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How to Treat Muscle Cramps

Ways to Treat Muscle Cramps

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

How to Reduce Muscle Cramps

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

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

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

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

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

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

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

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

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

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

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

Tommy John Rehab

Rehab After Tommy John Surgery

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

Hall of Fame pitcher Tommy John

 

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

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

 

General Guidelines for Tommy John Rehab

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

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

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

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

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

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

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

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

 

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

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

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

Can This Injury Be Prevented?

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

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

 

ACL Rehab Must Have’s

7 Things You Gotta Have for ACL Rehab

We see lots of people with anterior cruciate ligament (ACL) reconstructions.  ACL rehab after surgery is a long, arduous process that takes several months.   Unfortunately, the internet is a sea of misinformation on what to do/not to do.  It’s littered with various experts, horror stories, and various pundits who all have a different take, which adds to confusion.  Complicating matters further is that everyone seems to want to base outcomes on a professional athlete’s outcomes, or be committed to the idea that it has to be a specific time frame, commonly 6 months, prior to return to sport after ACL surgery.  Your ACL rehab should be a collaboration with you, your operating surgeon, and your sports physical therapist.  So what are the key things you need to have for ACL rehab?

Keys to ACL Rehab

Get your knee as straight as possible as soon as possible.  This is critical for proper muscle function as well as normal walking, and for you athletes, running eventually.  Studies have found as little as a 3° loss of extension adversely affects function, so make sure this is a priority.

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

Get your quad muscle working.  In order to walk, it is imperative that your quads work correctly.  These are the muscles on the front of your thigh.   These are the muscles you contract when you stretch in the morning and extend your knees.  As soon as you are able after surgery, you should start “setting” the muscle with brief contractions to get it firing. Think of it almost like a heart beating.  A nice tool to help with this is a muscle stimulator.  Multiple studies have shown that a muscle stimulator on the quads helps subjects improve gait and quad functioning than those that don’t.

Maximize your bending as much as your physician allows.  Try not to let that knee get too stiff.  Doing either heel slides, sitting at the edge of the bed, or using a bike for range of motion only are some ways you could do it.  Your doctor may get you a Continuous Passive Motion (CPM) machine but studies show it is not required.

Heel slides to improve knee bending using a bed sheet.

Use a crutch/es until you are walking completely normal!  This one is huge.  Amazingly, many physicians tell people to ditch the crutches and then watch them walk out of the office limping.  This may be our biggest pet peeve with physicians.  All eliminating the crutches does is keep your knee swollen, inhibit your quad, and delay your recovery.  Even if you don’t need two crutches, use one on the opposite side of the surgery (yes, the OPPOSITE side) or even a cane until you are walking completely normal.  Trust us – you’ll thank us later.

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

You must get your thigh muscle mass no more than 1 cm difference than your non-injured leg.  Many people who have chronic trouble with their involved leg long after surgery is often due to not getting their quad mass back.  Persistent pain, swelling, and dysfunction ultimately affect their function.  Many physical therapists fail to actually measure thigh mass throughout the course of rehab.  An analogy is having no shocks on a car, or having half inflated tires.  What do you think would happen with either of these scenarios?  The car would break down faster and have problems.  Well, your knee is no different.  This may take a year or so after surgery to get back, but someone should keep checking throughout your ACL rehab process.

Don’t forget about the hamstrings!  In real estate circles, people talk about “curb appeal.”  Make the house look nice in front – new paint, trimmed bushes, a nice freshly cut lawn.  Then you look at the backyard.  May be a disaster.  The focus on making the thigh muscle bigger neglects the critical hamstrings.  For the recovering athlete with an ACL reconstruction, your hamstrings are your best friend.  They are the “brakes” that limit the risk of the ACL being torn.  Therefore, make sure you do lots of stiff leg deadlifts, exercise ball bridges, ball curls, leg curls, and the Nordic hamstring curl as part of your ACL rehab.

