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ACL Injury

by | Dec 18, 2018 | Health Tips

by Scott Vocke, DPT, CMTPT
Physical Therapist

The ACL is one of four ligaments that helps to stabilize the knee. It is most commonly injured during quick stopping and twisting motions of the knee with the foot planted on the ground. Surgery can be performed to repair or reconstruct the damaged ligament. In many cases, ACL surgery is the best option for treatment. This is especially true for athletes that participate in physically demanding sports that involve cutting and pivoting movements, which require an intact ACL for optimal knee stability. However, research suggests in many instances nonoperative management may be a better option.

Research for ACL Operative vs. Non-operative Management

In a systematic review published in “The Knee” journal (an Official Publication of the British Association for Surgery of the Knee), researchers presented evidence that suggests ACL reconstruction surgery for a specific group of patients may not be any more beneficial than conservative management (also known as rehabilitation without surgery).1 Research has also been conducted to identify two categories of patients with ACL injury: “copers” and “non-copers.”2 Patients who are considered copers are individuals who are able to perform functional activities despite an ACL rupture. Non-copers are patients who are unable to perform functional activities and have repetitive episodes of the knee “giving-way” (also known as instability). These non-copers are less likely candidates for non-operative treatment. There are many evidence-based assessment tools that physical therapists can use to help determine if a patient is a coper or non-coper, thereby indicating whether conservative management is a potential treatment for their injury.

Research for Exercise to Improve Knee Function Early After ACL Injury(3)

A study published in the Journal of Orthopedic Sports Physical Therapy investigated a progressive five-week exercise therapy program early after ACL injury with the following goals:(3)
• Present a progressive exercise program that can be used for patients with ACL injury.
• Evaluate changes in quadricep and hamstring muscle strength
• Assess dynamic lower extremity muscular power and strength compared to the unaffected leg with validated single leg hop tests
• Determine changes in knee function based on self-assessment tools
• Study the difference between coper and non-copers after completion of the exercise program
• Examine potential risk of adverse events from an intensive exercise program early after ACL injury

Researchers hypothesized that patients would:

• Improve knee function based on strength measurements, hop test outcomes, and knee function self-assessment scores
• Non-copers would improve knee function more than copers
• Patients would not have any adverse events during the progressive therapy exercise program.

Participants

• 100 patients 13-60 years of age
• Participate regularly in pivoting sports
• Complete ACL tear verified by MRI within the 90 days of initial visit and without evidence of other structural damage to the knee.
• Ability to participate in exercise program two times per week

Exercise program

The exercise program was started as soon as knee joint swelling was eliminated and full range of motion was restored. Subjects participated in the exercise program two to four times per week, which included intensive muscle strength training, plyometric exercises and neuromuscular re-education exercises. Dosage of exercise was based on recommendations form the American College of Sports Medicine and the specific exercises from the program are identified in the following diagram from the research article:

ACL Injury Exercise

Outcomes

Findings from the study showed significant increases in knee function, increased hamstring and quad strength, and improved single leg hop test performance in both coper and non-coper groups. Based on these results, researchers concluded that the progressive exercise therapy program was low risk for adverse events. Therefore, the program should be used for non-operative management of ACL tears as well as to improve knee function prior to ACL surgery.

Physical Therapy First Approach

Determining if a patient is a candidate for non-operative management of an ACL injury is a multidisciplinary approach and may include an orthopedic surgeon. If non-operative management of an ACL injury is determined to be the best option for a patient with an ACL injury, he/she will undergo a full physical therapy evaluation to determine impairments and functional limitations.

These impairments and limitations will be addressed with evidence-based treatments, such as the exercise program from the article reviewed above. Physical therapy treatments to help recover from an ACL injury may include:

• Joint mobilization
• Soft tissue mobilization
• Specific muscle strengthening
• Neuromuscular re-education interventions
• Balance training
• Muscle stretching
• Correction of biomechanical faults in functional movement
• Home exercise program development
• Physical therapy modalities, such as, moist heat, cold packs, ultrasound, electrical stimulation, phototherapy/laser

References

1. Smith TO, Postle K, Penny F, McNamara I, Mann CJ. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee. 2014;21:462–70. [PubMed]
2. Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000;8:76–82. doi: 10.1007/s001670050190. [PubMed]
3. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Orthop Sports Phys Ther. 2010 November ; 40(11): 705–721. doi:10.2519/jospt.2010.3345.

