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Rehab after an Ankle Sprain

Ankle Sprain Rehab

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

What gets injured?

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

What is the cause of ankle sprains?

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

Do you need X-rays after an ankle sprain?

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

Should I use crutches?

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

Do I need rehab?

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

Physical Therapy after an Ankle Sprain

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

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

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

Pre-Operative Exercises for Knee Surgery

Should You Do Pre-Operative Rehab Before Knee Surgery?

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

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

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

Pre-Operative Exercises before Total Knee Replacement

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

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

Figure 1: Heel slides with sheet for range of motion

 

 

Figure 2: Heel Hangs

 

 

Figure 3: Straight Leg Raise

 

 

Figure 4: Quadriceps setting exercise

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!

Salvador Perez: Intercostal Strain

Salvador Perez Injury: Intercostal Strain

Royals All-Star catcher and fan favorite Salvador Perez recently went on the disabled list for an “intercostal strain.”  As of now, he’s on the 10-day disabled list.  At first glance, you might be thinking, “C’mon Salvy, it’s a rib muscle! How serious can it be?”  So what’s the deal with intercostal strains?

What are the Intercostals?

Quite simply, the intercostals are muscles that run between the ribs and act to elevate the ribs during normal breathing.  When they expand and relax, they move the chest wall to allow the lungs to expand.

How are they injured?

These can be injured in many ways.  Sometimes, a violent cough or sneeze can do it!  However, it sounds like Salvador Perez swung on a strikeout and caused the injury.  Certainly, an awkward throw or twist could cause the muscle to strain.  Heck, he could easily strain the intercostals during one of his infamous “Salvy Splashes” lifting those coolers!

Why are intercostal strains a problem?

The reason why these are a problem are twofold.  One, they are painful.  These muscles can’t rest!  They are moving with every breath you take.  Intercostals are not like the hamstrings or a hip flexor that you might strain.   You can support them with wrapping and avoid running or aggravating activities.  However, we can’t put a cast or supportive wrapping on the ribs – you’ll suffocate!  The second reason is that these just take time to heal.  Like rib injuries and abdominal oblique injuries, these just need time that athletes often don’t have.

What’s the rehab of intercostal strains look like?

For the most part, rehab is just watching the clock.  Pain is managed with medications, possibly a steroid injection to take the edge off.  Things like heat, cold, ultrasound, laser, and electrical stimulation won’t do much here either.  With intercostal strains, you just have to rest until the pain subsides, then you can get back at it as tolerated.

We’re sure Salvy will be back soon to finish out the race for the division title and hopefully much more than that.

While there’s not much we can do at SSOR to treat intercostal strains, we’re experts at figuring out what you have going on if you come see us for an injury.  Make no mistake, if you need to see a doctor, we’ll make sure we make that happen for you.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

 

Golf after Rotator Cuff Repair

When Can You Golf After Rotator Cuff Repair?

We have a results-oriented population here at SSOR and our clientele expect to be as functional or better than they were prior to surgery.  Our patients are active and want to live an active lifestyle when formal rehab is complete.  Rotator cuff repairs are a common procedure we see around here and we have many people that want to play golf again when it’s all said and done.  Inevitably we get asked, “When can I play golf again?”  Unfortunately, there are no controlled studies that look at this question.  The decision is largely based on what the orthopedic surgeon feels is appropriate and hopefully, after consultation with the physical therapist.  Hopefully, this post will help answer some questions.

What’s the big deal? The tear is “repaired” right?

It’s a little more complicated than that.  First of all, your physician needs to give you the “green light” to play.  Your age matters too.  Typically, the older you are, the more the tissue is less elastic and well, there’s some “tread on the tires” so to speak.  The size of your tear and the quality of the tissue also matter.  If you have a small tear and good tissue, you’ll likely be able to play sooner.  However, if you have a massive tear, are older, and the tissue that was repaired isn’t good quality, you’ll probably wait much longer to play.  Truthfully, something to consider too is how good a golfer you are.  If you don’t play much and don’t have a very good swing, you may for example, strike the ground in your downswing which could hurt your surgically repaired rotator cuff.  Experienced golfers typically have a better, more efficient swing which will help minimize the risk of re-injury.  Lastly, your medical history matters too.  If this is a revision rotator cuff repair, you’re likely to have a much more conservative post-operative course and a longer time before you can golf again.

