Tag: physical therapy

Don’t Forget Your Back

Most of us spend a large portion of the day hunched forward.  Think about when you are working on the computer, cooking, driving or even relaxing.  Your typical posture during these activities is head and neck forward, shoulders rounded forward, back curved and hips flexed.    When you remain in this position for an extended period of time, the muscles in the front of the body tend to shorten or contract, while the muscles in the back of the body tend to weaken.    This can be a set up for back, neck and shoulder problems and in addition, tends to make you look shorter, heavier and less confident.

Stretching before and after exercise as well as during the day is often overlooked in the rush to “get your workout in”.   Stretching however, has numerous benefits.   According to a study published in the Annals of Physical Medicine and Rehabilitation Medicine in September 2016, by I Fekhfekh, et al, dynamic muscle stretching of the knee musculature actually resulted in an increase strength gain in those muscles.  Interestingly, this study also found a decrease in the postural stability of the knee after stretching.    In English, it appears that stretching helps your to build strength, but may decrease the stability of the muscles you stretch at least temporarily.

In general, stretching helps to improve flexibility, joint range of motion, and usually is helpful for injury prevention.    Stretching helps by increasing blood flow to the muscles stretched.  This increased blood flow carries important nutrients to your muscles to allow for muscle growth and repair.  In addition, the increased blood flow helps to wash away muscle “waste” which leads to decreased soreness and inflammation of the muscle.

If allowed to remain in a contracted position for a prolonged period of time, our muscles will shorten.  For example if you spend a large portion of your day sitting in a chair or driving, the muscles in the front of the hips, your hip flexors will shorten.  These muscles have a direct effect on both your posture and your back health.

 

So what should you do?

It is important to stretch the muscles in the front of the body at least daily.

Exercises that focus on the hip flexors:

-Kneeling hip flexor stretch  – in the position of a lunge, allow your back knee to touch the floor and drive the hip of your front leg forward.  This will stretch the hip flexor of the knee on the floor

–Pigeon stretch – extend your right leg straight back and bring the heel of your left leg underneath your right hip.  Then drive your hips forward towards the ground.  Stretch and repeat on the other side.

– Yoga poses such as: low lunge, crescent lunge, upward facing dog, and revolving side angle pose

 

Stretches that focus on the chest muscles and prevent rounded shoulders:

– Door Frame stretch- stand in a doorway or at the corner of a room with your arms up like you were going to stop traffic.  Line your arms up from the elbow to the hand with the doorframe or in the corners of the wall.   Step towards the door and you should feel a stretch in your chest (pectoralis “pec” muscles) and hold for 20-30 seconds.

– Wall slides – stand with your back to the wall and keep your shoulders against the wall.  Walk forward 1-2 steps and slide your arms up and down the wall and squeeze your shoulder blades together.  You should feel a stretch in your upper chest muscles.

–Shoulder squeeze stretch –  clasp your hands together behind your back and slowly try to lift your hands.  Squeeze your shoulder blades together to stretch out the chest wall.

– Yoga poses include : bridge pose, camel pose, cobra pose and cow face pose

 

Stretches for your neck:

– Chin Tucks (Neck Retraction) – keep your shoulders back and your head in a neutral position (eyes facing forwards, chin level) slowly move your head backwards until you feel a slight stretch in the back of your neck.  Hold for 10-20 seconds and repeat.  If needed you can apply a gentle pressure on your chin with your fingertips to press your chin backwards and deepen the stretch.

Incorporating these exercises into your daily routine will help to prevent shortening of the muscles in the front of the body which leads to poor posture and often pain of the neck and back.  As always, if you are having pain which persists you should be evaluated by a certified health care professional to ensure that these exercises are safe for you.

This week we primarily discussed stretching exercises to prevent muscle contraction, and next week we will discuss the importance of strengthening the back muscles to further combat the issues of a hunched posture.

Common Causes of Knee Pain

The primary function of the knee is to bend and straighten the leg, to allow for a smooth gait during walking and running and to allow for jumping.    It is very common to develop knee pain in both new and seasoned exercisers.  Often the type of pain which develops is related to the type of exercise being done.

To understand knee pain, it is helpful to have a basic understanding of knee anatomy.

The knee joint can be divided into intra-articular and extra-articular compartments.