You have two legs, balance training needs to be on both legs.  Humans are a bipedal species – we walk and run on both feet.  Balance after an ACL reconstruction is impaired and needs to be a part of your rehab.  Why on earth would you only do balance work on one leg?  Usually, deficits that may have caused your ACL tear are present bilaterally.  Therefore, what you do on one, do on the other.

Get your heel to your butt!   This is critical for people that want to play sports again.  When you run, your heel needs to get all the way to your glutes to sprint correctly.  Many athletes get their “active” range of motion back (what they can do), but lack the “passive” range.  The passive range is the “extra” range when you pull.  This is illustrated when you stretch your quads.  If you lift your heel up to try and touch your glute, it can’t get all the way up.   That’s the active range.  When you grab your foot and pull it up to your glute, that’s the passive part – the “leftover” slack.  You have to have that to run right.  If not, you won’t be as fast, and you’re at risk for hamstring strains.  There are many techniques to get this back, and it’s more than just cranking on it till it gets there.   You should wait several months before you aggressively stretch.

Stretch for the quadriceps muscles.

Make sure you get tested before you get “cleared.”  The biggest mistake doctors make is telling patients they’re “cleared” without explaining the difference between being “medically” cleared and “physically” cleared.  Unfortunately, it puts the idea in the patient’s head that he’s good to go.  The doctor clears you medically.  They tell you that your new ACL is healed and you have no infections or any reason to stop training/progressing.  However, physical readiness is totally different.  It shocks me how many people get “cleared” to practice/play when no one has ever watched them cut, sprint, or jump on one leg.  At a very minimum, you should have your strength tested and perform a series of single leg functional tests to make sure that your involved leg is at least 90% of your uninvolved one before getting released.  Once you do that, then you are “physically” cleared.  We promise, our functional testing algoithm is thorough and specific.  You will always know where you are in the continuum of recovery.

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

 

Do Inversion Tables Work?

Are Inversion Tables Effective for Back Pain?

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

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

History of Inversion Tables

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

 

Conventional Traction versus Inversion Tables

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

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

 

 

What’s the Evidence on Conventional Traction?

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

 

 

What is the Evidence for Inversion Tables?

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

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

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

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

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

Summary of Inversion Tables

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

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

 

Treatment for Low Back Pain

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

Rehab after a Separated Shoulder

Exercises for a Separated Shoulder

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

What is a Separated Shoulder?

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

What are the causes of a separated shoulder?

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

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

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

Physical Therapy for a Separated Shoulder

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

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

 

Pendulum exercise to help reduce pain and stiffness.

 

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

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

 

 

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

 

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.

Do You Need Surgery for a Torn ACL?

Torn ACL: I Gotta Get it Fixed, Right?

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

What’s the ACL?

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

How is it torn?

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

Do I need surgery for a torn ACL?

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

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

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

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

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

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

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

Our team of qualified, dedicated sports physical therapists are passionate about helping our patients get back to the activities they enjoy.  We are well-versed in treating torn ACL’s, either operative or non-operative.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park and Prairie Village to serve you.

Pre-Operative Exercises for Knee Surgery

Should You Do Pre-Operative Rehab Before Knee Surgery?

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

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

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

Pre-Operative Exercises before Total Knee Replacement

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

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

Figure 1: Heel slides with sheet for range of motion

 

 

Figure 2: Heel Hangs

 

 

Figure 3: Straight Leg Raise

 

 

Figure 4: Quadriceps setting exercise

How to Squat Properly

Learn How to Squat Correctly

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

 

 

Figure 1:  Poor squat form, trunk leaned forward

 

Figure 2: Poor squat, heels off ground

Figure 3: Knees collapsed inward, toes pointed out

Reasons for Poor Squat Form

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

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

 

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

Key Aspects of a Proper Squat

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

Figure 4: Proper Squat Form

 

Exercises to Improve Your Squat

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

Figure 5: Assisted squat, using a cable

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

Figure 6: Assisted squat, heels elevated

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

 

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.