Stationary Cycle and Treadmill

ACL Excercises

ACL Exercises

What are the Risk Factors for Reinjury Following an ACL Reconstruction?

by | Dec 3, 2018 | Health Tips

by Alex Tan, PT, DPT OCS
Physical Therapist

Background:

Anterior cruciate ligament (ACL) rupture rate is the highest in young athletes who participate in sports involving cutting and pivoting (basketball, skiing, soccer) and when they occur tend to be season-ending injuries requiring surgical reconstruction. Female sex and young age have been viewed as common risk factors for initial injury. Even after successful surgical reconstruction and rehabilitation, reinjury to the reconstructed ACL and/or ACL of the opposite limb can occur. At this time, research suggests that environmental and genetic factors may be causes of reinjury. Recently, more studies have become available focusing on the rates of reinjury in younger active individuals, but their results have not been summarized.

Literature search and data analysis to determine possible risk factors for reinjury:

In a recent article by Wiggins et al researchers reviewed existing literature and analyzed data found within to evaluate whether a patient’s age and activity level could be seen as risk factors for another ACL injury following reconstruction.

The researchers narrowed down a database search to 19 articles for review. Then they recorded data from populations included in these articles regarding: total ACL reinjury rate (of the same side and/or opposite limb), specific sport an individual returned to if provided, the nature of the sport (low risk or high-risk involving cutting/jumping), and demographics.

The researchers hypothesized that returning to sport and a younger age would place individuals at higher risk for a second ACL injury.

An analysis was performed on the data from the entire included population and a separate analysis was performed on data sets broken down by individuals of a young age, those who returned to a sport, and from those who were young and returned to a sport.

Results

  • In individuals across all ages who underwent ACL reconstruction: 7% reinjured the same ACL and 8% reinjured the opposite side
  • In individuals < 25 years old who underwent ACL reconstruction: 21% had another ACL injury with 11% being the opposite knee
  • In individuals who returned to sports following reconstruction: 20% had another ACL injury with 12% being the opposite knee
  • In individuals who were <25 years old who returned to high-risk sport following reconstruction: 23% had another injury with 12%

ACL Reinjury Data Graph

Conclusion

Individuals who return to a high-risk sport and those of a younger age are at risk for ACL reinjury. Almost one-fourth of individuals who are of a younger age (<20-25) and return to a high risk sport that involves pivoting and cutting will either reinjure the reconstructed ACL or injure the opposite side. Based on the current literature the majority of these secondary injuries occur in the knee that has not undergone previous surgical intervention.

What Can Physical Therapists Do to Prevent Reinjury?

Individuals who have or have not undergone a previous ACL repair can be examined by a physical therapist who can determine if they are at risk for injury/reinjury due to factors such as:

  • The individual’s improper performance of functional movements
  • Muscular imbalances
  • Strength and flexibility deficits
  • Improper running and landing mechanics
  • Balance deficits
  • Asymmetrical strength/power between limbs

Your therapist will then address these issues with a personalized plan of care which may include but is not limited to interventions such as:

  • Exercises to strengthen or improve flexibility in specific muscles
  • Plyometric or jump training
  • Activity modification recommendations
  • Neuromuscular re-education
  • Bracing

Original Article: Wiggins Amelia, Grandhi Ravi, Schneider Daniel, Stanfield Denver, Webster Kate, Myer Gregory. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis Am J. Sports Med. 2016 July; 44(&): 1861-1876

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501245/

Physical Therapy and Online Programs to treat Hip Osteoarthritis, Knee Osteoarthritis, or Both

by | Nov 5, 2018 | Health Tips

by John A. Baur, PT, DPT, OCS, CSCS, FAAOMPT
Physical Therapist

Many people are finding information about treatments for health conditions on the internet. A novel approach to physical therapy takes advantage of this propensity to engage online with treatment. This blended approach combines face-to-face visits with an online program or e-Exercise. But is this as effective as traditional physical therapy?

Comparing a Blended Approach with Traditional Physical Therapy

Researchers in a recent study[i] compared the short and long-term effectiveness of a blended approach, which uses an online e-Exercise program to the traditional approach of physical therapy alone. They focused on patients with osteoarthritis of the knee and/or hip. This condition is the most common chronic condition of the joints, causing pain, stiffness and swelling.

