Tag Archives: why should I see a physical therapist

Shoulder Impingement

The shoulder stabilizes the arm in all activities. Therefore shoulder pain can cause significant impairments in function and quality of life. Subacromial impingement is one of the conditions that causes pain in the shoulder and upper arm. The arm bone that connects to the shoulder is called the humerus. Imagine the top of the humerus as a golf ball and the part of the shoulder that it sits in as a golf tee. The rotator cuff muscles act to stabilize this golf ball on the tee to keep it in place as the arm moves in different directions.

This is the picture of the bursa and the bones of the shoulder.  A sharp force in the downward direction will cause the shoulder to come out of the shoulder.

This is the picture of the bursa and the bones of the shoulder. A sharp force in the downward direction will cause the shoulder to come out of the shoulder.

If you follow the top of your shoulder blade out to the tip of your shoulder you will feel your acromion. The rotator cuff muscles wrap around your shoulder blade and pass under your acromion to attach on the humerus. The area under the acromion is called the subacromial space, and this is where the rotator cuff tendons can get irritated.

However there are other structures that also pass though this space, such as the tendon of the biceps muscle and the subacromial bursa, which is a fluid filled sac meant to decrease the friction of the shoulder joint with movement. These structures can also become irritated with overuse of the shoulder. Subacromial Impingement Syndrome (SAIS) is the term used to describe this irritation of the structures that pass through the subacromial space.

Treatment for SAIS

Physical therapy treatment of SAIS can include multiple interventions such as exercise, electrical stimulation, manual therapy, and patient education on proper posture. The goal of a treatment program is to relieve pain, promote healing, restore pain free range of motion, reverse abnormal muscle imbalances and increase strength. Stretching is important to improve healing of the tissues by decreasing stiffness and increasing elasticity of the tendons.

Posture can be an important component of shoulder pain. Forward head posture with the neck coming forward contributes to both neck and shoulder pain as the head places a greater force on the neck in that position, which can often refer down to the shoulders. This head posture is often accompanied by rounded shoulders which limits that subacromial space leaving the shoulder at risk for impingement. Over time, the rounded shoulders position can also weaken the back and rotator cuff muscles as they are constantly being stretched.

To change bad posture it is important to be aware of bad posture and know how to correct it. The ears should be directly over the shoulders with the shoulders down and back. When sitting at a desk, the elbows should be at your side at 90 degrees with the wrists in neutral and if possible your computer screen should be at eye level to prevent bending at the neck. In standing the head should be in line with the spine with the feet hip width apart.

Strengthening Exercises

Strengthening of the rotator cuff also is important in order to allow the muscles to control the movement of the golf ball (humerus) on the tee (shoulder joint). Isometric exercise is based around holding a muscle contraction in a certain position without moving the muscle. Imagine you have your elbows at your side bent at 90 degrees with a resistance band wrapped around your hands. If you were to move your hands away from each other, you would increase the resistance of the band. Holding that position for 30 seconds, with multiple repetitions, is an example of an isometric exercise.

Isotonic exercise, on the other hand, involves you moving your arms through your range of motion in order to strengthen the rotator cuff and build endurance of those muscles. Imagine laying on your stomach at the edge of your bed with your arm hanging off the side. Lifting your arm straight up toward your head 10 times is an example of an isotonic exercise. This exercise can be performed in different directions (moving your arm straight out to the side or back toward your feet) and can be progressed by adding hand weights.

Both isometric and isotonic exercises should incorporate stabilizing the scapula as well as strengthening the rotator cuff. The scapula should be thought of as the foundation for all shoulder movement. For every 2 degrees of movement you see at the shoulder, the scapula moves 1 degree. If this rhythm is off it can affect how the shoulder functions. Exercises such as squeezing the shoulder blades together can help strengthen the muscles involved in scapular movement to allow for a more efficient movement pattern at the shoulder.

Exercise, in combination with other interventions such as manual therapy, has been proven to be effective in reducing pain and improving function in individuals with SAIS. There are multiple ways to work these muscles, utilizing both isometric and isotonic work, and above are just a few examples of that. Exercise plans should always be specific to the individual’s needs and limitations and should focus on the goals of that individual.  For more information on physical therapy and all Total Performance services visit www.totalperformancept.com.

Call Total Performance Physical Therapy today to schedule your appointment!

The benefits of aquatic therapy

Aquatic therapy is a form of skilled physical therapy that takes place in the water, usually a small pool, under the supervision of a physical therapist. It is a well-tolerated form of exercise that allows for non-weight bearing or limited weight bearing activities and is most commonly utilized by an older population, as normal joint degeneration and deconditioning occurs with aging.

Aquatic therapy is beneficial because it promotes relaxation of muscles, decreases muscle spasms, increases range of motion, improves circulation and heart and lung health, and decreases edema. It is also especially beneficial for joint pain and stiffness, including back pain, and can help with certain conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia, lymphedema, and lupus.

How does aquatic therapy work?

Aquatic exercise does not necessarily mean swimming. Aquatic therapy is one on one and can therefore be tailored for an individual based on their specific needs and limitations. Exercises are specifically designed based on where strength or range of motion are lacking. It can include walking in the water, marching in place, balance work such as standing on one leg, kicking in different directions, squats, etc.

Patients are able to perform these exercises because the pool is like nature’s body weight support system. By reducing the forces placed on the joints, patients can move freely in the same walking and movement patterns they need for normal life, but can work at a higher level than what they can tolerate on land. Patients can push their limits a bit more without worrying about falling because they are able to walk faster and more evenly right to left.

Decreasing the risk of injury, especially for those patients who are fall risks, is another advantage of aquatic therapy. The water provides security to those patients who are susceptible to losing their balance. The buoyancy of water provides a non-threatening environment and allows patients to get into certain positions and make particular movements they may not be able to make on the land.

