Orthopaedic Treatment for Benign Calf Amyotrophy

by Ray Moore, PT, DPT, OCS

The purpose of this capstone project was to describe the case of a patient who presented to the clinic with an uncommon motor neuron disease including the treatment plan and discussion of orthopaedic manual therapy principles.  Benign calf amyotrophy is a sub category of lower motor neuron diseases often called benign focal amyotrophy.  This condition was originally reported by Hirayama et al. (Cintas 2017) and focused on Asian male youth with distal upper extremity muscle atrophy and weakness.  Lower extremity involvement was later reported as Wasted Leg Syndrome by Prabhakar et al. in 1981.  Since, several forms and presentations of benign focal amyotrophy have been studied and reported on yet there remains a gap between empirical studies and clinical treatment.  Relative to other motor neuron disorders such as ALS and myopathies, little is known of the etiology, cause and treatment of benign focal amyotrophy.  Some reports indicate that fewer than one hundred cases involving the lower extremity have been diagnosed, with most in the eastern hemisphere, particularly India.  Consequently, this author was unable to locate significant research pertaining to physical therapy or other treatment of benign calf amyotrophy (Cintas 2017).

There are two proposed origins leading to benign focal amyotrophy: repetitive trauma and idiopathic cause.  The available literature notes that males are considerably more affected, up to 10:1 male to female ratio, and most patients are under the age of 30 at diagnosis (Cintas 2017).  There is some variability of age range in different parts of the world which has led some to believe that benign focal amyotrophy is a diverse condition with varying types of presentations.  The earlier upper extremity variant described by Hirayama was believed to be caused by repetitive cervical spine flexion trauma or microtrauma causing flattening of the cord. 

However, MRI of the lumbar spine of patients with lower extremity involvement are typically normal with no cord or nerve root abnormalities detected (Cintas 2017).  However, MRI showed “marked atrophy and increased signal intensity were found mainly in gastrocnemius and soleus muscles” in one study (Hamano 1999).  EMG is one of the most helpful diagnostic tools and findings include “fibrillations, positive sharp waves and fasciculations” (Cintas 2017).  Nerve conduction velocity can be normal or slowed. 

(Stain of normal gastrocnemius cells vs. muscle cells in BCA, Felice et al. 2003)

Other signs indicative of lower motor neuron involvement can be present including hyporeflexia, absent Babinski sign, visible atrophy, calf muscle fasciculations, and fatigable weakness.  Surrounding musculature is typically spared such as foot intrinsics however Hamano et al. reported involvement of some quadriceps and hamstring muscles in one patient (Hamano 1999).  To date, there is no clear explanation for the predominant involvement of the gastroc-soleus muscles.

A key difference between benign focal amyotrophy and other motor neuron diseases is the lack of progression and self-limiting nature.  Patients with benign calf amyotrophy experience lower leg weakness over a period of months to years which can last for a variable period.  Most reports suggest that lower leg weakness and atrophy slowly worsens then stabilizes.  Due to the lack of long term studies, it is unclear whether patient experience a full return of muscle strength, girth and function once the progression has ceased.  Treatment for severe upper extremity cases can include avoidance of cervical spine flexion, cervical collar use, and cervical spine surgery with duroplasty (Cintas 2017).  A search for treatment of lower extremity or benign calf amyotrophy revealed no empirical studies other than a brief mention of physical and occupational therapy.  Given the lack of findings on lumbar MRI versus cervical and upper extremity involvement, novel functional treatment approaches must be discovered.

Case Presentation

The patient, referred to as Robert, presented to our clinic and was referred by a neurologist with a special interest in neuromuscular disorders and EMG.  He is a 28 year old male of Greek origin who began experiencing gradual right calf weakness about one year prior to this evaluation.  Robert reported no trauma or known change in activity level prior to symptom onset.  He also experienced right lateral foot numbness which did not progress.  Prior to this evaluation, Robert reported some left lateral foot numbness but states that this fully resolved.  Robert’s right calf weakness progressed over several months and six months later he began seeing his neurologist.  At this point, Robert reported visible right calf atrophy compared to the left.  His neurologist ordered lumbar spine MRI with and without contrast which was unremarkable and EMG/NCV testing.  Robert’s NCV testing was normal bilateral but needle EMG showed fibrillation potentials and positive sharp waves in the right medial gastrocnemius muscle and to a lesser degree in the tibialis posterior.  There were no motor unit action potentials of the right gastrocnemius and reduced recruitment of the tibialis posterior.  Additionally, Robert’s serum creatine kinase was elevated at 596 U/L. 