Intra-articular – structure inside the knee  joint

Extra-articular – everything else

The knee joint is where the surfaces of the leg bones meet and interact.  In order for the bones to move smoothly against each other and to provide additional stability, there is articular cartilage or cushioning shock absorber called the meniscus on both sides of the knee joint.  There are also many important ligaments which connect one bone to another and provide stability.  In addition, there are fluid filled sacs called bursae which allow for separation between solid tissues so that smooth movement can occur.

To help visualize the components of the knee, let’s break it down into 3 parts.

  • The anterior (front) of the knee
    •  Knee cap or patella
    •  Quadriceps tendon
  •  The medial aspect (side) of the knee  closest to the other knee
    • Medial meniscus (cushion)
    • Medial part of the joint capsule (the whole joint capsule encloses the entire knee)
    • Medial Ligaments  (provide stability for the knee and connect bone to bone)
  •  The Lateral aspect (outer) part of the knee
    • Lateral part of joint capsule
    • Lateral meniscus
    • Lateral ligaments

The knee is actually more complex then described above and does have the ability for rotation in addition to bending and straightening and other components not described above.  For the purpose of this article, we will focus on basic knee motions and components.

Now that we have a basic understand of the knee, let’s focus on what can go wrong with the knee.

In general, knee pain can be caused by:

  • Injuries due to trauma
  • Overuse injuries due to
    • Body misalignment
    • Muscle imbalances
  • Degenerative conditions
  • Injuries in the hips or feet

Patellofemoral syndrome (Anterior knee pain – front of the knee)

Common in new exerciser, especially runners and jumpers.  This is usually due to irritation between the patella (knee cap) and femur (thigh bone).  This pain can occur with increased jumping, squatting, running and climbing stairs.  Usually pain occurs if there is repeated stress on the knee or if there is a sudden significant increase in physical activity.   It is often treated with rest, ice, elevation and compression (RICE) and specific exercises to strengthen muscles surrounding the knee, and core.

Structural Injuries 

Knee injury can also result from structural changes or damage such as a dislocation, slippage or tears of the menisci or ligaments surrounding the knee.

Meniscal Injuries – The meniscus serves as a shock absorber for the joint.  Injuries of the meniscus can be the result of a twisting injury and can cause considerable pain, joint swelling, difficulty with stairs and the sensation of locking of the knee.  Occasionally the pain in the joint due to meniscal injuries will cause the brain to “shut off” the quadriceps at the knee causing the knee to “give way”.

Ligament Injuries – Ligament tears, such as a tear of the ACL (anterior cruciate ligament) can occur with a twisting injury and results in knee instability and may require surgical intervention depending on the degree of the tear.  It is common to sense a “pop” and immediate leg instability with this injury.    If surgery is used to repair the ACL, recovery is long and only low impact exercises are recommended initially to strengthen the muscles around the joint.  In contrast, PCL (posterior cruciate ligament) tears often can be treated non surgically with physical therapy and if indicated bracing.   When ligaments are torn or lax (loosened) it is common to have the sensation of poor balance or joint instability.

Tendon Injuries – Tendons are tissues that connect muscle to bone.  Typically, complete tendon ruptures are abrupt and result in the inability to move the joint.  The quadriceps tendon is quite large and a significant amount of degeneration must be present for it to rupture.  More often this injury is the result of a high force injury.   A completely torn tendon requires surgical intervention, but a partially torn one, will likely heal with immobilization followed by physical therapy.

Overuse injuries

Overuse injuries such as bursitis (inflammation of bursae), tendonitis (inflammation of the tendons), muscle strains, and Iliotibial band syndrome are usually the result of repetitive stress on a muscle, tendon or bursa.  Usually there is a component of body malalignment, muscle strength imbalance, improper shoe wear, or poor form which leads to the development of these conditions.  Treatment may include RICE (rest, ice, elevation, and compression) along with a detailed musculoskeletal exam to determine the etiology of the injury.  This will allow for a proper treatment plan to prevent recurrence.

Arthritis

Arthritis can be divided into Osteoarthritis (wear and tear), Rheumatoid (immune mediated), Gout (due to gout crystal build up) and Septic (due to infections).   Arthritis may be the result of poor diet or gluten sensitivity in some individuals.   While some forms of arthritis are genetic, diet modifications, weight loss, proper shoe wear and exercise may help to offset the severity of these conditions.