The cardiovascular effect

Aquatic therapy can also increase heart rate and work the cardiovascular system more efficiently because patients are able to perform these quicker movements. This can lead to improvements in overall cardiovascular and respiratory health. In a recent study done on individuals with COPD (chronic obstructive pulmonary disease), those that received aquatic therapy, vs individuals that were trained in a therapy gym, reported that they had less fatigue and less breathlessness when completing activities of daily living such as showering and dressing. They also noted improved stamina and ability to complete tasks such as walking long distances and shopping.

The researchers performing the study felt that the water-based exercise program was more beneficial because of the effect of buoyancy, which supports the body weight while reducing the forces on the joints and allowing for greater movements. They also attributed the improvements made by this group to how the warm water assisted in pain control by improving blood circulation and also provided resistance to movements. It is more difficult to move your arms through water than it is to move them through air. Your heart has to work harder to push against the resistance that water provides, and therefore this effect also helped these individuals to build endurance. Moving through water is an added challenge to the body without placing an added stress to already painful joints.

If you think you may benefit from aquatic therapy, contact Total Performance PT to schedule an appointment with a physical therapist.

I keep rolling my ankle

There are approximately 23,000 ankle injuries daily in the US, making up 10-15% of sport related injuries. A lateral ankle sprain is the most common and this happens when the ankle rolls inward, called inversion, while the ankle is in plantarflexion (up on the toes with the heel off the ground). This typically involves an injury to the anterior talofibular ligament (ATFL) which runs from the bottom of the fibula, which is the large bone protruding on the outside of the ankle, forward to the talus, the first bone on the top of the foot. Involvement of the ATFL alone is considered a grade 1 sprain. A grade 2 sprain also involves an injury to the calcaneofibular ligament (CFL) which runs from the bottom of the fibula down to the side of the heel. A grade 3 sprain is an injury/rupture of the ATFL, CFL, and the posterior talofibular ligament (PTFL), which runs from the bottom of the fibula around the back of the ankle to the talus.

Ankle sprains involve ligaments which a tough fibrous tissue that connects bone to bone.

Ankle sprains involve ligaments which a tough fibrous tissue that connects bone to bone.

One of the most common impairments associated with an ankle sprain is joint laxity, which means the ligaments responsible for keeping the joint stable have become loose, making the joint vulnerable to future ankle sprains. Impairments also include pain and decreased strength, specifically of the muscles responsible for ankle eversion, called the peroneals. Eversion is the opposite motion of inversion as it turns your ankle outward. When these muscles are weak they are less able to resist inversion, which is the most common position for an ankle sprain. Another common deficit is decreased joint mobility, particularly in dorsiflexion range of motion (ability to lift your toes up) and mobility between of the small bones of the foot. With decreased ROM, the foot becomes more rigid and is therefore less able to adapt to different surfaces and terrain.

An ankle sprain may also disrupt the sensory nerve fibers in the supporting structures of the ankle (ligaments, tendons, and muscles) which can cause decreased proprioception, also called joint position sense. This is one’s ability to perceive the joint’s position based on internal cues instead of visually seeing the position of the joint. More specifically, proprioception is the ability to detect motion in the foot and make postural adjustments of the whole body in response to these motions. It also involves our ability to perceive the position of the foot before it contacts the ground, as inversion ankle sprains may occur because the foot is already in an improper position as it contacts the ground and receives the additional force of your body weight. With decreased proprioception you are at further risk of future ankle sprains because you are less able to perceive foot positioning and make adjustments accordingly.

Chronic Ankle Instability

Up to 33% of individuals with an ankle sprain will resprain within 3 years, which may lead to chronic ankle instability (CAI). CAI is characterized by repeated ankle sprains with a history of giving way and feeling of instability at the ankle joint. Individuals with CAI report a significant decrease in function, due to both a mechanical and functional instability. The mechanical deficits include joint laxity with decreased mobility while the functional deficits refer to the altered proprioception and secondary neuromuscular and dynamic postural control limitations.

There is a 30% prevalence of CAI after the first ankle sprain often because first time acute ankle sprains are generally mismanaged or the athlete is allowed to return to sport too quickly. Management should include manual therapy based on ROM deficits and to improve joint mobility, neuromuscular re-education to improve proprioception, and sport specific training (jump/landing training). Prolonged immobilization only encourages decreased joint mobility, proprioception/balance, strength and ROM.

Balance training for CAI

Balance training is crucial after an ankle sprain to restore ankle strength and proprioception in order to prevent CAI. As stated above, with decreased proprioception you get decreased postural stability because the body is no longer able to detect and adjust to ankle movements. Poor balance is then demonstrated by an increased postural swaying in response to ankle movement, particularly while standing on just the affected foot.

Balance training is focused on the awareness of body position by maintaining the center of gravity over the base of support (the foot). This functional training should include standing on a wobble board and adjusting to an unstable surface and progress to more dynamic single leg weight bearing activities, like a single leg squat for example.

Be cautious!

With an ankle sprain it is always important to rule out the possibility of a fracture. Red flags include tenderness at the bones of the foot and ankle and an inability to bear weight through the injured foot. If a fracture is suspected you should seek care from either your primary care provider or visit the emergency room. If a fracture is not suspected physical therapy can be beneficial.

For more information on ankle sprains, contact Total Performance Physical Therapy to schedule an appointment.

