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Total Hip Replacement: What You Need to Know

Total hip replacement is a procedure that has a lot of success with helping people reduce pain and improve function that is lost from often years of dysfunction due to arthritis.  At SSOR, we see many patients after total hip replacement that have goals as simple as walking and taking stairs to being able to more complex activities like gardening or hiking or sometimes even sports.  We are committed to helping you achieve those goals and we take an approach that is both manual therapy and exercise based with your goals and priorities at the center of our treatment plan.

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Why should I get a Total Hip Replacement?

For most people, the primary indication is hip pain.  A secondary indication is often limping as a result of the arthritic changes in the joint causing limited motion and pain.  Really, these two indications go hand-in-hand.  If you have stiffness, limited range of motion in the hip, limping, and low tolerance to activity, you might be a good candidate.

What is physical therapy like after Total Hip Replacement?

Usually, your physician will guide when he/she wants you to start physical therapy.  Sometimes, they have you do a few weeks of home-based physical therapy because leaving the house is just too painful or you may have co-morbidities that are affecting your ability to get around.  Most of the time, this is about 3 weeks or so.  During this time of home-based physical therapy, you’ll of course work on range of motion (ROM) and strengthening, but also such things as getting in/out of the shower and on/off the toilet.  Believe it or not, those seemingly simple activities are challenging after a total hip replacement.

More than likely, you will be using a rolling walker for ambulation.  We strongly advise you to transition to a cane first before walking without any assistive device.  For some reason, physicians always take people off of their assistive devices and patients end up limping all over town. That is not normal and shouldn’t be encouraged.  Talk to your physical therapist about what your next step should be when it comes to gait.

Once you get to outpatient physical therapy, the focus will be on restoring your ROM and gait.  Additionally, we do extensive soft tissue mobilization on the hip and thigh.  Years of dysfunction and pain have left a quagmire of tender points and soft tissue limitations that not only contribute to pain, but also affect muscle function.

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Soft tissue mobilization for the thigh after total hip replacement

As your ROM improves and you are closer to walking normal again, we’ll go to work getting you stronger.  We start with exercises on your back and side to build a base, then gradually add things like step ups and squats to get you stronger for your day-to-day activities.  In addition, we’ll do strengthening exercises for muscles that support the hip like the quadriceps and calves.

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Bridges for gluteal strengthening


Another critical piece of your therapy after your total hip replacement will involve balance training.  Balance declines naturally with age anyway, and after surgery, it is worse.  Balance activities may start with a narrow base of support (one foot in front of the other) and progress to single leg stance.  In these positions, you’ll perform various activities to challenge your balance and prepare you for life’s unexpected happenings so when they do happen, you’ll be more able to avoid falls and other injuries.  All the strengthening exercises we do initially help “set the table” for better balance down the road.

When is PT done?

We like to see that you are walking normally and taking stairs in a “normal,” reciprocal fashion without using railings.  Additionally, your balance should be the same on both sides.  We also like to see that you can lay down on your uninvolved side, raise your operated leg up and down with perfect form and be able to hold it against our resistance.  Finally, we want to make sure that your pain is minimal at best and you are well-versed in techniques to alleviate pain if it surfaces.
Obviously, we’re a little biased, but we never feel like PT ever ends!  “Structured” physical therapy typically goes for 6-8 weeks.  After PT is formally complete, you should continue a structured program to prevent a decline in physical function.  At SSOR, we offer a program that you can continue your “therapy” with us through a “therapy gym” membership.  We’ll see up your program for you, make sure you are comfortable with how to perform exercise and use the equipment, and you can come and go as you please and as often as you like.  Plus, we’re here to answer any questions or concerns you may have.

Can I play sports?

This is a common question and one you should take up with your doctor.  Most of the time, things like jogging and high-impact activities like basketball are discouraged.  Things like tennis, golf, swimming, pickleball and other low impact activities are OK.  However, if you’ve played a specific sport for a number of years and are technically proficient at it, many physicians will let you do them, albeit reluctantly.

You should expect more from your physical therapy after total hip replacement than just a sheet of exercises.  Therapy after total hip replacement is more than just exercises – it’s a comprehensive approach to help you achieve your goals.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

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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 Buy Diazepam Uk Forum on BFR in 2014 and numerous Buy Ambien Online Reviews have used this and some Buy Zopiclone Via Paypal 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?

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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 (Cheap Valium Pakistan, Buy Generic Lorazepam Online, Order Alprazolamare 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.

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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!


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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:

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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.

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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.

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What Causes Sciatica?

Well, there are a host of potential causes.  If you have a disc bulge or Buy Soma From Trusted Pharmacy, the pressure on the nerve can cause the pain and/or numbness.  Buy Xanax From India, 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 Buy Xanax Mexico Pharmacy 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.

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“Clamshell” exercise for hip external rotator strengthening

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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.

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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?

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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 comprehensiveBuy Ambien Fast Deliveryon MCL anatomy and function.

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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.

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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 Buy Carisoprodol Fedex, Buy Ambien 10Mg Online, and Order XanaxLaser 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 Buy Adipex For Cheap Onlineusing 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.

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    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.

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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?

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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 Buy Clonazepam Online Safe 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 Klonopin Cost has supported the use of isometric exercises to help with tendon pain.  This Buy Klonopin 1 Mg Blue Pill specifically shows how to do this for the Achilles. Buy Soma Medicine 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.  Buy Lorazepam From India 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.

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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.

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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.

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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 Buy Zopiclone Thailand have been proposed, but what are some easy things you can do to avoid muscle cramps?

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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.

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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!

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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 Buy Phentermine With Online Prescription.  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?

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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.

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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 Order Alprazolam Online From Canada

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.

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

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“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.  Buy Zolpidem Nz is an informative site dedicated to giving up to date information on injury prevention and pitch counts.  Another very good site is Order Adipex Online Prescription.  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 Buy Xanax From Europe 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!


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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.

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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.

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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.

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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.