercises are done until full range is achieved, then strengthening of the shoulder takes place after that.  People who suffer this injury do well long-term without much problems, provided they see the rehab through.  Sometimes pushing/pressing overhead can cause some discomfort and sleeping on that shoulder can cause some discomfort, but by and large, this injury isn’t a big deal if it isn’t a severe one.  Sometimes for more moderate shoulder separations, you may actually see that your collarbone isn’t even or looks elevated in the mirror.  Really, this is more cosmetic and is not typically a problem and is just a result of the injury.  This may only be a problem if you’re a swimsuit model and want to look “symmetrical” with your shirt off! Otherwise, no big deal.

Picture of a man with a separated shoulder. You’ll see the collar bone on one side is elevated

 

Pendulum exercise to help reduce pain and stiffness.

 

Cane press. Lay on your back and press a cane towards the ceiling. Depending on severity, this may really hurt, so proceed with caution.

Internal/External Rotation. Sit up straight and place a rolled towel in your armpit. Use the uninvolved arm to move the arm in/out.

 

 

We are confident that we can help you with your separated shoulder. It would be a privilege to serve you and partner with you in your care.  Give us a call!

 

Do You Need Surgery for a Torn ACL?

Torn ACL: I Gotta Get it Fixed, Right?

We have an active population here at SSOR and we have a host of patients who tear their knee anterior cruciate ligament (ACL).  ACL tears are well-documented in sports and most of us probably know someone that tore their ACL, either playing sports or sometimes doing rather benign activities.  It’s a painful injury and one that can limit activity and even bother you with daily life.  Certainly there are volumes of studies showing success after ACL reconstruction, but many of our patients assume that surgery is necessary.  So does a torn ACL inevitably lead to surgery?

What’s the ACL?

The ACL is a ligament on the inside of the knee that helps limit the tibia or “shin bone” from moving too far forward when you jump or plant and cut.  It also helps limit “twisting” of the knee.

How is it torn?

ACL tears are about 75% non-contact.  Most of the time, people tear their ACL with planting and cutting, landing from a jump, or any kind of quick deceleration.  Sometimes, their torn with a combination of the above on a “straight knee.”  The picture below shows a typical mechanism where the knee “buckles” inward.

Do I need surgery for a torn ACL?

You may be surprised, but there is evidence showing that a knee can stabilize over time, particularly in non-athletes.  Research has shown here, here, and here that surgery may not be necessary, particularly if you are not playing cutting/pivoting sports.  Heck, there are even pro athletes that played with no ACL!

This is a question you should discuss with your doctor.  That said, here’s three things you should consider:

Is your knee giving out?  Instability in the knee is the main reason to get it fixed.  If you’re just walking along and your knee gives out or buckles, that’s not a great sign.  You might be a stay-at-home mom that just does some basic aerobics classes, but if you have young kids and you’re carrying them around and your knee gives out, that could hurt the both of you.  This is just one example, but hopefully you get the point – instability is not good.   That is the principle reason to get ACL reconstruction.

Are you in a lot of pain?  Sometimes people have a lot of pain after this injury.  While it’s not the chief reason to have surgery, it’s something you should think about.

Do you plan on leading an active lifestyle with cutting/pivoting sports?  If you’re just a recreational jogger, a swimmer, a cyclist, or well, just not that active, you should consider rehab on your knee.

How do you rehab a torn ACL if I go the non-operative route?

Basically, there are four central tenets to non-operative ACL rehabilitation.  The first is restoration of quadriceps strength.  After this injury, the quadriceps or “thigh” muscles, lose their strength and mass.  It’s important to get that back.  Secondly, you need particular emphasis on hamstring strengthening.  The hamstrings are the best friend to the ACL.  They help prevent that tibia from moving forward because they attach on the back of it.  Think about reins pulling back on a horse.  With good hamstring strength, they will protect your knee should you get back to sports activities again.  Third, you need perturbation training.  You might think of this as balance training, but perturbation training is a little different.  Perturbation training involves adding activities that challenge your stability of your knee from an outside influence, either standing on a wobble board  with someone causing it to tip quickly or being able to sustain a push from someone without your knee buckling.  A qualified sports physical therapist or licensed athletic trainer can work with you on this.  Finally, movement re-training is necessary to help you avoid the movement patterns that may have caused the torn ACL in the first place.  So, learning to land properly from jumps or changing direction more efficiently are two things that might be addressed.  Hopefully, your sports physical therapist will objectively measure how these things are improving and then progress you with running and jumping activities to see how you respond. Understand though that even in the best of circumstances, you may need to have ACL reconstruction for your torn ACL should any of the indications above (instability, pain, desired activity level) surface.