SLAP tears

The shoulder is a ball and socket joint made up of 3 bones: the humerus, which is the bone in your upper arm, the scapula, or shoulder blade, and clavicle, which is your collar bone. The head of the humerus at the top of the bone is the ball. It sits in a rounded socket in your scapula called the glenoid. The head of the humerus is much bigger than the glenoid, like a golf ball sitting on a golf tee. However, the glenoid has a strong fibrous ring surrounding it to help deepen the socket by 50% in order to stabilize the head of the humerus in the shoulder joint and prevent the ball from falling off the tee.

This is a picture of a rotator cuff tear.

This is a picture of a rotator cuff tear.

This ring is called the glenoid labrum and serves as the attachment site for both muscles and ligaments that work at the shoulder joint. A labral tear occurs when this ring is disrupted, frayed, or torn completely. When this occurs, the shoulder joint becomes unstable and is prone to further injury. The most common injury to the glenoid labrum is a SLAP tear: superior labrum anterior to posterior. Meaning in this injury, the superior or top portion of the labrum is injured. This is where the biceps tendon attaches to the labrum and the tear occurs both in front of (anterior) and behind (posterior) the biceps attachment site.

There are 4 classifications of these lesions. Type 1: the labrum has degenerative changes over time and fraying at the edges but remains firmly attached to the glenoid rim. Type 2: the superior rim is detached completely from the anterior to posterior glenoid rim and is lifted up by the biceps tendon. This creates an unstable biceps tendon attachment. Type 3: part of the superior labrum is displaced into the joint. Imagine how a bucket handle drops to the side of a bucket when released. This is how the labrum appears, however part of the labrum is still attached to the glenoid rim with the biceps tendon intact. Type 4: a greater percentage of the superior labrum is involved in the bucket handle tear, including a splitting of the biceps tendon.


SLAP tears can commonly be caused by either acute trauma or repetitive motions of the shoulder joint. A few examples of trauma include a motor vehicle accident, a fall onto an outstretched arm, shoulder dislocation, forceful pulling on the arm like when trying to catch a heavy object, or forceful movement of the arm in overhead activities. Athletes who participate in repetitive overhead sports, such as throwing athletes or weightlifters, are also at a higher risk of labral tears due to the repeated and forceful shoulder motion.

It is important to note that in older individuals SLAP tears may result from wearing down of the labrum that occurs slowly over time. Tearing or fraying of this labrum may be seen as part of the normal aging process and is different from an acute injury that may occur in a younger population.


Individuals with a SLAP tear may report popping, catching, or clunking with shoulder movement because the torn or frayed labrum has loose ends that get caught in the shoulder joint as the arm moves through its range of motion. These pieces may even get trapped in the joint. Another common symptom is pain with lifting objects, especially overhead, and maintaining a specific position. There may be a decrease in shoulder strength and range of motion or a feeling that the shoulder is going to pop out of the joint. Baseball pitchers specifically may notice a decrease in their throwing velocity.

However, not all labral tears produce the symptoms listed above. When tears are small and if proper care is taken not to stress the injury further, there may not be any pain at all. A tear may pop or click without being painful but due to the lack of blood supply available at the labrum it is likely that a tear can progress and lead to pain and weakness without proper treatment.

Can physical therapy help?

When labral tears cause minor symptoms without greatly affecting the stability of the shoulder joint, physical therapy can be helpful in decreasing those symptoms and returning the shoulder to its prior level of function. The first step in PT is patient education. It is very important to advise patients with SLAP tears to avoid putting excessive stress on the biceps muscle, as the tendon attaches directly on the superior labrum and can further damage that tear if not rested. For example, overhead movements and particularly bicep curls should be avoided until the labrum is more stable.

Manual therapy is utilized to improve pain free range of motion and decrease the tension that can build up in surrounding muscles. With a shoulder injury, it is common for people to start to use muscles improperly to compensate for the pain. For example, instead of just lifting the arm straight up over their head, they may lift their whole shoulder, engaging neck and back muscles, and use momentum to achieve that movement. Over time, these movement patterns start to negatively affect those surrounding muscles, which is where manual therapy comes in. Techniques such as deep tissue massage and myofascial release use pressure to help ease the tension that can build up and contribute to shoulder pain.

Physical therapy will also focus on shoulder strengthening. Improving the strength of the muscles surrounding the shoulder will help decrease the stress placed on the labrum and allow for better healing. Exercises in internal and external rotation are the initial focus as they target muscles of the rotator cuff without putting excessive forces on the labrum. A stretching program is also important because a decrease in flexibility of the shoulder can lead to poor posture habits. Stretching can help restore a normal balance between the muscles surrounding the joint to help them work better together.

Is surgery necessary?

If physical therapy is unsuccessful in reducing the symptoms of a SLAP tear, or if an individual presents with excessive instability at the shoulder joint, surgery may be appropriate to stabilize the joint. The type of surgery recommended depends on the type of tear. A type 1 tear is typically regarded as benign and surgery is not necessary. For a type 2 tear an arthroscopic repair is recommended to reattach the labrum to the glenoid. A type 3 tear may require an excision or repair of the displaced labrum depending on how much of the labrum has torn away and a type 4 tear will also require a repair of the biceps tendon. Following surgery physical therapy is highly recommended in restoring shoulder strength and range of motion. The PT protocol is typically up to the surgeon.  For more information on physical therapy visit www.totalperformancept.com.

For further information on labral tears, contact Total Performance Physical Therapy to schedule an appointment.

I think I pulled my hamstring

What is a muscle strain?

A muscle strain can be a micro or macro tear in the muscle, where the muscle and tendon meet, or where the tendon attaches to the bone. There are 3 degrees of muscle strains. A first degree strain is a micro tear that is inflamed and painful when the muscle is contracted or stretched. A second degree strain is a larger tear that is also painful when the muscle is contracted or stretched but presents with swelling, bruising, and muscle spasm. Lastly a third degree strain is a complete tear of the muscle with severe pain, bruising, and loss of function and strength. With third degree strains you can feel a defect in the muscle just by touching it.

