Tag Archives: why should I see a physical therapist

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.

SI Dysfunction

Often when a person experiences low back pain the first thought that comes to mind is a pulled muscle or an injury to the spine.  However, this is not always the case. In some instance low back pain can stem from a dysfunction of a joint that most people have never heard of; the sacroiliac joint (SI).  Before a person can begin to understand what causes SI dysfunction a basic knowledge of the function and anatomy of the SI is required.

The SI joint is formed by the tailbone (sacrum) connecting to the left and right sides of the pelvis bones (Ilium).  The function of the SI joint is to act as a link to the lower spine and the pelvis. This allows the SI joint to function as a shock absorber for the pelvis and the lower back.  The SI joint also allows the hips to slightly rotate or twist while a person is walking or running.  This helps provide stability throughout the pelvis and disperse forces evenly through the pelvis and spine.

The most common cause of dysfunction of the SI joint is hyper-mobility or excessive movement.  The SI joint is an inherently rigid joint.  It is vital that the SI joint does not have too much uncontrolled motion or the SI joint will be placed in an abnormal position which will place additional stress onto the joint which results in pain.  In addition, if the SI joint becomes too flexible its ability to act as a shock absorber and transfer forces evenly throughout the pelvis and spine will be reduced, which also results in pain. SI hyper-mobility may occur after trauma such as a motor vehicle accident or falling and landing on ones buttock.

A person with a SI dysfunction will commonly complain of low back, buttock or hip pain. The pain may even transfer down the leg and mimic other conditions such as a bulged disc or sciatica.  Typically symptoms are worse when standing, walking or running and are relieved when lying down or resting. Bending over, climbing stairs and rising out of a seat can become difficult and painful too.  A person may notice that lying on their side for prolonged periods reproduces their pain as well.  There are many risk factors for developing an SI dysfunction.   Women are more likely to develop SI dysfunction than men.  Women who have given birth are also at greater risk.  People who are more flexible (i.e. gymnasts) are at greater risk of developing SI related pain as well.

In order to prevent excess motion from occurring, the muscles surrounding the SI joint must be well conditioned.  Specifically the transversus abdominis and oblique abdominals attach onto the surrounding area of the SI joint and aid in maintaining the position and stability of the SI joint.  Research has shown that contracting or firing the transversus abdominis significantly stiffens and stabilizes the SI joint. Furthermore, research has shown that the deep buttock muscles (gluteus medius and gluteus maximus) are important in maintaining the stability of the hips and pelvis.  If any of the muscles become too weak or lack proper endurance the likelihood of SI hyper-mobility increases.

Before a physical therapist can begin to treat a patient for SI Dysfunction a detailed evaluation has to be given.  For this condition X-rays and MRIs are not particularly useful in diagnosing SI dysfunction.  Instead, a history and a thorough physical examination has to be administered.  First the physical therapist will need to determine that the pathology is not originating from the back or the hip. The physical therapist will also observe for any strength deficits and if the patient is walking with any compensation patterns that could contribute to their pain.

Once the diagnosis of SI dysfunction has been reached the physical therapist will first focus on reducing any inflammation.  This may include ice or taping techniques which will unload pressure off of the SI joint.  In order to begin stabilizing the SI joint the physical therapist will then begin incorporating exercises that focus on strengthening the deep hip and core muscles.  As the patient’s ability to activate these muscles progresses exercises that focus on firing these muscles while the body is in motion will then be incorporated.  When the body is in motion (i.e. running) the SI joint is more likely to demonstrate excessive motion.  By performing more complex and dynamic strengthening exercises the deep core and hip muscles are forced to stabilize the SI joint.  This will result in restoring the patient’s ability to perform their favorite activities without discomfort.  The intensity and the difficulty of these exercises will vary depending on the patient’s overall goals and the severity of the patient’s symptoms.  Some people may just want to be able to bend over without discomfort while others may be planning on running a marathon or trying out for their favorite sport.

If a person seeks treatment then their prognosis for this condition is very good.  The majority of individuals with SI dysfunction respond well to conservative treatment.  Unfortunately, if a person ceases to perform their prescribed exercises their symptoms may reoccur.  Because of this it’s imperative that the patient continues to perform their home exercise program a few days each week, otherwise the patient may not be able to maintain their desired activity level.  Whether you are an avid runner or a couch potato a physical therapist can make SI instability become a thing of the past.

Don’t put up with low back pain; call Total Performance Physical Therapy for an examination today.