Our team of qualified, dedicated sports physical therapists are passionate about helping our patients get back to the activities they enjoy.  We are well-versed in treating torn ACL’s, either operative or non-operative.  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.

Stay Fit While Recovering From Injury

How Do You Stay Fit After Injury?

We have a results-oriented population here at SSOR.  Our team of physical therapists see people that lead active, healthy lifestyles and have specific goals in mind when they come see us.  Whether they are competitive or recreational athletes or just want to stay in shape, injury and surgery can really cause otherwise healthy, fit people to get out of shape fast.  Particularly if you have surgery, you can’t move your arm or leg much or are unable to weight-bear, so your options are limited.  It’s a vicious cycle potentially – no activity, sit around, snacking a lot, not getting the heart rate up, repeat.  All of a sudden, the pounds add up and you’re panting going up the stairs.  On top of that, some people have a visceral need to exercise, otherwise they can’t sleep or are very moody.  So what can you do do stay fit after injury?

Ways to Stay Fit When You’re Recovering

If you have an upper body injury or surgery, consider stationary recumbent or upright biking.  Biking is a good choice because you don’t really have to move your arms.  Depending on what injury you have, even walking might not be a good idea because your arms sway back and forth during normal gait.  When your arms sway, your shoulder muscles are still contracting some.  If you had a rotator cuff surgery for example, a brisk walk with arm movement may cause pain and be detrimental to your recovery.  Cycling on stationary bikes is a great choice until you can do more.

Take the stairs or park at the far end of the lot.  Depending on your injury, this might be tough to do, but instead of taking the elevator take the stairs.  Stairs can be quite the workout and help you burn a few extra calories.  Similarly, parking at the far end of the parking lot gets you a little longer walk in.

Get in the pool!  We love the pool here.  We suggest pool exercises for patients all the time, whether professional athletes or our older patients.  You are lighter in the water and the circumferential pressure of the water helps with swelling.  If you move fast, the water provides more resistance.  Again, depending on your injury, you can take water aerobics classes or do deep water running.  Try it sometime, it’s harder than it looks, especially if you move fast!  In the water, you can also use those “water dumbbells” that provide more resistance for you to work through.  If you’re appropriate to be using those, they are a nice option.

If you have a lower body injury and can’t weight-bear/have limited weight-bearing or are in a cast, consider an upper body bike.  “Arm bikes” are a great option.  Try doing the bike in intervals – sprint for a short time, then recover, repeat. Trust us, this will get your heart pumping and get that sweat you desire.  Most fitness facilities have them.

Confined to a wheelchair? No problem! Get on the open road and start pumping!  Similar to the arm bike, working hard on the wheelchair is a great way to get your heart rate up too.  Again, you can try intervals to shake things up a bit.  There are also a number of workouts you can do with bands or dumbbells in a wheelchair.  Give those a shot!

Whether you have an acute injury, had a surgery recently, or have chronic trouble from an injury, our team of physical therapists is ready to help you.  We’re qualified, competent, and will provide an enjoyable atmosphere for you to get back on your feet. 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.

Sitting Posture Tips

Try These Things to Improve Sitting Posture

We see lots of patients here complaining of back, neck, and shoulder pain and many times, a contributing factor is sitting posture.  It’s affecting people of all ages nowadays though because we’re just a sitting society now.  Everyone is huddled in front of computers or devices for much of the day.  Improving your sitting posture will help you get through your day with less pain and discomfort and hopefully help minimize the risk of having to see one of our physical therapists for treatment.  The following are some guidelines for you to consider if you’re a “desk jockey” to help improve your sitting posture.

Sitting Posture Tips

Make sure your shoulders are relaxed, your wrists are neutral, and your elbows are bent to 90 degrees.  

Stay square to the computer.  Do you have multiple screens going at once? Do you have your screen in front of you but your desk/workspace and/or your phone to your right or left?  Do everything you can to stay square with what you’re working on.  Otherwise, you’ll be rotating your neck and body in suboptimal positions and that can lead to pain.