Strains commonly occur when there is a forceful stretching or contraction of the muscle, or when the muscle is overloaded in an eccentric contraction. This type of contraction occurs when the muscle is stretched to end range while opposing a force. For example, an eccentric contraction of the biceps occurs when you start with the elbows bent with a weight in your hand and slowly lower the weight as you bring your hand away from your shoulder. This places a greater load on the muscles than a concentric contraction, which works in the opposite direction as you raise the weight back up to your shoulder. This contraction is a greater challenge to the muscle because the muscle fibers are separating as they are stretched while also contracting to control the movement.

How do the hamstrings get injured?

Hamstring strains are a common condition occurring in athletes. There are 3 muscles that run down the back of the thigh that make up the hamstrings: semitendinosus, semimembranosus, and biceps femoris.  These muscles start at the bottom of the pelvis and cross the knee joint. Semitendinosus and semimembranosus attach on the inner side of the knee while the biceps femoris attaches on the outside of the knee. These muscles work at both the hip and knee joints, extending the hip backward and flexing the knee, bringing the foot up towards the butt.

One of the most common ways hamstring strains occur is sprinting. During sprinting, we shift our weight from one leg to the other. As one leg pushes off the ground the other lands in order to support our body weight. The supporting leg moves backward as we propel our bodies forward. The hamstrings eccentrically contract while that supporting leg is extended back and the toes are used to push off and move forward. The hamstrings are stretched as the knee is straightened and they are loaded by both body weight and the force required at push off to move the body forward.

Contributing Factors

There are a few factors that may predispose you to a hamstring injury. Decreased flexibility of the hamstrings means that there is increased tension in the muscle, commonly described as muscle tightness. With increased tension there is a higher risk of injury as the muscle is not able to move through its full range of motion and function properly.

A muscle imbalance is also another source of injury. Human movement requires a proper balance of muscle length and strength throughout the body to allow joints to function efficiently.  A muscle imbalance occurs when one muscle group is stronger than a surrounding muscle group. For example, hamstring strains often occur when the quadriceps muscles of the front of the thigh are stronger than the hamstrings on the back of the thigh. The quads tend to be more powerful during high speed activities such as sprinting and the hamstrings tend to fatigue faster. Fatigue reduces the muscles’ ability to absorb energy during movement, which can lead to a strain.

Poor conditioning can be another contributing factor of hamstring strains. Weak muscles are not accustomed to the stress of exercise and are therefore less able to cope with that stress, leaving them more likely to be injured. Another possible cause of injury is improper warm up. Muscles are like rubber bands and for individuals who sit at a desk all day, those rubber bands are not being used. They become extra tight and constricted when you are not active. If you jump right into explosive exercise, like sprints, those unstretched rubber bands get pulled apart very quickly and can snap.


In the early stages of a hamstring strain it is important to rest, especially avoiding exercises that aggravate pain, such as sprinting. Ice is also an important part of treatment and is an excellent way to fight the inflammation that can occur at the hamstrings. It should be used for 15-20 minutes at a time and can aid in pain relief. Heat may also help to relieve symptoms by encouraging blood flow to the hamstrings for more rapid healing. Heat helps to ease the tension that builds up in injured muscles which can restrict normal blood flow.

Manual therapy is another way to promote blood flow and ultimately muscle healing. Myofascial release (MFR) is a soft tissue technique designed to relieve the tissue tension and trigger points that can form in the injured muscles. Trigger points are small knots that develop in a muscle after injury. These areas are highly irritable and sensitive to pain when pressure is applied and can often send referred pain to other areas.

Once an individual’s pain is more manageable stretching and strengthening exercises can be incorporated. Stretching of the hamstrings will decrease the tissue tension built up in those muscles and allow for a more functional range of motion. Strengthening is also key in order to adjust the muscle imbalances of the leg. Eccentric activities should be progressed as pain decreases to challenge the muscles further and prevent future injury. Along with these exercises, agility training should slowly be incorporated to prepare the individual to return to their sport or activity.  For more information visit www.totalperformancept.com.

If you think you may have a hamstring strain, contact Total Performance Physical Therapy to schedule an appointment.

I have a pain in my butt

The piriformis is a small muscle which runs from the back of your pelvis to the top of your thigh bone (femur) and is deep to the gluteal muscles. It is responsible for rotating the leg outward and stabilizes the hip joint enabling us to walk, shift our weight from one leg to another and balance on one foot. These are major components of running as you are constantly shifting your weight back and forth between feet while always having one foot off the ground.

The piriformis can get injured in runners specifically because of the repetitive stress placed on the muscle as it works to shift the body weight back and forth. In overuse injuries to the piriformis, the muscle is forced to work beyond its capability without being given the proper amount of time to recover. The muscle then responds by tightening up, increasing the tension between the muscle and the tendon connecting the muscle to the hip bone.

What is piriformis syndrome?

Piriformis syndrome is a neuromuscular disorder that occurs when the piriformis muscle compresses the sciatic nerve. The sciatic nerve is a thick, long nerve that passes alongside the piriformis muscle and travels down the back of the leg, branching off into smaller nerves throughout the leg and into the foot. However, in as much as 22% of the population, the sciatic nerve either pierces or splits the piriformis muscle, predisposing these individuals to piriformis syndrome.

The muscles surrounding the hip need to be kept strong to help limit pain.

The muscles surrounding the hip need to be kept strong to help limit pain.