Jumper’s Knee

For most people sporadic aches and pains are just part of being an athlete. One of the more common areas that an athlete will experience pain is the knee.  Typically after a day or two of rest the pain subsides and the athlete is able to return to their prior level of activity with minimal to no discomfort. But there can be a cause for alarm when the pain doesn’t subside, especially if the pain begins to worsen.  If left untreated knee pain can prevent an athlete from competing, and in severe cases the pain can make simple activities such as climbing a flight of stairs difficult. A common culprit of knee pain in an athletic population is patellar tendonitis or jumper’s knee.

The knee joint.

The knee joint.

The patellar tendon is located directly below the knee cap (patella) and attaches on the shin bone and the knee cap.  Its function is to work with the quadriceps muscle to straighten out the leg.  Jumper’s knee usually occurs when the patella tendon is repeatedly overstressed.  This stress can lead to inflammation which can lead to pain and swelling.  The patella tendon is most stressed when a person is jumping, running or kicking.

There are several causes and risk factors for developing jumper’s knee. Individuals are more at risk if they are involved in a sport that require running and repeated jumping (i.e. basketball volleyball, football etc.).  Athletes who rapidly increase their intensity and/or the volume of training are at risk as well.  People who are not flexible especially around the quadriceps and hamstring are also at greater risk of developing jumper’s knee. Athletes may also develop jumper’s knee if they demonstrate poor hip and knee control during the landing phase of a jump. In rare cases jumper’s knee can occur in individuals who sustain trauma to the knee and do not allow for an adequate amount of time for the patellar tendon to heal before returning to their sport.

Symptoms include tenderness of the patellar tendon, pain with jumping and prolonged running.  Knee pain will often become gradually worse as the athlete progresses through a practice/game.  The knee may actually become swollen and feel warm to the touch as well. The knee may also begin to feel stiff in the morning.  In severe cases the patellar tendon will become thicker and appear larger than the unaffected knee.

After a physical therapist diagnoses a patient with jumper’s knee the therapist will then provide several interventions in order return the athlete back to playing their sport pain free.  If the patient presents with a very mild case of patellar tendonitis then RICE (rest, ice, compression, and elevation) may suffice as a treatment.  But in more moderate to severe cases a more extensive approach will have to be taken.  Often if a patient has muscle imbalances or demonstrates compensation patterns while running or jumping trigger points will begin to form and this will lead to the muscle being tight and painful.  The physical therapist will identify if the athlete has any muscle imbalances and trigger points and they will use hands on techniques to release these trigger points.  The physical therapist will also instruct the patient on how to properly use a foam roller to help release these trigger points on their own.  This will aid in decreasing the tissue tension of the quadriceps and as a result place less strain on the patellar tendon.

To further reduce any built up tissue tension the therapist will also prescribe exercise that help stretch the quadriceps and hamstrings.  To reduce the overall force on the patellar tendon the physical therapist will also utilize specific taping techniques.  The physical therapist will also evaluate the athlete’s running and jumping mechanics.  If compensation patterns are observed the therapist will provide feedback and prescribe exercises to strengthen any deconditioned muscle(s).  Once the patient’s symptoms begin to improve, plyometrics will then be introduced to help grade the athlete’s exposure to sport related movements.

For more chronic cases, the physical therapist will employ eccentric exercises for the quadriceps muscle.  Typically when a muscle is firing it shortens or contracts.  An example of this is when a person is performing a biceps curl.  The bicep shortens as you lift the weight. Here the physical therapist will prescribe exercises that make the quadriceps fire while in the lengthened position.   This increases the force and the work load onto the quadriceps and the patellar tendon.  These exercises help the quadriceps and the patellar tendon to better cope with the intense workloads an athlete must endure during training, a game or a practice.  At first these exercises may be painful to perform or the patient my experience increased soreness afterwards, but this is expected.  Research has consistently shown a significant reduction in symptoms and a better chance of returning to their sport after performing an eccentric based exercise program in athletes with jumper’s knee.

With jumper’s knee the key to a great prognosis is early detection.  If left untreated patellar tendonitis can manifest into patellar tendinopathy.  This is where the patellar tendon sustains small tears. As a result the patellar tendon thickens in order to attempt to compensate.  In these individuals the overall treatment does not change, but the recovery time can be much longer and the reoccurrence rate tends to be higher.  If an athlete does not try to push through the pain and seeks care early on then the chances of them returning to their sport at a competitive level with no pain increases dramatically.

If knee pain has been impeding your ability to run or play your favorite sport make sure to contact Total Performance Physical Therapy for an evaluation today.