Keep your monitor no less that 20″ away or an arm’s length from you, slightly below eye level.  Below eye level encourages you to have a more upright head posture rather than the poor forward head position.  Here is a good link that properly shows not only monitor distance but also shoulder and elbow positions that should be encouraged.

On the phone a lot? Get a headset.  A headset will just help you avoid having your head sidebent/tilted one way.  It’s just an awkward position and if done for prolonged periods, can definitely lead to neck pain and headaches.

To change things up, try positioning your knees below your hips or straddle your chair.  This is a big one and may help.  Try it yourself.  Scoot to the edge of your chair and put your knees below your hips or put another way, tuck your feet under you.  You should feel that it immediately helps straighten you out.  Even “perfect” posture showed in the link above can occasionally get uncomfortable.  The pictures below show some positions you might consider.

Knees below hips position.

Straddle the chair.

“Booster seat”. Roll up a pillow and place it under your “sit bones.” This elevates your hips above your knees.

Get a standing desk.  Standing desks are definitely being used more and more and for good reason.  It gets us out of this sitting posture and as stated above, it changes things up for your body.

We hope these tips and tricks help you.  You may also consider trying these 3 things if you sit all day at your desk to help you get through your day.  Should you start having neck, shoulder, or back pain, the physical therapists at SSOR know how to help you. It would be a privilege to partner with you in your care.  Give us a call! Remember, you can see a PT in Kansas without a physician referral.

 

Stretching: Before or After Activity?

When Should You Do Stretching Exercises?

A majority of our patients here are an active bunch.  They lead active, purposeful lives and do a wide array of physical activities.  They’re always asking us about stretching.   Routintely, we get asked how long to hold stretches, when to do them, and which ones to do.  For seemingly years, it has been an accepted dogma that you must stretch before exercise, although no research proves that it’s necessary for injury prevention.  A review by Witvrouw et al (Sports Med, 2004) showed that there is an obscure relationship between stretching and injury prevention.  Thacker et al found in a systematic review of literature that there is no evidence to endorse or discontinue stretching before or after exercise to prevent injury.  Intuitively, it would seem that it can’t be true, but the research has not shown otherwise.  We imagine the reason that it’s always been assumed that we should stretch before exercise because the perception is that if you go into an exercise or competitive session “tight” you are at risk for injury.  Clinical experience and the literature reveals that this argument is partly true.

Different Types of Stretching

First of all, it’s important to understand the different types of stretching.  Static stretching is what we’re most familiar with – placing a muscle or joint on stretch and holding the stretch position.  For example, placing your foot on a chair to stretch your hamstring.  Now, static stretches can be active or passive.  Active is when you do it yourself and determine amount of stretch, or passive when someone does it for you.  Dynamic stretching is basically stretching while moving.  An example of dynamic stretching is doing lunges with exaggerated steps, doing “high knees” while running, etc.  Finally, PNF (proprioceptive neuromuscular facilitation) is the last type.   Here, a muscle is stretched by contracting the opposing muscle.  PNF is used both for flexibility, strengthening, and for rehab.  It is an excellent treatment tool.

Static stretching (place and hold) has been shown to actually decrease acute strength and power.  Winchester and others (J Strength Cond Res, 2008) have found that it impairs sprint performance and Robbins et al (J Strength Cond Res, 2008) found that it adversely affected vertical jump performance.  Other studies have substantiated these conclusions.  The proposed reason that this occurs is basically due to muscle’s length-tension relationship.   Essentially, muscle physiology principle says that the muscles contractile proteins (actin and myosin) are supposed to have an optimal position so maximize muscle function.  It is believed that acute bouts of stretching increases that length and subsequently decreases the ability of the muscle to contract at its best.

All that being said, the trend is shifting in that performing dynamic stretching before exercise is the best way to “stretch” before exercise.  Ce et al (J Strength Cond Res, 2008) and Manoel et al (J Strength Cond Res, 2008) are just two groups of researchers that have recently found that dynamic stretching is the optimal way to increase power prior to sport performance.  First of all, because it’s dynamic, you are moving and you’re likely to work up a sweat.  If you are sweating, there is increased blood flow which has been shown to increase tissue extensibility.  The problem with static stretching is that in order to get benefit, you can’t be “cold”.  By “getting hot”, your tissues are more elastic and ready for activity.  Examples of dynamic stretching are walking lunges, jumping jacks, high knees, butt kickers, and squats just to name a few.  Here’s a link to a clip on some good ideas for dynamic stretching.