In piriformis syndrome, trauma to, spasm or repetitive contraction of the piriformis muscle compresses the sciatic nerve causing pain, numbness, or tingling of the buttock and leg.  It may present as pain directly in the center of the buttocks that can be elicited with direct compression over the piriformis muscle, as a tight muscle can become sore due to decreased blood flow to the area. Piriformis syndrome can also present with pain that travels down the back of the leg into different portions of the lower leg. The pain travels down the sciatic nerve and can progress along any of the branches of this nerve.

Piriformis syndrome may also present as pain in and around the outer hip bone, as the increased tension of the muscle can create a bursitis. Bursitis is an inflammation of the bursa, or fluid filled sac that cushions a joint to help reduce the friction caused by movement. The increased tension of the piriformis can place an added stress on the hip joint, causing this inflammation of the bursa.

The most common complaint of individuals with piriformis syndrome is pain with sitting greater than 15-20 minutes. Other symptoms include pain starting in the gluteal area that radiates down the back of the thigh usually stopping above the knee, pain that improves with walking and is worsened by no movement, pain when rising from seated or squatting position, numbness in the foot and weakness throughout the leg.

Causes of piriformis syndrome

Piriformis syndrome may be primary or secondary. Primary piriformis syndrome has an anatomic cause, such as those individuals who present with a split piriformis or split sciatic nerve as the nerve passes through the piriformis muscle.

Secondary piriformis syndrome is more common however and is characterized as a macrotrauma (such as falling on the buttocks causing soft tissue inflammation or spasm with resulting nerve compression) or a microtrauma as a result of overuse of the muscle (such as in long distance running or prolonged sitting). Often overuse injuries occur because of weakness of the surrounding muscles. This is common in piriformis syndrome, as the piriformis has to work extra to stabilize the joint because it must compensate for weakness throughout the hip.

Piriformis syndrome is more common in women than men, possibly because women tend to have a wider Q angle, which is the angle between the hip and knee as women tend to have a wider pelvis creating a greater angle at the knee.


Patient education is always the first step in treating any injury. Any position that compresses the sciatic nerve and triggers pain should be avoided. For runners, running on flat, even surfaces is advised, avoiding running on uneven terrain or hills that will create extra work for the piriformis in stabilizing the hips. Ice is an excellent way to fight the inflammation at the piriformis. It should be used for 15-20 minutes at a time and can aid in pain relief. Heat may also help to relieve symptoms, as it encourages blood flow to the injured muscle for more rapid healing, as muscle tightness restricts normal blood flow.

Another was to promote blood flow and ultimately muscle healing is through manual therapy. Manual therapy techniques such as myofascial release (MFR) can be applied to help relieve the tissue tension and trigger points that can form in the piriformis and surrounding muscles. Trigger points are small knots that develop in a muscle when it becomes injured or overworked. These areas are highly irritable and sensitive to pain when pressure is applied and can often send referred pain to other areas. MFR can help decrease the pain caused by trigger points and should be used in combination with exercise.

Once the pain is more manageable, piriformis stretching and hip strengthening should be introduced. Stretching of the piriformis muscle will help to decrease the tissue tension of the muscle while also deceasing the stress the piriformis is placing on the hip joint.  It is also crucial to strengthen the surrounding hip muscles in order to relieve some of the stress that is placed on the piriformis. If the hip is strong overall, the piriformis will not have to work as hard to control movements at the joint.

Nerve glides are also a technique that help to reduce the symptoms of piriformis syndrome as they travel down the sciatic nerve. The concept behind nerve gliding is to place a stretch on the sciatic nerve, just as you would stretch a muscle, in order to decrease the neural tension caused by the piriformis muscle. This allows for increased signal conduction from the nerve to the muscle. These glides may reproduce some of the leg symptoms initially, but the goal is to desensitize the nerve to allow for increased movement without symptoms.

Differential Diagnosis

It is important to note that piriformis syndrome may present very similarly to other conditions, particularly of the low back. The sciatic nerve originates from the lumbar spine and can not only be compressed by the piriformis muscle, but can also be impinged when the discs separating the bones of the spine herniate or bulge outward, pressing on the nerve. The spine can also be compressed by conditions such as degenerative disc disease, compression fracture of the vertebrae, and spinal stenosis, which is a narrowing of the spinal canal which the spinal cord travels through. It is very crucial to have both the back and hip thoroughly inspected to rule out any other possible causes of sciatic nerve pain. If you are experiencing any of the symptoms described above, contact Total Performance Physical Therapy to schedule an appointment.

Is poor posture the source of your pain?

Neck pain is an important public health issue that affects a large portion of our population, resulting in disability for individuals and increased health care costs for the general public.  It is currently a widespread belief among health professionals that some nontraumatic neck pain can be related to posture. As we spend more time sitting at a desk in front of a computer screen at work, we start to see changes in our bodies. In recent years, forward head posture with rounded shoulders has become more prevalent as periods of prolonged sitting increase.  This causes changes in the soft tissues of our neck and shoulders, creating injury to those structures and ultimately leading to increased pain, decreased range of motion, and potentially more serious nerve related problems.  The spinal column is made up of small bones stacked on top of each other and separated by discs that help cushion the forces that movement can place on the spine. When viewed from the side, a healthy spine should naturally curve forward and backward slightly to help absorb the forces of gravity and everyday activities. Your cervical spine, at your neck, gently curves forward to support the weight of your head. Next the thoracic spine, which starts right above your shoulders blades, curves slightly backward. Then the lumbar spine, which is considered the “low back”, curves forward again. This curve tends to be the biggest because it supports the most amount of body weight. It is often greater in women due to structural differences and how they carry their weight. Lastly, the sacral curve begins at the back of pelvis and curves backward to help support our body weight in sitting.