Fibromyalgia is a condition that presents with chronic pain, tenderness and fatigue.  If left untreated fibromyalgia can reduce a person’s quality of life which often leads to depression. There is no imagining or test that can be performed that will clearly identify if you have fibromyalgia.  Fibromyalgia is a diagnosis of exclusion, meaning that all other possible diseases have to be ruled out before a diagnosis can be made.  Although diagnosing fibromyalgia is often difficult it is still one of the most common chronic pain conditions.  In fact, over 10 million Americans are affected by this disorder.

Although an exact cause of this disorder is unknown there are several risk factors correlated with developing Fibromyalgia.  Females are approximately three times more likely to develop fibromyalgia than men.  A diagnosis is usually made between the ages of 20-50 and as a person ages the chances of developing fibromyalgia increases.  Severe trauma has also been linked with developing fibromyalgia. It has also been correlated with becoming ill or contracting specific diseases such as lupus or rheumatoid arthritis. There is a strong genetic component to developing this disorder as well.  Therefore, you are at greater risk of developing fibromyalgia if a closely related family member has developed this disorder in the past.

A person with Fibromyalgia will often complain of specific points on their body that are very painful and tender to the touch. There are 18 common tender points that people who have fibromyalgia complain of.  These tender points range from the knees, hips, back, shoulders, all the way up to the neck.  A person’s symptoms will usually vary; some days may be symptoms free while other days may be filled with debilitating pain. There are a wide range of symptoms a patient may experience; they include chronic fatigue, profound amounts of pain, stiffness, tenderness, restless sleep, irritable bowel and bladder and depression. Often these symptoms can create a vicious cycle.  Wide spread tenderness and stiffness can result in difficulty sleeping which can promote chronic fatigue and lead to worsening depression and a lower quality of life.  In addition, not knowing how to treat and cope with fibromyalgia can lead to anxiety and increase stress levels which can leave a person feeling distraught.

Fortunately physical therapy is a method that can help increase the amount of “good” days a patient experiences and lessen the amount of “bad” days.  Research has proven that physical therapy can provide a significant reduction in symptoms and an improvement in quality of life for people struggling with Fibromyalgia.  This can be accomplished by multiple methods.  At first a patient with fibromyalgia may be too sensitive to tolerate exercises on land.  This is where aquatic therapy comes into play.  Research has shown that performing aquatic therapy three times a week can reduce a patient’s symptoms significantly.  This is because the overall amount of pressure that is placed upon the joints is reduced when a person is submerged in water. This increases the patient’s tolerance for exercise.  In addition, the warm water can help increase blood flow to the muscles which can loosen stiff joints and accelerate the healing process. The water also provides resistance which helps strengthen the muscles.

As a person’s tolerance for aquatic exercise increase, they will then be gradually transitioned to physical therapy on land.  A physical therapist will first begin by prescribing exercises that help to stretch out stiff muscles without causing an increase level of discomfort.  If a patient is not too sensitive, a physical therapist will focus on using hands on techniques to help decrease any increased muscle tension.

The physical therapist will also focus on increasing aerobic activity and strength training.  Studies have shown patients with chronic pain who begin performing aerobic activity on a consistent basis report reduce levels of pain. This is because during aerobic activity hormones called endorphins are released in the body.  Endorphins are pain fighting hormones that reduce stress, anxiety and even depression.  This doesn’t mean a patient with fibromyalgia needs to become an avid jogger in order to reap the benefits from aerobic activity.  Even walking on a consistent basis will reproduce these beneficial results.  A physical therapist will also provide a patient with pain education and on advice on how to better manage their “bad” days.

As a person’s tolerance for exercise on land increases strength training will then be incorporated.  Strength training on lands provides more resistance to the patient’s muscles than aquatic therapy.  As a patient’s muscles become stronger the amount of force placed on the joints becomes lessened which reduces the amount of pain experience by the patient.  These treatments will result in increased ability to walk further distances, increased energy and patients will be able to perform daily activities with less discomfort.

Living with fibromyalgia can be challenging and at times may seem like an impossible task, but significant improvements in pain reduction, fatigue and quality of life can be made if the patient is motivated and willing to work with a team of health care professionals.  No matter if your goal is to just walk a block without pain or return to running again a physical therapist will work with you to reach your goals.  For more information on physical therapy services visit www.totalperformancept.com.

If you have been struggling with fibromyalgia make sure to contact Total Performance Physical Therapy for evaluation today.

ACL Tears and Reconstruction

One of the most common and dangerous injuries an athlete can endure is a torn ACL.  At the very best the athlete will have a long road to recovery and at the very worst a torn ACL can mark the beginning of the end of a young athlete’s career.  It’s estimated that there are over 250,000 ACL related injuries each year, and more than 100,000 ACL reconstruction surgeries are performed in the United States every year. To understand why ACL injuries are so common in athletics one must understand the basic anatomy of the knee.