Research Participants

The study enrolled 208 patients selected from 143 physical therapy practices. Patients had to meet the following criteria:

· 40 – 80 years of age

· Osteoarthritis of the hip and/or knee

· Not on a waiting list for hip or knee replacement surgery

· No contra-indications for physical activity without supervision

· Moderately physically active

· No current physical therapy program in the last 6 months

· Access to the internet

Blended Approach

This approach combines physical therapy with an online application. It involves 5 face-to-face sessions with a physical therapist and enrollment in an e-Exercise program that has a graded activity module, exercises and information modules. Once the patient is enrolled in the online, e-Exercise program, the physical therapist can adapt the program to the patient’s needs and monitor login frequencies and assignment evaluation. They can then discuss progress during the face-to-face physical therapy session.

Traditional Approach

The traditional approach to treating osteoarthritis over a period of 12 months involves 12 face-to-face sessions with a physical therapist. During those sessions the physical therapist will share information about the disease and treatment and work the patient on a program of physical exercise and strength and stability exercises.

Results

Patients were assessed at 3 and 12 months on quality of life, physical functioning and physical activity. The assessment used an online questionnaire.

At 12 months there was no difference between the groups on health-related quality of life, physical functioning or physical activity. Both approaches achieved the same results.

Recommendations

When choosing between a blended approach that incorporates e-Exercise and traditional physical therapy, the preferences and predisposition of the patient should be considered. The blended approach requires more motivation on the part of the patient and they must take a more active role for the treatment to be successful. If the blended approach is used, it may also be wise to incorporate a personal activity tracker to keep patients motivated and on task.

Physical Therapy First Approach – Treatment for Osteoarthritis

At Physical Therapy First each patient undergoes a complete examination to determine the underlying biomechanical cause of her/his knee/hip osteoarthritis. Physical therapy can help knee/hip osteoarthritis and it all starts with a thorough examine which will include assessing:

– muscle imbalances

– specific muscle weakness

– muscle flexibility

– joint mobility

– shoe wear assessment

– functional movement

– posture

– neurological exam

Based on the finding from the initial physical therapy assessment, a custom treatment plan will be designed to restore movement quality and efficiently, and ultimately decreasing the pain resulting from knee/hip osteoarthritis.

Some of the treatments that may be provided in physical therapy to help address patients with osteoarthritis includes:

– individualized online/e-Exercise program

– adaptive equipment

– bracing

– proper shoe wear

– joint mobilization

– soft tissue mobilization

– specific muscle strengthening

– muscle stretching

– postural correction

– correction of biomechanical faults in functional movement

– physical therapy modalities, such as, moist heat, cold packs, ultrasound, electrical stimulation, phototherapy/laser

[i] Corelien J J Kloek, Daniël Bossen, Peter M Spreeuwenberg, Joost Dekker, Dinny H de Bakker, Cindy Veenhof; Effectiveness of a Blended Physical Therapist Intervention in People With Hip Osteoarthritis, Knee Osteoarthritis, or Both: A Cluster-Randomized Controlled Trial, Physical Therapy, Volume 98, Issue 7, 1 July 2018, Pages 560–570, https://doi.org/10.1093/ptj/pzy045

Is Physical Therapy the best treatment for Gluteal Tendinopathy?

by | Oct 25, 2018 | Health Tips

by John A. Baur, PT, DPT, OCS, CSCS, FAAOMPT
Physical Therapist

Gluteal Tendinopathy – Hip Pain

Patients know it as hip pain, but the medical term is gluteal tendinopathy and this is often seen in conjunction with Trochanteric/Hip Bursitis. Gluteal tendinopathy can occur after performing an unaccustomed activity or after caring out a common activity for longer period than normal or under too much resistance. Gluteal tendinopathy arises when the gluteal tendons fails to heal completely.  One in four women over the age of 50 have gluteal tendinopathy and 10-25% of the general population will experience this disorder. The hip pain and tenderness of gluteal tendinopathy interferes with sleep and daily physical activities. It is equivalent to severe hip osteoarthritis.

Treatments for Gluteal Tendinopathy

The traditional method for treating gluteal tendinopathy is with cortisone injections. A more contemporary approach is physical therapy combined with patient education. Another approach is to just wait it out.

 

Research to Determine the Most Effective Treatment

A recently published clinical trial in the British Medical Journal researchers compared the success of the following treatments for gluteal tendinopathy [https://www.bmj.com/content/361/bmj.k1662]:

  1. Cortisone Injection
  2. Physical therapy
  3. Wait and see

Researchers hypothesized that physical therapy and cortizone injection use would be better than a wait and see approach in the short term (after eight weeks), whereas physical therapy would be better than cortisone injection use in the longer term (after 52 weeks).