On examination, Robert is a tall and physically fit individual who was previously an avid runner.  Robert is a school teacher and waited six months after seeing his neurologist to schedule a PT appointment due to his schedule.  Upon PT evaluation, the primary diagnosis was a suspected S1 nerve root lesion and benign calf amyotrophy was not mentioned on his PT prescription.  He reported no history of pain and Robert demonstrated abbreviated stance on right lower extremity during gait with limited toe push off in end stance phase. 

Robert’s right mid-calf muscle girth measured two cm less than the left and his right Achilles deep tendon reflex was absent while all other lower extremity reflexes were within normal limits.  Sensation to light touch was normal except diminished over right lateral 5th metatarsal.  Lumbar and lower extremity range of motion was normal, straight leg raise and slump tests negative, and Babinski/clonus were absent.  Small, infrequent fasciculations were detected in the right gastrocnemius and ankle plantarflexion was measured at 3+/5 compared to 5/5 on the left.  All other lower extremity MMT was 4+/5 to 5-/5 and normal for his age. 
Of note, there was minimal palpable contraction of the right gastroc-soleus during resisted plantarflexion.  No significant lumbar or other orthopaedic abnormalities were found during the examination.  Robert was instructed in some lower extremity therapeutic exercises and we attempted to finish the session with Russian muscle stimulation to the right gastroc.  Interestingly, Russian stimulation was unable to evoke muscle activation or twitch response from Robert’s gastroc-soleus, though he did feel increasing tingling sensation, a finding I had not previously seen in eight years of experience. 

At a subsequent follow up visit, Robert reported that he had seen his neurologist to review findings and she suspected he had benign calf amyotrophy, which is often a diagnosis of exclusion once other neuromuscular pathologies are ruled out.  Since I was not previously aware of this rare condition, I researched the topic thoroughly to best provide a treatment plan for my patient and quickly found a lack of evidence or even non-empirical discussion.  While benign focal amyotrophy is a self-limiting lower motor neuron disease, it is still possible to positively affect a patient’s outcome and quality of life with orthopaedic manual therapy and other physical therapy interventions.

Treatment and Research

Erl Pettman discusses the facilitated segment and its impact on extremity strength (NAIOMT 2005).  In this article, Pettman details how acute or repetitive injuries leading to segmental stiffness can cause additional unexpected outcomes.  Facet hypomobility at a segment can cause an adjacent or nearby hypermobility.  For example, limited left hip spin can lead to lack of left hip extension and/or rotation.  For normal gait to occur, this individual will have to hyperextend a segment in the lumbar spine or sacroiliac joint to allow upright gait.  Similarly, an L3 hypomobility into extension may lead to an extension hypermobility at L4 or L5 to promote full normal lumbar extension during functional movement.  When this issue becomes sub-acute to chronic, abnormal segmental input to the segment occurs which can present with both changes locally and in the extremities (Pettman 2005).
Segmental facilitation can cause muscle tenderness, hypo or hyperreflexia, altered skin and muscle sensitivity, muscle hypertonicity, inhibition of antagonist muscle groups, and muscle weakness that it typically not fatigable.  Pettman discusses common segmental facilitation at C2/3, C5/6 and L4/5, though it can occur at any spinal segment.  “It is proposed that the constant afferent barrage ultimately leads to a state of ‘central segmental excitation’ that, in turn, lowers the synaptic resistance and facilitates neuronal transmission” (Pettman 2005).  Furthermore, as discussed throughout the lab courses in the Fellowship program, manual therapy treatment to the axial spine can be beneficial in improving peripheral signs and symptoms.