Best Approach to Stretching

So, what’s the best way to stretch?  We always prefer a general warm up first.  A bike, a short jog, an elliptical trainer, or stair stepper is just a way to get the heart rate up and work up a sweat.  After a 5-10 minute warm up, we suggest performing a specific or dynamic warm up.  Here, they’ll perform a series of movements in the upper and lower extremities.  Lunges, mountain climbers, jumping rope, and arm circles are just a few examples that would follow for another 5-10 minutes.  We encourage athletes to continue moving and take no rest between these movements to keep the heart rate up.   After this is done, you should be ready to move into your workout.

Once the session is done, a brief stint on a bike or a short jog is a good way to “flush” the body of waste products created during exercise to help minimize delayed onset muscle soreness (DOMS).  We assure you’ve had DOMS if you woke up the morning after an intense workout and could barely walk!  You might consider foam rolling too.  After the cool down period, close with static stretching.  In theory, static stretching should be more productive at this point because the tissues are much warmer and more extensible at this time as opposed to being “cold” prior to any exercise.

How Long Should You Hold Stretches?

Two studies by Bandy and others (Phys Ther, 1997) have shown that holding stretches for 30 seconds is the optimum time frame to hold a stretch for acute increases in flexibility.  The “rub” here is that you aren’t going to sustain the new length unless you consistently stretch.

Summary on Stretching

1.  Warm up with light exercise, like jogging, biking, or the elliptical, followed by dynamic flexibility like lunges, high knees, “butt kickers”, etc.  Do not perform static stretches BEFORE activity.

2. Static stretches AFTER activity.

3. Hold stretches 30 seconds – no more, no less.

It would be a privilege to serve you and partner with you in your care.  Remember, in the state of Kansas, you can see a physical therapist without a physician referral.  Give us a call!  Our team of physical therapists are competent, professional, and will give you specific tasks to achieve your goals.

How to Treat a Pulled Muscle

DIY for a Pulled Muscle

We have an active, results-oriented population here at SSOR.  Our patients are competing in many different activities, whether it’s recreationally, competitively, or just to stay in shape.  Elite athletes pull muscles just like “regular Joe’s” do.  The difference is that many regular Joe’s don’t have their sport as their job!  Most of us are working regular jobs and taking care of our families.  We just don’t have time to get treatment all day to get better after these like the pro athletes do.  So if you pull a muscle, what should you do? There are many misconceptions about how to treat a pulled muscle.  We’re experts in the treatment of pulled muscles here and sports physical therapists should be your first choice in treating them.  There are varying degrees of severity of pulled muscles, so these suggestions have some caveats to them.  Obviously, these should be treated by a professional, but for those of you who insist otherwise, here’s a summary of what you should do.

Signs of a Pulled Muscle

Typically when you pull a muscle, you know it!  Most people report a stretching, tearing, or popping sensation that is painful.  It hurts to stretch and if you try and run, it’s either not possible or very painful to do so.  It’s usually very sore and hurts to do basic things like bend over or get in/out of the car.  If you really did a number on yourself, you may have extensive bruising and be very tender at the site of the pulled muscle.

Bruising along the inner thigh from a groin muscle strain

Why Do Pulled Muscles Happen?

There are many reasons why you pull muscles.  You may have a strength imbalance.  For example, hamstring strains are pretty common.  Many people do exercises to strengthen the quadriceps but don’t also strengthen the hamstrings.  The resulting muscle imbalance may lead to a strain.  Another reason for pulled muscles is lack of flexibility.  While there is some debate about this in the scientific literature, if you ask your muscles to reach their outer limits of flexibility during activity but don’t have the elasticity to get there, you might be at risk for a strain.  If you don’t stretch regularly and try and leg out a triple in that rec league softball game, you might put yourself at risk.  Third, you could be dehydrated.  A good analogy is filet mignon versus beef jerky.  With proper hydration, your muscles are like filet – tender, juicy, and less stiff.  Hydrated muscles are more elastic and flexible.  However, if you’re more dehydrated, your muscles are like beef jerky – they get tough and lose their elasticity.  So, if you drink a ton of coffee without also drinking water or if you maybe are playing sports while drinking beer/s, you’re losing water from sweat and both coffee and alcohol are diuretics – they make you lose more water!  Here’s a good link on proper hydration guidelines.  