This is the picture of an ACL tear.

This is the picture of an ACL tear.

The ACL (anterior cruciate ligament) is one of the four ligaments in the knee. This ligament is essential for maintaining knee stability.  It accomplishes this by limiting the overall motion of the knee joint. Approximately 70% of ACL injuries are non-contact injuries.  Usually when an individual plants their foot down and then attempts to pivot the ACL is more likely to be torn. This is because this particular position places more stress on the ACL and makes it more likely to tear.  Another common way a person will tear their ACL is when they are landing after jumping.  If an individual lands with their knee bowing inward this will also place additional pressure onto the ACL and make it more prone to rupturing.  Because of this sports that require frequent jumping, cutting and juking increase the likelihood that an athlete will tear their ACL. In fact, out of all sports basketball and soccer have the highest exposure to ACL tears.

Other than what sport a person plays the gender of the individual can place the athlete at risk for developing an ACL tear.  In fact, females are three times more likely to develop an ACL tear than males. This is most likely due to several factors including muscle imbalances, biomechanical and anatomical differences, hormonal changes and strength deficits. Another risk factor is having a past history of injuring or tearing an ACL.  This makes the individual much more likely to re-tear their ACL. When a person tears their ACL usually they feel as if their knee is giving out.  Also an audible popping sound is heard or felt within the knee. This is usually accompanied by moderate to severe pain.  Often the athlete will not be able to place full weight through their leg and may not be able to walk without considerable discomfort for the next couple of days.  Swelling and inflammation usually occurs soon after the initial injury as well.

Determining whether ACL reconstruction surgery is the best course of action depends on several factors.  A prime candidate for surgery is a young, competitive athlete whose sport requires agility based movements (i.e. cutting).  ACL reconstruction surgery replaces the ACL with a tendon from another part of the individual’s body, usually the patellar or hamstring tendon. This aids in restoring knee stability and gives the individual the best chances of competing at their previous level. After surgery is performed physical therapy is a must. The patient will present with profound quadriceps weakness, decreased range of motion, swelling and inflammation. The most pressing issue a physical therapist will first address is achieving full knee extension and reducing swelling.  Most people would think restoring the knee’s ability to bend is more important, but if a person cannot fully straighten their knee then they will not be able to walk or run properly. The physical therapist will also focus on activating and strengthening the quadriceps muscle.  Often after a knee surgery the patient will experience great difficulty on firing or contracting their quadriceps muscle. This is known as quadriceps inhibition and it’s very common after severe trauma (i.e. surgery).  To overcome quadriceps inhibition neuromuscular electrical stimulation will be implemented.  This forces the quadriceps to fully contract and has been shown to increase quadriceps strength and accelerate the rehab. process.

In order to promote knee stability while walking and running, exercises that strengthen the patient’s hip musculature will be prescribed by the therapist. This will aid in controlling the knee when the patient is squatting, lunges and while they are running.  The physical therapist will also incorporate balance exercises which will further increase the stability of the knee and begin preparing the athlete for sport related movements. As the patient’s walking pattern normalizes and their quadriceps strength returns the patient will begin plyometrics and eventually jogging.  The physical therapist will assess the patient’s biomechanics and overall form while performing plyometrics and jogging. This will help identify any deficits and help prevent re-injury.  As the patient continues to progress agility based exercises will be stressed.  This will increase the patient’s ability to tolerate sport related movements such as cutting and pivoting.

Although ACL reconstruction surgery is usually recommended for athletes it’s not always the best option for a patient.  If a patient is older and does not participate at a competitive level in a sport that requires agility based movements, or if they simply do not want to have surgery performed than conservative management is usually the best approach for these individuals.  Although physical therapy cannot repair the torn ACL, knee stability can improve from physical therapy.  First a physical therapist will focus on reducing the swelling and inflammation by focusing on ice, compression and elevation.  As the swelling and inflammation decreases the physical therapist will focus on exercises that strengthen the quadriceps, hip and core musculature. If the muscles that surround the knee are strengthen then the patient’s knee will be less likely to demonstrate excessive motion while performing dynamic activity such as running or lunges.  The physical therapist will also evaluate and adjust the patients running mechanics.  As the patient’s symptoms improve the therapist will also incorporate balance and agility based exercises which will further challenge the patient to maintain control of their knee. As the patient strength and balance improves the patient will slowly be graded back into sport related movements and eventually back to their sport of choice.  Whether a patient’s goal is to play their favorite sport at a competitive level or just return to jogging a physical therapist will assist the patient in achieving their desired goal.