One of the hallmark examples discussed by Pettman is the treatment of C5/6 for tennis elbow caused in part by segmental facilitation (Pettman 2005).  Manipulations, mobilizations, proprioceptive mobilizations, muscle energy techniques, and proprioceptive neuromuscular facilitation can improve the afferent barrage that this segment is receiving and reduce the peripheral consequences of that segment.  One such benefit of these treatments is the increase of peripheral myotomal muscle strength.

In a randomized controlled trial, Chilibeck et al. tested the effects of spinal manipulation on imbalances in lower extremity strength (Chilibeck 2011).  These authors performed segment specific chiropractic manipulations on subjects found to have a 15% or higher strength discrepancy between lower extremities.  Chilibeck et al. performed manipulations and placebo treatment to the spinal level associated with the muscle that they found weakness.  For example, subjects with hip flexor weakness received treatment to the corresponding L2-3 level.  This study found that lumbar spine manipulation can lead to a statistically significant increase in strength in knee and hip flexion for individuals with 15% or greater difference in pre-treatment strength.  The authors discuss possible explanations for increased lower extremity strength following spinal manipulation including “reduced nerve impingement, altered discharge from muscle spindles, Golgi tendon organs, mechanoreceptors and nocioceptors, altered sensory processing in the spinal cord, and altered skeletal muscle reflexes….to cause an increase in motor neuron excitability” (Chilibeck 2011).  This can lead to improved motor unit firing and increased strength in the associated myotome.

Robert’s mechanical lumbar exam did not show any significant instabilities, hypomobility, or considerable tenderness.  Robert was limited in thoracic-lumbar junction right rotation and demonstrated hypermobility into right extension at L5-S1 as measured by PPIVM, PAIVM and H/I testing.  Robert’s end-range was excessive but pain free.  For this reason, a thoraco-lumbar junction manipulation was performed followed by neuro-muscular re-training to this level.  Robert’s right rotation immediately improved but hypermobility was still noted at L5-S1.  While it was understood that the cause of Robert’s right calf weakness was clearly not restricted to the musculoskeletal system (given his negative lumbar MRI and other findings), it was hypothesized that some deficits may be caused by segmental facilitation at L5-S1, or that the minor mechanical lesions in the lumbar spine were a result of altered gait pattern due to neuropathic gastroc-soleus weakness.

Following the thoracic-lumbar junction manipulation, proprioceptive wobble PA mobilizations were performed at L5/S1 to improve afferent inputs with the possibility of increasing some gastroc-soleus strength that was limited by potential segmental facilitation versus motor neuron pathology.  Given the self-limiting nature of the patient’s diagnosis, it was explained that any additional safe method to increase his lower extremity strength would be worth a trial.  After two treatment sessions, the patient reported about 10% improvement in his right lower extremity strength with weight bearing activities and he began to demonstrate a slight observable and palpable contraction of his gastroc-soleus muscle upon voluntary contraction.

An early indication that Robert’s condition was not limited to the musculoskeletal system was his response to Russian current muscle electric stimulation.  Following his initial evaluation, I and a colleague attempted to apply muscle stimulation to Robert’s gastroc-soleus.  Using multiple currents and variations of parameters, we were unable to elicit a single twitch response.  The patient was able to feel the current sensation but no muscle contraction.  After reviewing Michelle Cameron’s Physical Agents in Rehabilitation, I found that “denervated muscles do not contract in response to the pulses of electricity that produce contractions in innervated muscles” since the “current causes depolarization of their motor nerves” (Cameron 2003).  At this time, I hypothesized that this patient was experiencing a condition related to pathologic denervation.  Cameron mentions that denervated muscles can be stimulated by “long pulses of electricity, lasting for 10 ms or longer.”  The typical treatment for denervated muscle is direct current stimulation however research has shown that any effect may be related to placebo and DC stimulation could hinder nerve regeneration (Cameron 2003).  Therefore, I did not continue with muscle electric stimulation.  However, in retrospect, I may have considered Russian muscle stimulation to the lumbar multifidus for the same reasoning as mobilization/manipulation for segmental facilitation.