What should I be able to do before I can play golf?

Range of motion is critical after your rotator cuff repair.  The pictures below show a few examples of some things you should be able to do.  First of all, you should be able to flatten your back against the wall and raise both arms overhead in Figure 1 (like you’re saying “Touchdown!”).  If that doesn’t feel symmetrical or very close to it, you don’t have enough flexion range of motion.  Another is a “wall angel” (Figure 2).  Here, you put your arms at 90° and try and raise your arms, keeping them on the wall.  Painful? Can’t get there? Well, there’s some mobility restrictions there that you’ll need to keep addressing.  Lastly, because your arms have to go across your body, you should be able to do that without “hiking” your shoulder to get there or without pain (Figure 3).  Lastly, you have good strength of your rotator cuff, and the only way to really know that is testing from your physical therapist.

Figure 1. With your back against the wall, you should be able to get your arms against the wall

Figure 2. Wall Angel. Place your arms on the wall as pictured, and keeping your arms against the wall, raise your arms till they’re straight overhead

Figure 3. Horizontal adduction.

What should I work on to maximize results for my golf game?

Obviously, range of motion and strength in the shoulder are critical.  The “genie stretch” pictured below can help increase posterior shoulder mobility so you can bring your arm across your body.  Another very important component is thoracic rotation, pictured below.  Thoracic rotation is important for two reasons.  First of all, the more your spine can rotate, the less strain on your shoulder.  Without thoracic rotation, your shoulder will have to compensate or “overcorrect” for the lack of spine rotation, which could damage your recently repaired rotator cuff.  Secondly, your swing is more efficient with better rotation.  Think of winding up a toy – the more it’s wound up, the farther it goes/faster it moves.  Well, the more you can rotate, the more you can “coil” and “uncoil,” effectively using your body’s own elastic energy.  Of course, mobility in your hips matters too.  As we age, we lose mobility there too.  Without hip and thoracic spine mobility, you’ll be needing us for physical therapy for low back pain.

Genie Stretch. Lay on your affected side and lift your arm off the ground. You should feel a stretch in back of the shoulder

Seated thoracic rotation. Place a ball between your knees and make sure your feet are flat on the floor. Rotate each direction.

So when can I play again?

We have to define what “play golf” means.  Full, unrestricted release to playing golf is much longer time frame than say, putting and working on chipping.  Again, provided your doctor gives you the OK, you can start putting around weeks 6-8 or so once you’re out of the sling.  Chipping and working around the greens is the next step and usually you can start that somewhere between 12-16 weeks post-op.  From there, a progressive return to golf program starts with working on irons and of course, hitting off the tee is last.  Most people are back on the course playing with no restrictions anywhere from 4-6 months after surgery.  Again, all of that depends on factors mentioned above – age, size of tear, quality of tissue, experience playing golf, other medical history that may affect your swing.

If you had rotator cuff repair, look no further than the expert staff at SSOR to help you restore your function and your way of life.  Athlete or not, we understand what is done surgically and what has to be done long-term for you to maximize your outcome.  If you love to play golf, this is the place to be – we know what it takes to not only get your shoulder right, but make sure you’re at your best when you get back on the links again.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

The One Thing All Patients Expect

One Thing that Matters to Most Patients

People have lots of reasons why they make the decisions they do – cost, location, past experience, word of mouth, convenience, just to name a few.  When choosing a physical therapist, patients of course expect results, competence, convenient location and scheduling, affordability, and a likable treating physical therapist.  The topic of things that matter to patients has even been highlighted in this blog.  All of those are great things to keep in mind when choosing a physical therapist.  However, one thing that our patients have told us consistently over the years is not often what is found in many physical therapy facilities, but rest assured, you get it here at SSOR – you stay with who you start with and you don’t get passed around between physical therapists.