Participants

Individuals selected for the study met with following criteria:

  • Aged 35-70 years
  • Lateral hip pain for more than three months
  • Pain at least a 4 out of 10 on the pain numerical rating scale
  • Gluteal tendinopathy confirmed by clinical diagnosis and magnetic resonance imaging
  • No cortisone injection use in previous 12 months
  • No current physical therapy
  • No total hip replacement
  • No neurological conditions.

Results

All three groups; physical therapy, cortisone injection and wait and see, were different from each other in success rate. The success rate was determined by how well the patient said they had improved and their pain level.

At eight weeks the Physical Therapy Group had highest success rate

  • Physical Therapy success rate was greater than Wait and See
  • Cortisone Injection success rate was greater than Wait and See
  • Physical Therapy success rate was greater than Cortisone Injection

At 52 Weeks Physical Therapy Success Group had the Highest Success Rate

  • Physical Therapy success rate was greater than Cortisone Injection
  • Physical Therapy success rate was greater than Wait and See
  • Cortisone Injection success rate was equal to Wait and See

Conclusions

Physical therapy is the best treatment option for managing gluteal tendinopathy. Patients experience improvement in the short-term (at 8 weeks) and in the long-term (at 52 weeks) than they would with a cortisone injection or with a wait and see approach.

Physical Therapy First Approach

At Physical Therapy First each patient undergoes a complete examination to determine the underlying biomechanical cause of her/his hip bursitis / tendinopathy.  Physical therapy can help hip bursitis / tendinopathy and it all starts with a thorough examine which will include assessing:

  • muscle imbalances
  • specific muscle weakness
  • muscle flexibility
  • joint mobility
  • functional movement
  • posture
  • neurological exam

Based on the finding from the initial physical therapy assessment, a custom treatment plan will be designed to restore pain-free movement quickly and efficiently, and ultimately decrease the pain resulting from hip bursitis / tendinopathy.

Some of the treatments that may be provided in physical therapy to help recover from bursitis / tendinopathy includes:

  • joint mobilization
  • soft tissue mobilization
  • specific muscle strengthening
  • muscle stretching
  • postural correction
  • correction of biomechanical faults in functional movement
  • home exercise program
  • physical therapy modalities, such as, moist heat, cold packs, ultrasound, electrical stimulation, phototherapy/laser

 

Original article: Mellor Rebecca, Bennell Kim, Grimaldi Alison, Nicolson Philippa, Kasza Jessica, Hodges Paul et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial BMJ 2018; 361 :k1662 https://www.bmj.com/content/361/bmj.k1662

Suffering from Gluteal Tendinopathy? Give us a call or contact us today to set up an assessment

The Key Benefits and Goals of Physical Therapy

by | Oct 12, 2018 | Health Tips

The Role of Physical Therapy

The role of physical therapy is to help regain and restore the pain-free and comfortable movement and overall health that a person experienced prior to an injury, illness or disability.

To achieve this, the physical therapist will design and monitor a planned program using a holistic approach. The goal is both to restore physical health, quality of life and overall wellness to the patient, while minimizing the risk of injury or illness in the future.

Physical therapy can be helpful for people of all ages, with a wide range of health conditions. The role of the referring primary care physician and family members or care-givers, will always be included in the plan, wherever this is appropriate or required.

Physical Therapy Instruction Rotator Cuff

A conservative approach to managing problems

In many cases, the patient will have approached a physician seeking relief from physical pain. They may be experiencing a nagging lower back pain, shoulder pain or knee pain that is affecting their quality of life. Because physical therapy is the most conservative and least intrusive approach to managing health problems, doctors regularly refer patients to a physical therapist as a first resort. Many doctors report that once patients understand and accept the benefits of the program, they respond quickly and positively, with excellent results

Pain relief – the first and most obvious benefit.

Physical therapy can successfully alleviate the majority of painful musculoskeletal conditions. Chronic pain can be one of the most frustrating conditions to experience, especially if the underlying cause is unknown. However, physical therapy techniques and therapeutic exercises can help mobilize the patient’s joints and soft tissue and restore muscle function, reducing aches or eliminating pain altogether. Provided patients continue to perform the prescribed physical exercises regularly, it can keep the pain from returning.

An important corollary – avoiding the need for surgery

A number of studies have shown that physical therapy may often be as effective as surgery for providing pain relief. One example is in the case of lower back conditions, many of which are shown to respond very favorably to non-invasive physical therapy.