Can Pulled Muscles be Prevented?

You can certainly reduce the likelihood of these happening.  If you look at the potential causes above, make sure you stay flexible, make sure you have balance in exercise routines, and make sure your water intake is adequate.  A good warm-up routine to heat up your tissues to make them more “ready” for activity will help too.  Activities like a light jog, jumping jacks, walking lunges, high knees, skipping, “butt kickers,” shuffling/defensive slide, and cariocas are just a few options.  The idea is to “prime the system” before more intense activities take place.  Finally, a great way to prevent pulled muscles is to stay active – it’s a bad idea to sit all all week or be a sedentary person, then ask muscles once in a while to perform at their best.  It’s just not a good idea.

sports injury

Treatment for a Pulled Muscle

The following are general guidelines for a pulled muscle.  Keep in mind, there are different grades of pulled muscles and exercises will be a little different based on what muscle group you pulled.  Additionally, you may have pulled the tendon rather than the muscle.  Tendon strains take longer to heal than muscle strains do.  You probably pulled your tendon if your pain is real close to the joint.  So, if you pulled your hamstring, you got the tendon if it hurts real high near your glutes, or real low by the back of the knee.  All that being said, here’s some things you might try:

  1. Rice, ice, compression the first 3-5 days.  After a pulled muscle, there is a gap at the site of the tear, almost like frayed ends of a rope.  The body will begin the healing process to try and “patch” the damage.  Therefore, rest is critical and ice is as well to manage pain from the inflammatory process.  During this time, there shouldn’t be any stretching, even though it feels tight.  The repair is very weak and “immature” to handle stretch.  Use a compressive wrap of some kind to support the muscle and to help minimize swelling.  The worse the strain, the longer you should rest.
  2. Use a crutch/es if need be.  Sometimes with these muscle pulls, it can cause people to limp.  If that is the case, the scar tissue won’t lie down appropriately and will actually cause the muscle to shorten further.  Use a crutch or a cane on the opposite side of the injury until walking is normal.
  3. Ride an exercise bike after the first 3-5 days.  A good guideline to start is that it’s not tender to touch and you are able to walk normally.  Riding an exercise bike not only helps move fluid out of the area but also gets the muscles contracting/relaxing in a non-impact, low intensity manner to help minimize further declines in function.  No need to ride aggressively or for a long time – an easy 10-15 minute ride will suffice.
  4. Start stretching about day 5 after the injury.  Stretches should be gentle and not painful.  Hold stretches for 30 seconds and repeat 3-4 times per day.  Stretching can start when walking is normal.
  5. Once range of motion is pain free, begin light resistance exercises.  Depending on the muscle group, this could mean a multitude of exercises.  Regardless, resistance should be light enough to allow full range of motion and limited pain.  Repetitions should initially be high (20-30) and reduce as resistance increases.  Consider doing step ups, lunges, and squats in a pain free range as well.
  6. Once resistance exercises are pain free, consider dynamic warm up activities.  High knees, “butt kickers,” shuffling, cariocas, and jogging are all activities that you can attempt.  Speed should gradually increase from 25%, then to 50%, then to 75%, and finally 100% effort gradually over the course of the next 2-3 weeks.
  7. Increase the speed of your exercises.  To better replicate running and sprinting, your resistance exercises should also be performed quickly.  This is only after the strength is restored.  Do not sacrifice form, but go with lighter weight and perform repetitions fast.
  8. Once you get back to playing sports, dynamic stretch before, static stretch after.  Research is supporting more activities like walking lunges, skipping, jumping jacks, and shuffling before activity to break a sweat, then do “place and hold” stretching afterwards.
  9. Consider wearing compressive shorts once you get back to playing.
  10. Ice after activity.
  11. Stay hydrated!  If you are dehydrated, a muscle is more prone to pulls.

If you get a pulled muscle, look no further than the sports physical therapists here at SSOR to get you back to the activities you love to do.  We have a competent and professional team of physical therapists to help you.  It would be a privilege to serve you and partner with you in your care.  Give us a call! Remember, you can see a PT in Kansas without a physician referral, so don’t delay getting better!