The poor posture that comes from prolonged periods of sitting hunched over a computer leads to an increase in both the cervical and thoracic curves and a decreased lumbar curve. Imagine bringing your shoulders and chin forward, spreading your shoulder blades apart and bending over from your mid back, flattening the arch of your lower back. This is the common position referred to as forward head with rounded shoulders, leading to kyphosis (increased thoracic curve).

These are the curves of the spine.

These are the curves of the spine.

This position puts more wear and tear on the spinal structures, including the bones, discs, ligaments, and surrounding muscles, and can lead to permanent changes in spinal curves. In this position, the muscles that run down the back of your neck to your shoulders and also connect the shoulder blades to the spine are stretched out and become weak. They are no longer properly able to control movements at the shoulder or neck so you start using different muscles to compensate for this weakness. This often leads to increased pain or possible injury to the neck and shoulder due to the altered body mechanics. Conversely, the muscles in the front of your neck, chest, and shoulders become shortened and may even get compressed from the altered body position. Over time, you may lose range of motion of these structures as a side effect of the changes in the spinal curve. This also changes how your body is able to perform certain movements, like reaching over head.

How to prevent these changes

An important aspect in preventing these changes is to utilize proper sitting posture. The ideal sitting posture is with your feet firmly planted on the ground with your knees and hips bent at 90 degrees. When at a computer, your keyboard should be set up so your elbows are also bent at 90 degrees at your side, not leaning forward, with your wrists in a neutral and relaxed position. For head and neck alignment, imagine your ears directly over your shoulders, with your shoulders back and directly over your hips.  When you have been sitting too long, pain is your body’s way of warning you that it is working improperly and should be used as a signal to modify your body mechanics. It is important to avoid staying in any position too long. If you sit at a desk all day, set an alarm for yourself to get up every 15-20 minutes to avoid the neck stiffness that can come from prolonged sitting. Also, there are multiple exercises you can do right at your desk to prevent this pain or stiffness from worsening. For example, you can raise your shoulders up toward your ears and slowly roll them back, squeeze your shoulder blades together slowly then release, tuck your chin in by nodding your head down and back, or roll your head around in a full circle in both directions. These can all be repeated about 10 times and should be performed multiple times throughout the day to keep your muscles moving and prevent those static postures.

Aside from sitting all day, certain sleep positions can also aggravate this neck and shoulder pain.  Sleeping on your back is the best for your spine, as it allows you to maintain the most neutral position possible. However, using too big of a pillow puts you in that forward head posture which may contribute to your neck pain. When sleeping on your side it is important to use an appropriately sized pillow to prevent your neck from bending too much to one side or the other. It is also a good idea to place a pillow between your knees to keep your hips and low back aligned. Sleeping on your stomach is the worst position for your neck because it forces you to fully rotate you head to one side. This position should be avoided if possible.

How will physical therapy help?

A major goal of physical therapy for posture related neck pain is education for proper postural habits, including sitting, standing, and sleeping posture as well as proper lifting mechanics. PT also focuses on pain relief strategies, utilizing ice, heat, ultrasound, and electrical stimulation when it is appropriate. Ice is used to help fight the inflammation process, while heat, ultrasound, and electrical stimulation are used to promote blood flow and relieve tissue tension to aid in healing the damaged tissues.

Manual therapy techniques such as deep tissue massage (DTM) can also be applied to help relieve the tissue tension and trigger points that can form in the muscles. Trigger points are small knots that develop in a muscle when it becomes injured or overworked. These areas are highly irritable and sensitive to pain when pressure is applied and can often send referred pain to other areas. DTM can help decrease the pain caused by trigger points and should be used in combination with exercise.

Neck and shoulder strengthening and stabilization exercises are the final piece of the puzzle that should be introduced and progressed as pain and tension calm down. As stated above, the muscles that help stabilize your shoulder blades, which are crucial postural muscles, become weak after being placed on constant stretch from the rounded shoulder position. This position also leads to a shortening of the muscles in the front of the shoulder and chest, like pectoral muscles. Physical therapy will focus on strengthening the muscles that are weak and stretching the muscles that have then become short. To schedule an appointment with a physical therapist please contact Total Performance Physical Therapy.

Could my knee pain be arthritis?

Osteoarthritis (OA) is the most common joint disease causing disability, affecting more than 7 million people in the United States. It is a degenerative joint disease characterized by the breakdown and loss of joint cartilage that is meant to cushion the joint. This causes the bones to rub together with movement, resulting in extreme pain at the joint.

Knee arthritis can wear away at the joint and make it very painful to perform activities.

Knee arthritis can wear away at the joint and make it very painful to perform activities.

The knee is the joint that is most commonly affected by OA. The knee joint is formed by the intersection of the femur (thigh bone) and the tibia (shin bone), with the patella (knee cap) sitting on top. In a normal functioning knee these bones are able to glide seamlessly against each other over a layer of cartilage that covers the ends of the bones. The cartilage protects the bones and allows them to glide smoothly with normal activity and acts as a shock absorber for high impact activity, like running or jumping. With knee OA, this cartilage begins to wear away. This results in pain, tenderness, stiffness of the joint (usually after periods of inactivity), lack of flexibility, a grinding sensation with movement, and sometimes bone spurs, which are small hard lumps felt around the joint.

What causes knee OA?

The most common cause of knee OA is age, as the ability of the cartilage to heal with injury decreases as a person gets older. Gender is also a factor, as women 55 and older are more likely to experience knee OA than men. Obesity, additionally puts an individual at risk of developing knee OA and is often a cause of OA’s further progression as the added body weight further increases the pressure on the joints. Heredity can also contribute to one’s likelihood of developing knee OA, including inherited abnormalities in the shape of the bones that make up and surround the knee.