Wherever the more conservative approach is appropriate, it is obviously to the benefit of the patient to explore that route first. Given the proper treatment, the body can often heal itself without the need for surgery.

Recovery post-surgery

Where surgery is obviously the only choice, as for example, in repairing a fractured hip, the patient will start on a properly planned regimen of exercises as soon as possible after the surgery. The role of the physical therapist then becomes paramount in guiding the healing process.

When surgery is required, there may also be a benefit from pre-surgery physical therapy. Because it strengthens the patient, it enables faster recovery after the surgery.

Improving general mobility

Physical Therapy Mobility

At all stages in life, mobility can become an issue. This may be due to a minor accident, aging, sports injuries or the sedentary life-style that so many people lead. Even in advanced or chronic cases, and at all ages, physical therapy can be extremely advantageous in ameliorating problems with walking or moving. The classic stretching and strengthening exercises can restore movement to a large degree and re-enable the quality of life the person experienced before.

Other Health Issues

Recovery from serious illnesses such as a stroke or a heart attack can often be assisted in large measure by a physical therapy program designed to help the weakened parts of the body recover.

Aerobic and body strengthening exercises are also of great value managing diabetes by controlling blood sugar levels.

Arthritis and osteoporosis which may develop with age, can affect joints and mobility. The effects of these conditions can be greatly reduced and controlled by properly designed stretching exercises.

Physical Therapy with children

It is perhaps a common misconception that physical therapy is largely limited to adult conditions. In fact, it also plays a very important role treating children who have motor skill issues. These can often result in behavioral problems and impinge on the general cognitive development of the child.

Physical therapy can assist children to improve the fine motor skills that may have been impaired by neurological causes such as cerebral palsy and are very effective when aiding recovering from surgery.

Modern lifestyles and obesity in children

With modern sedentary lifestyles resulting in children being far less active than was the norm a few decades ago, a lot of attention is being focused on how to solve this problem. Spending hours playing games on their phones and computer related hardware, or texting with their friends, the need for reintroducing proper exercise has become paramount. Obesity and its related ills are affecting children to a degree unheard of before, and the physical therapist can play a powerful role in helping to design programs to combat this.

What the future holds

Across the age spectrum the need to promote fitness and mobility is one of the most important health issues facing society today. The goal of physical therapy is to solve as many of the health-related issues as possible, and the work of the physical therapist will doubtless play an increasingly large role going forward.

 

Low-Impact Pinched Nerve Exercises

by | Aug 7, 2018 | Health Tips

Back stretches for pinched nerves:

Side bends

  • Start in a standing position with your hands on your hips.
  • Maintain straight posture.
  • Gently stretch your lower back by leaning to the left and the right. Perform five side bends towards each side of your body.

Twist

  • Start in a sitting position while placing the legs at shoulder width.
  • Placing your left hand on your right knee and pull your body forward to gently stretch your back muscles.
  • Hold for five seconds then repeat on the opposite side.

Shoulder shrugs

  • Perform in a standing position.
  • Keeping both arms at your sides, shrug your shoulders backwards in a rotating motion.
  • Return to the original position in a similar movement from the opposite direction. Perform a set of 15.
  • Take a 30 seconds break between each set.

After light stretching, consider low-impact aerobic exercise such as walking, cycling and swimming. These activities will increase blood circulation to the damaged nerve, facilitating healing and reducing the pain associated with a pinched nerve. Try to avoid high-impact exercises that cause you to repeatedly twist your spine. You don’t have to give up on your favorite work outs, but try to substitute them with a low-impact, comparable exercise.

If you love running because it challenges you and helps you build endurance, try cycling instead. You can still set and surpass personal records for speed and/or distance! Unlike running, cycling won’t make your spine absorb the shock of impact every time your foot strikes the ground.
If play competitive contact sports, give swimming a shot. This low impact aerobic exercise is a great full-body workout, and you can still seek out a competition by participating in relays or races amongst your friends.

If you relied on group exercise classes to get your blood pumping, look for a yoga class. Moving from one yoga pose to the next in smooth succession can get your blood flowing in a group setting, but you won’t have to worry about high impact movements like box jumps, kettlebell swings, jumping rope, etc. Yoga can help you increase your flexibility and strengthen the muscles in your neck and back, also helping you facilitate the results of your pinched nerve treatment.

Still experiencing pain? Contact us.

*As a reminder, always discuss any questions or concerns with your physician regarding your own health and dietary needs, as the information written should not replace any medical advice.