Hamstring Injuries

 

The hamstring muscles are actually a group of 3 muscles located in the back part of your upper leg. The hamstrings muscles originate from the pelvis (buttocks) and the femur (leg bone) on the backside of the leg and cross the knee joint to insert on the medial (inside) and lateral (outside) part of the leg just below the knee. The main jobs of the hamstrings are to extend (straighten) the hip and to flex (bend) the knee.   In addition, some of the hamstring muscles play a role in rotating the lower leg.

The most common thigh injury is a hamstring strain.   These injuries can often occur when the hip is flexed and the leg is extended, as in a single leg front kick. This is because 2 of the 3 muscles that make up the hamstring group cross over two joints (the hip and the knee).   These muscles are maximally stretched when the hip is bent and the knee is straight, and if movements are quick, the muscle can get strained or even tear.

Certain physical findings can increase your chances of getting a hamstring injury, such as:

  • Tight hamstring muscles – (inability to completely straighten your knee on standing)
  • An imbalance between the muscle strength in the upper leg (hamstrings and quadriceps)
  • Tightness of the quadriceps or hip flexor muscles (inability to completely stand up straight while the legs are straight — you will notice that you bend forward at the hips slightly if your legs are otherwise straight)
  • Insufficient warm up before exercising
  • Poor muscle coordination
  • Muscle fatigue
  • Muscle strength or flexibility imbalances

Usually a hamstring injury will present with pain on the backside of the upper leg, possibly with swelling, bruising, and an associated popping sensation at the time of injury.   If the hamstring muscle is fully torn, there may be an obvious mass which is actually the muscle contracting into a “ball”.

Treatment of hamstring injuries can be broken down into the acute phase that occurs immediately after injury and for the first 2-3 days. The sub-acute phase that occurs for several days to a few weeks after injury and the chronic phase that begins several weeks after injury.

Acute treatment of a hamstring injury generally follows the acronym PRICE.

Protection – In a severe hamstring strain or tear, an individual may require a crutch or a cane to protect the injured leg while walking.

Rest – for the first few days, remain off the injured leg as is possible, as this will enable the hamstring to begin healing.   The caveat is that stretching muscle begin shortly after injury because the muscle will scar down as it heals leading to further muscle tightness and predisposing you for another injury.

Ice– using a plastic bag filled with ice and water for 20 minutes 3 times a day is helpful to further reduce swelling. Heat is initially not recommended because heat increases the blood flow and is thought to worsen swelling. However, a few days after an acute injury heat can be helpful as heat increases blood flow to the injured area and helps with healing.

Compression – An ace wrap or compression dressing should be applied to the upper part of the thigh to prevent further swelling.

Elevation – Elevating the injured leg helps to further prevent swelling.

As mentioned above, hamstring injuries require both stretching and strengthening in order to recover. The main issue is that after a tear or strain, the muscles heal by scarring down. This scarring results in decreased flexibility of the muscle.

One big mistake athletes and weekend warriors make after sustaining a hamstring injury is to return too quickly to their prior level of activity. It is very important to only return to exercise after the pain has subsided. This is because if you return to exercise too early, you will change your biomechanics (i.e. alter your posture or positioning) to compensate for the pain. This altered position or step length while exercising can allow the muscle to shorten. When the muscle heals and contracts (shortens and scars down) you are then at increased risk for a repeat strain or tear.   Typically it takes at least 4-6 weeks for the muscle to properly heal.

It is helpful to begin stretching and strengthening exercises under the supervision of a qualified physical therapist so that you do not re-injure yourself and you can recover optimally. It is possible to regain or even surpass your pre-injury strength and flexibility with a proper treatment regimen.

PRP or Platelet Rich Plasma injections are sometimes recommended for assistance with tissue repair and quicker recovery time. However, an article published in 2015 from the Department of Sports Medicine at St Lucas Andreas Hospital in Amsterdam, reviewed the data for the treatment of hamstring injuries and found that lengthening exercises (stretching the hamstrings) provided the quickest return to play time, but did not affect re-injury rate. PRP injections did not improve outcome or re-injury rate when compared to controls. Therefore, at this time, it appears that a physical therapy regimen focusing on first stretching the hamstring muscles, then strengthening them (while maintaining improved flexibility) provides the best chance for recovery and return to exercise.   It was also suggested in this study that progressive agility training and trunk (core) strengthening and stability might reduce re- injury rates.