If you sustained a sport related injury don’t delay contact Total Performance Physical Therapy for an evaluation today.

Shoulder Dislocation

The shoulder joint is the most flexible joint in the human body. This enables us to reach behind our back, reach above our heads and across our bodies with ease. But this great range of motion comes at a cost.  The more motion a joint has the less stable it will be.  As a result the shoulder is vulnerable to dislocating and subluxing. In fact, people who sustain a shoulder dislocation and are younger than 25 have an 80% chance of re-dislocating their shoulder.   A shoulder dislocation occurs when the head of the upper arm bone (humerus) is forcefully pulled out of the shoulder socket. A shoulder subluxation is when the humerus is pulled partially out of the shoulder socket and slides back into place on its own.

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.

Trauma is the most common reason a person will experience a shoulder dislocation.  Typically, a great amount of force is quickly placed upon the shoulder and this forces it out of its socket.  This can be caused from falling with an outstretched hand or take place during a tackle in a football or rugby game. Athletes who are required to perform repetitive overhead throwing motions (i.e. pitchers) are at greater risk to develop a shoulder dislocation.  This throwing motion can place excessive stress on the ligaments that surround and support the shoulder.  Overtime this can cause these ligaments to become lax. This will force the rotator cuff muscles to work harder to try to stabilize the shoulder. If the person’s rotator cuff muscles are weak then this will leave the individual at risk for developing a dislocation while moving the shoulder at end ranges of motion.  Genetics also plays a role in developing a shoulder dislocation.  Some individuals are very flexible and they are sometimes referred to as being “double jointed” while in fact they just have very lax ligaments.

When a person dislocates their shoulder an intense amount of pain is usually experienced. Often a patient will describe a popping sound or sensation accompanied by trauma. The shoulder will often look deformed as well. In some cases the head of the humerus can put pressure on nerves when it’s dislocated and if the humerus is not placed back into the socket soon after the patient may experience neurological symptoms such as numbness and tingling and profound weakness throughout the arm. After the humerus is placed back into the shoulder socket less pain will usually be experienced, but the pain will still be present. A person may even feel as though their shoulder is loose.  This is because the ligaments that surround the shoulder joint have just been stretched significantly.  This makes it much more difficult for the ligaments to secure the humerus in the shoulder socket.  Usually a person will avoid positions that place the shoulder at end ranges of motion because of pain or the feeling of instability. A person may even experience other episodes of the shoulder popping or giving out. Because of these overstretched ligaments after a person experiences their first shoulder dislocation they are at much greater risk for experiencing another dislocation in the future.

After the shoulder has been placed back into its socket the patient will usually experience pain whenever they move their shoulder.  The shoulder will initially be placed in a sling to reduce pain, provide extra support and to help immobilize the shoulder.  Although a physical therapist cannot tighten the shoulder ligaments they can take other approaches to help prevent future dislocations from occurring.  First, after an examination the physical therapist will focus on decreasing pain and inflammation. This may include ice, compression and elevation.  Taping may also be used to reduce swelling and promote stability. To further relieve the patient’s pain the therapist may also perform a soft tissue massage on the shoulder. At this point in time stretching of the shoulder should be avoided.

As the patient’s pain and inflammation becomes controlled exercises focusing on strengthening the rotator cuff muscles and the muscles that stabilize the shoulder blade will begin to be incorporated.  One of the major functions of the rotator cuff muscles is to maintain shoulder stability while it’s actively in motion.  This is essential if the patient is an active person who utilizes their shoulder often, especially if they participate in throwing activities.  In addition, the shoulder blade acts as the foundation for the shoulder, thus if the muscles that control and stabilize the shoulder blade are weak than the shoulder will be more likely to feel loose and will be more prone to dislocating. If the patient wishes to return to activities that are physically demanding, throwing or other overhead activities the physical therapist will incorporate exercises that focus on increasing the shoulders speed, agility and coordination in the overhead position.  This will better prepare the shoulder for more intense dynamic activities.

Individuals who sustained a shoulder dislocation at a young age and elect not to have conservative management are at much greater risk of developing future shoulder dislocations with fairly minimal trauma.  However, if a person immobilizes their shoulder with a sling for 2-3 weeks and opts for conservative management after sustaining their first shoulder dislocation then they are significantly less likely to dislocate their shoulder while playing their favorite sport and activities.  For more information on physical therapy visit www.totalperformancept.com.

If you have sustained a shoulder dislocation don’t wait, call Total Performance Physical Therapy for an evaluation today.