 

Why Consistency Matters

Think about why you like going to your favorite burger place, hairdresser/barber, or car mechanic – they know you, you know them, you like them, you trust them, and you get consistent results.  Physical therapy is no different.  The physical therapist you start with understands your history, why and how you got here, and what makes you tick.  When you say your pain is a 6/10, they know what your “6” is better than another PT that hasn’t worked with you.  You get comfortable with how they talk to you, their exercises, their hands-on techniques, and the rapport that you’ve developed with them.  When some physical therapy clinics pass you around for whatever reason, it’s like starting all over each time.  You have to tell them your whole story.  Maybe their mannerisms are different.  Maybe you just don’t “click” with them.  Perhaps they told you something totally different than your initial physical therapist. Maybe their manual techniques are a little different (they may get the same results, but they’re still not the same!).  Maybe you tell them that your pain is a 4/10 today but that might not mean a lot because your initial physical therapist knows that you started at a 6/10.  Hopefully, you get the picture here.  It is very important that you build a level of trust, rapport, and confidence in your physical therapist. That’s why this “one thing” really matters to a majority of our patients.

How do you know this is so important?

We know this one thing is important for a number of reasons.  First and foremost, patients tell us that’s why they like us or why they left “the other place.”  We know this because if one of our physical therapists works at both locations, their patients follow them wherever they go.  We know this because the cancellation rate spikes when a physical therapist is on vacation or out of town or patients just don’t schedule when “their PT” is out.  We know this when they call back with a new PT problem and they only want “their PT” even if that PT isn’t immediately available to get them evaluated.  We know this because they tell their friends that their guy/gal is the best and this is the only person to see. Finally, we learn this from our discharge surveys when patients tell us what they liked most about us – they stayed with who they started with.

The SSOR Approach

So, it’s pretty clear that this is hallmark of how we do things here at SSOR.  We work very hard to make sure you “stay with who you start with.”  Of course though, we have a plan in place just in case schedules don’t match, your PT is too busy at your requested time, or your PT is out of town on vacation for a week.  In those instances, our physical therapists will introduce you to the “new” PT and give them the run down – why you’re visiting us, relevant history, your restrictions, what you like/don’t like, what the treatment plan is, and what to work on.  Immediately, your confidence increases that this visit won’t be a waste of time and that your “new” PT knows everything they need to know to make sure you have a meaningful visit while “your” PT is out.  If your PT is out for an extended time, like a full week for vacation, each PT writes out a brief summary for each patient that’ll be seen by other physical therapists.  Nothing worse than opening a chart and seeing a treatment log for a patient you know nothing about and they know nothing about you.

We not only care about our outcomes and our approach, but we also care about the “little things” that are “big things” to our patients.  No question, the one thing that is non-negotiable to most patients is consistency.  Patients deserve to have the person they are comfortable with – someone that knows them best, and vice versa.  It would be a privilege to serve you and partner with you in your care.  Give us a call! We’re confident you will be pleased.

Soreness After Exercise

“Soreness After Sports/Exercise: Should I Be Worried?”

One of the more important roles we have as physical therapists is to help our patients wade through the ebb and flow of pain and discomfort and the proverbial “soreness” after activity, whether it’s work or sport.  Not all pain is “bad” and not all pain means pathology is present.  Sometimes soreness and pain just results from the body adapting to the stress we put on it.  For example, many patients complain of pain after ankle surgery once they go back to work and are on their feet all day for the first time.  They come in worried that something bad happened or they did damage because they’re limping, swollen, or sore.  Our main job at physical therapists in this situation is to calm their anxiety by helping them understand that it was a big step for their ankle today to work an 8-10 hour day after being off work for several weeks and they’ll be fine – the ankle is just having a temper tantrum right now.  Here’s what we do to make that better.  In a short time, the work day is a “piece of cake” then they jog for the first time and the process repeats itself.