As always, if you suspect you might have a hamstring injury or other leg injury it is important to be evaluated by a trained health care professional. It is quite possible that you will be referred to a physical therapist for optimal treatment that includes a both a stretching and strengthening regimen. While initially your treatment will focus on the injured muscles, it will be important to analyze and treat your body mechanics to prevent repeated injury.

Carpal Tunnel Syndrome

 

One of the most common causes of hand and wrist pain is a condition called Carpal Tunnel Syndrome. This condition is usually the result of the median nerve getting trapped and compressed in the carpal tunnel as it courses towards the hand.

The carpal tunnel is a tunnel in which the bottom and sides of the tunnel are formed by the carpal or wrist bones and the top is formed by the transverse carpal ligament. This ligament or fibrous band connects the top two carpal bones. Inside the carpal tunnel is the median nerve as well as 9 of the flexor tendons for the fingers and thumb. The purpose of the carpal ligament is to stabilize the carpal bones and anchor some of the tendons for the hand muscles (finger flexors) to enable them to work correctly.

Carpal tunnel syndrome occurs due to compression of the median nerve running through this tunnel. The compression can be due to swelling of the tendons, inflammation of the tendons, overall fluid retention in the body (due to pregnancy, allergies, or other inflammatory conditions) and over-use injuries (such as typing).

Carpal tunnel syndrome can be classified as mild, moderate or severe.

Mild carpal tunnel presents as primarily sensory symptoms with numbness and tingling of the fingers and hand. As the median nerve gets more compressed the symptoms of carpal tunnel syndrome becomes more severe and the motor component of the nerve gets involved. When this happens, weakness and atrophy (muscle wasting) can be seen.

Common Symptoms of Carpal Tunnel Syndrome:

Mild:

  • Numbness, tingling or aching of the thumb, 2nd, 3rd, and part of the 4th fingers
  • Nighttime hand/wrist pain and numbness
  • Difficulty typing, or with fine finger movement involving the first 3-4 fingers
  • Numbness and tingling which worsens when the wrist/hand is bend at a right angle (either flexed forward or extended backwards)
  • Electric shock sensations radiating into the hand
  • Pain that radiates from the wrist upward towards the elbow

Moderate to Severe: (in addition to above symptoms)

  • Weakness in hand grip
  • Dropping objects from the hand
  • Muscle wasting in the palm of the hand, especially at the base of the thumb

For mild symptoms the use of a wrist splint at night will be helpful. These splints can be purchased over-the-counter at a pharmacy or medical supply store. The splint should have Velcro or adjustable type straps and should have some sort of support or rigid material on the underside of your wrist and palm, that will prevent your wrist from bending forward too much. The splint should be worn at night to prevent inadvertent wrist bending, and can be worn during the day if symptoms are continuously present.

Certain exercises may exacerbate carpal tunnel syndrome such as push-ups, planks, and low jacks. Any exercise which puts pressure through the wrist while it is at a 90 degree angle from the arm can further compress the median nerve in the carpal tunnel. Helpful exercise modifications include doing push-ups on your fists and keeping your wrists straight, or doing the push-up on an incline (with your head higher than your feet) so you are putting less weight through your wrists.

In addition, activity modification may be indicated if the above interventions are not helpful. If cleared by your doctor, adding a small amount of Vitamin B6 (<200mg/day) is beneficial for improvement of nerve function. Vitamin B6 acts a a diuretic (decreases swelling), helps the body to make neurotransmitters and helps with the function of the immune system.

Foods which contain B6 include:

  • Wild caught tuna
  • Bananas
  • Salmon
  • Grass-fed beef
  • Chicken breast
  • Spinach

If dietary, activity, and exercise modification are not successful in treating your carpal tunnel syndrome in conjunction with the use of a wrist splint and occasional anti-inflammatory medications, it is important to be evaluated by a health care professional. In addition, if your symptoms progress, are not localized to your first three fingers, or are associated with any other symptoms, make sure to get checked to rule out other causes of hand/finger numbness.

If conservative treatments fail, other interventions such as physical therapy, corticosteroid injections, prolotherapy, platelet rich plasma injections, or surgical release may be indicated.