Overuse and repetitive stress to any joint can also predispose people to knee OA. For example, people with certain occupations that include kneeling, squatting, or lifting heavy weights are more at risk for developing knee OA due to the constant pressure on the joint. The same goes for athletes, particularly in sports such as soccer and tennis, as the repetitive cutting can breakdown the cartilage, or long distance running due to the high impact of forces over an extended period of time.

With that said, it is important to note that regular moderate exercise strengthens the muscles surrounding the knee joint and can help decrease the risk of developing knee OA. In fact, there is a correlation between decreased quad strength and the disability and pain associated with knee OA.

Physical Therapy of Knee OA

Exercise has been proven to increase knee joint function and decrease symptoms of knee OA. Recent research suggests that physical therapy treatment of knee OA can reduce the need for knee surgery and steroid injections. The combination of strengthening exercises with manual therapy demonstrates improvements in motion, pain, and walking speed. Therapy programs should be designed specifically for each individual based on their particular impairments. For example, if you are lacking knee extension, meaning the ability to fully straighten your knee, both your exercises and manual therapy should focus on moving the joint in that direction. The same is true if you are lacking knee flexion and are unable to fully bend your knee. The problem may also be muscle tightness, in which case exercises should focus on stretching the muscles surrounding the knee.  Following exercise it is always recommended to apply ice to the knee to decrease swelling and pain throughout the joint.

Alternative Treatment

If conservative treatment such as physical therapy is unsuccessful in decreasing knee pain, there are other options to consider. Corticosteroid injections fight inflammation and can offer fast pain relief that may last several months. However, the benefits of injections are only temporary with a short term effect.

A more drastic option would be surgery. Arthroscopic surgery is a procedure where the surgeon can remove the damaged cartilage or any loose bone that may be causing pain in order to “clean up” the joint. This again can be seen as a short term solution in order to delay a more complex surgery, like a total knee replacement, which should be considered when all other options have failed. In this procedure, all or part of the knee joint is removed and replaced with an artificial joint made of metal and plastics. Though this surgery may take months to recover from, the relief can last years.

Physical therapy is a great place to start when experiencing knee pain. Surgery should only be considered if therapy is unsuccessful in reducing the pain caused by knee OA. It may be considered if the pain is severe and limits your everyday activities, if it persists while resting both during the day and at night, if you experience chronic swelling or if stiffness limits motion at the knee, causing inability to bend or straighten the knee. However, as previously stated, to prevent the need for knee surgery or to slow the progression of knee OA, regular moderate exercise is recommended.  Call Total Performance Physical Therapy to schedule your appointment today.

A weak core could be causing your low back pain

The spinal column is a series of overlapping bones stacked on top of each other and separated by discs that cushion the forces between the bones. They protect the spinal cord which runs through an opening in the bones, giving rise to the nerves which supply the entire body. This column is then stabilized by muscles, tendons, and ligaments to keep it in place. Irritation to any of these structures can cause low back pain or pain that radiates to other parts of the body. The symptoms and severity of this pain can vary greatly from patient to patient.

Low back pain has become a major health issue because of its high prevalence in the general population, being the second most common reason patients seek medical attention. It is a costly injury with an annual healthcare cost estimated to be nearly $100 billion per year.  Low back pain often occurs without the degenerative changes you would see on an MRI. This is referred to as nonspecific low back pain, which may be caused by poor muscle control of the trunk, poor posture, low body mass, decreased trunk extensor endurance, poor hamstring flexibility, or psychological distress.

Some red flags that may be a cause of concern with low back pain include fever and chills, unexplained weight loss or recent weight loss due to trauma, significant leg weakness, sudden bowel and/or bladder incontinence (either difficulty passing urine or having a bowel movement or loss of control of urination or bowel movement), or severe and continuous abdominal pain. If patients are experiencing any of these symptoms they should seek medical attention immediately.

Treatment for Nonspecific Low Back Pain

If none of the above symptoms are noted, physical therapy may be appropriate to treat the low back pain. With injury to the muscles or surrounding structures of the low back, aching pain with activity, movement, or lifting heavy objects is common.  Pain that moves around the groin, buttock, or upper thigh is also common, often with muscle spasms or soreness to touch. The severity of the pain may range from mild discomfort to disabling pain, depending on the extent of the injury.

The use of exercise is a major component of treatment for low back pain. The chronic nature of this pain is often accredited to core weakness and instability, particularly of the lumbar and pelvic regions. Core stability exercises can help decrease these impairments and restore patient function. Proper motor control of the back muscles and spine position are the keys to maintaining spinal stability during activities. Stabilizing exercises have been proven to be more effective in reducing long term pain compared to treatment by a general practitioner.

What do I mean by stabilizing exercises?

These exercises target both abdominal and deep lumbar muscles that help stabilize the core. Early in treatment it is important to isolate these muscles in relaxed positions (patient lying on their back with their knees bent) by drawing in the abdominals, bringing the belly button up and in toward the spine, feeling the muscles tighten. Normal breathing is important while maintaining a muscle contraction. While the patient maintains the abdominal contraction they can perform bracing, which is bending at the waist side to side, keeping their back down on the table, in a slow and controlled manner.

To progress this exercise to make it more challenging on the core, the patient can either hold one leg straight up and hold for 30 seconds, or raise both feet with the knees bent and hold, all while maintaining the same abdominal contraction. This can further be progressed by performing abdominal contractions and bracing in different positions like sitting, standing, or on their hands and knees (quadraped). In the quadraped position they can raise one arm and the opposite leg to further challenge the core. The last progression would then be to maintain abdominal contractions with high speed activities such as walking or running. The increase in function and decrease in pain is reportedly higher with stabilization exercises vs. strengthening exercises.