However, there are other times when our patients are completing a return to sport progression in say, swimming or baseball, and after motoring along for a few weeks, they have significant soreness that lasts maybe a couple of days.  Again, after asking some pointed and detailed questions, we’re able to determine better if this is “bad” pain or just pain from the body adapting.

All that being said, how can you determine if your pain is just from soreness or if there is something more concerning going on?

Soreness, muscle soreness, pain after activity

Considerations about pain and soreness

It is important to understand that pain isn’t always what it seems.  For example, many patients get an MRI on their lumbar spine and the report comes back that they have signs of pathology but are asymptomatic.  Well, we know now that up to 40% of people have positive findings on MRI but are asymptomatic.  Conversely, many patients have an MRI report that says one thing, but their symptoms say another.  Therefore, diagnostic studies don’t always match with what your complaints are.  Secondly, pain and how our body interprets it can be from multiple sources.  Stress, anxiety, lack of fear, past experience with pain, and previous injury can all have an affect on how we perceive the pain we’re experiencing.  Certainly, pain can match the injury – you roll your ankle you now have a swollen ankle that is tender and causes you to limp.  However, it is important to understand that our activity level and any spike in it, even if it’s only going from part-time to full-time work, can cause soreness.  Finally, sharp pain is different than dull, achy pain.  “Knife-like,” sharp pain may be indicative of more serious pathology.  On the contrary, dull achy pain that is more diffuse after activity that surfaces after exercise and lasts up to 24 hours later isn’t as concerning.

The Soreness Rules

The University of Delaware have developed a “Soreness Rules” guideline that helps us to help our patients understand their pain and soreness and what to do about it.  They look like this:

If you have soreness during warm-up that continues, take a couple of days off and drop down a step in your exercise routine or training.  For example, if you have pain during warm-up after jogging a mile yesterday, you might consider jogging a half mile in two days.

If you have soreness during warm-up that goes away, stay at that level that lead to the soreness, then increase to the next step once the warm-up is soreness-free.

If you have soreness that is present during warm-up that goes away again later , then surfaces again – take a couple of days off and again, drop down a step.

For throwing athletes, here are the general rules:

If sore more than I hour after throwing, or the next day, take I day off and repeat the most recent throwing program workout.

If sore during warm-up but soreness is gone within the first 15 throws, repeat the previous workout. If shoulder becomes sore during this workout, stop and take 2 days off. Upon return to throwing, drop down one step.

If sore during warm-up and soreness continues through the first 15 throws, stop throwing and take 2 days off. Upon return to throwing, drop down one step. If no soreness, advance one step every throwing day.

Ways to avoid soreness

There are many things you can do to control soreness.  Graded progression of activity and exercise is arguably the most important factor.  “Too much, too soon” is the kiss of death for soreness.  So, don’t train for that marathon and run 5 miles one day and then run 10 the next.  If your son plays baseball, don’t go from throwing 50 throws 90 feet to 100 pitches off the mound at full speed in the span of a couple of days.  There are numerous interval sport programs available for many different sports and can easily be found online that will provide specific guidelines on what to do.  Another way is to make sure you have discussed your intentions with your physician and/or your physical therapist.  They can provide guidance on what to do and how to avoid soreness.  Next, make sure you have the appropriate mechanics and technique of the activity.  Along those same lines, ensure you have proper mobility and strength to return to activity safely.  A physical therapist can help you to determine if you are physically ready.  Finally, consider things like icing, massage, proper cool down activities, and anti-inflammatory medications to manage soreness.

The physical therapists at SSOR are accustomed to treating results-oriented patients.  We know how to help our patients progress safely through their rehabilitation and eventually their return to activity, whatever that may be.  We don’t freak out when you’re sore and we’ll make sure you don’t either!  Rest assured though, if something’s amiss, we’ll help get you to the right providers.  It would be a privilege to serve you and partner with you in your care. Give us a call!