Deep tissue massage (DTM) is also a component of physical therapy treatment for low back pain. It is often used to decrease muscle tension, improve vascular circulation to the affected area, and treat trigger points. Trigger points are small knots that develop in a muscle when it becomes injured or overworked. These areas are highly irritable and sensitive to pain when pressure is applied and can often send referred pain to other areas. DTM can help decrease the pain caused by trigger points and should be used in combination with exercise.

Alternative Techniques

Research has found that yoga has also made significant improvements in functional, pain intensity, and depression in adults with low back pain. Yoga includes maintaining specific postures, meditation, relaxation, and breathing techniques. Maintaining prolonged postures improves endurance of the lumbar stabilizers and improves posture and flexibility. Breathing techniques and meditation help reduce pain and improve function in individuals with low back pain.

For more information on physical therapy services visit www.totalperformancept.com.

Carpal Tunnel Syndrome

Most people will occasionally experience hand or wrist pain, especially if their profession requires repetitive fine hand movements.  Fortunately the pain and achy sensation quickly subsides, but for some people hand pain and numbness can become chronic and even debilitating.  One of the most common reasons people experience pain and numbness in their hand is carpal tunnel syndrome (CTS).  In fact, it’s estimated that CTS affects approximately 3-6 percent of the adult population in the United States.

Carpal Tunnel.  As nerves run under this sheath they may become compressed.

Carpal Tunnel. As nerves run under this sheath they may become compressed.

The carpal tunnel is a structure located in your wrist which surrounds and protects nerves, blood vessels and tendons. The actual tunnel is formed by the bones that make up the wrist and a strong thick ligament called the flexor retinaculum.   CTS often occurs because of excessive amounts of pressure that is placed on the carpal tunnel.  As a result everything inside the carpal tunnel, including the nerves are compressed.  The nerve that runs through the carpal tunnel is called the median nerve.  After exiting the carpal tunnel the median nerve spreads out to the thumb, index, middle and partially to the ring finger.  As this nerve is compressed or pinched neurological symptoms such as burning, numbness and tingling will be experienced in the thumb and the aforementioned fingers.  The pressure in the carpal tunnel can increase due to a traumatic injury such as a fracture of the wrist.  This will lead to an increase amount of swelling and therefore increase the overall pressure of the carpal tunnel.  In addition, the pressure can also increase if anything inside the tunnel becomes larger.  If any of the wrist muscles become overused, thickening of these tendons can occur which will increase the pressure of the carpal tunnel.

A person with CTS may experience several symptoms.  Besides experiencing pain, burning and numbness in their wrist, thumb and fingers a person may become aware that their pain is worse at night, especially while sleeping.  A person may also notice that shaking their wrist when they are symptomatic may provide relief.  Bending the wrist may also provoke symptoms.  The wrist may even appear swollen.  If symptoms are left unchecked the muscles that surround the thumb may actually begin to weaken and shrink in size.  This will translate to a weaker and painful grip.  This may result in a person frequently dropping items and feeling clumsy.

There are many risk factors that go along with this disorder as well.  Women are more likely to develop CTS than men.  Diseases associated with inflammation such as rheumatoid arthritis can increase the likelihood of developing CTS.  Pregnancy and menopause often cause swelling of the wrist which subsequently increasing the pressure in the carpal tunnel. Diabetes and obesity also increases the likelihood of sustaining damage to the median nerve.  Occupations that require using one’s hands and wrist (i.e. typing) or vibrating tools may contribute to developing CTS.

Before a physical therapist can begin treating the patient, they have to make sure that the patient’s symptoms are actually originating from the wrist.  When a person complains of numbness and tingling in the hand more often than not the neck is responsible.  If a nerve in the neck is being pinched then this may replicate symptoms of CTS.  This is crucial, not only for the physical therapist, but especially if the patient is contemplating surgery.  If an accurate diagnosis is not made then any treatment or surgery for the carpal tunnel will certainly fail.

If sleeping is aggravating a patient’s symptoms then a night split may be recommended to help lock the wrist in a neutral position.  This prevents the patient from bending or rolling the wrist as they sleep, which will reduce the amount of pressure on the median nerve.  The physical therapist will also perform hands on techniques that help decrease any built up tissue tension around the carpal tunnel.  Often if the patient is experiencing pain, the muscles will become guarded and can potentially entrap or squeeze the median nerve even further.  By relaxing these muscles the patient’s symptoms can be further reduced.    A physical therapist may also perform techniques that increase the mobility of the median nerve.  Nerves are similar to muscles in the fact that they can both become tight and they both can be stretched.  If the nerve is stretched carefully the overall mobility of the nerve will increase and this will ensure that the nerve is moving freely and is unrestricted.

The physical therapist will also instruct the patient on how to perform exercises that help glide or stretch the median nerve in a safe manner.  To reduce the pressure on the carpal tunnel further exercises focusing on stretching the flexor retinaculum will also be incorporated.  As the patient begins to improve and becomes less irritable exercises focusing on strengthening the wrist and forearm will be incorporated.  This will aid in restoring the patient’s pain free grip strength.  To reduce symptoms further, the therapist will also focus on proper posture and ergonomics.  Here the therapist will provide advice on how to minimize their symptoms at work and will make sure their work environment is not perpetuating their symptoms.

Individuals with mild to moderate cases of CTS typically do quite well with conservative management.  Individuals with severe cases or chronic cases of CTS may require surgery, but some of these patients may still benefit from conservative management.  It’s important to remember that one of the most determining factors on whether a patient will have a positive outcome with physical therapy is if they seek treatment early on.  For more information on physical therapy services visit www.totalperformancept.com.

If you’ve been experiencing hand or wrist pain, don’t wait contact Total Performance Physical Therapy for an examination today.