Much of this patient’s treatment consisted of therapeutic exercise as well as a home exercise program.  Initially, Robert performed de-weighted calf raises in the seated position, single leg stance to tolerance with one hand assist, and theraband exercise for tibialis posterior strengthening.  Robert performed 3-4 sets of 20 repetitions for endurance training or he performed exercises to fatigue.  Robert was instructed to allow additional rest between sets for 45-60 seconds due to the fatigability of his lower extremity muscles.

Since Robert was an avid runner and weightlifter prior to this condition, his exercise routine included functional activities with modifications made as necessary.  Robert was unable to perform standing de-weighted bilateral heel raises, but after two sessions, he was able to complete sets of heel raises on the leg press on the lowest resistance.  Robert also performed bilateral leg press until he was able to complete weight bearing squats without excessive left trunk lean.  Resistance for the leg press was set based on Robert’s subjective ability to perform repetitions without heavily relying on the left lower extremity.  Robert also performed stool scoots early with right leg for activation of neighboring musculature.

Emphasized throughout the Fellowship didactic and lab work is the role of the individual spinal segmental stabilizers, like the multifidus, and their role in global stabilization and mobility.  Much like a train, if each car is not properly connected and stabilized, the entire train will not move.  If the multifidus and other segmental stabilizers do not properly stabilize a segment, such as L5-S1, then the entire mechanics of the spine can be affected and locomotion and functional mobility is not optimal.  For this reason, specific activation of the L4-S1 multifidus, as well as transverse abdominis and kegel exercises were implemented.  Robert was instructed on multifidus step-down activation with tactile cues.  Transverse abdominis and kegel muscle activation was added and more advanced exercises were built from this foundation.  Robert was encouraged to include segmental stabilizer activation in all static and dynamic activities of his daily routine.

After two sessions, Robert was able to progress to balance and higher level strengthening activities such as single leg dead lift with one hand assist, balance activities on soft surface, and hopping on trampoline on right leg.  Advanced balance and strengthening exercises such as plantarflexion and dorsiflexion on foam board and double leg squats on bosu ball were added at subsequent visits.  On the fourth visit, I saw Robert in the evening and he complained of lower leg swelling.  He stated that it was improving but he still experienced swelling in the evening.  Due to lack of function of the muscle pump, I provided Robert with a lower leg sleeve to be worn on days that he would be in the dependent position.  Additionally, since Robert is a teacher, I suggested that Robert take seated or supine rest breaks whenever possible and perform ankle pumps.  These modifications helped to reduce Robert’s complaints of lower leg swelling in the evening.

By his sixth visit, Robert reported about 25% improvement in right lower leg strength and 50% or more improvement in overall functional improvement since initial evaluation.  He was demonstrating a palpable and observable contraction of his gastroc-soleus and had progressed to exercises like right SLS on trampoline with soccer ball kick and the slide board for agility.  While Robert was unable to return to running, he was much more confident in his gait and did not experience tripping over his right foot.  Robert then had a follow up visit with his neurologist and left the country for a two week vacation.

When he returned three weeks later, Robert reported that he was being referred to another hospital for work up and treatment for benign calf amyotrophy.  He reported that while on vacation, he did not get to perform his home exercise program or other exercise much and stated that his right lower leg strength improvements had diminished.  However, functionally, Robert felt that he had made considerable improvements in physical therapy and reported improved confidence following treatment.  Robert was resuming teaching the following week and stated that he would have to self-discharge due to time restrictions.  Robert had a follow up EMG study that showed “some firing” compared with little to no activity prior.  He was able to voluntarily contract his gastroc-soleus with visible contraction during exercises.  Robert still complained of mild sensory deficit over the lateral foot but stated that it had improved since beginning physical therapy.  Robert’s right calf girth increased by one centimeter in a six week period.  Robert reported that he had experienced the most progress in over a year while he participated in physical therapy.  Robert was discharged with the recommendation that he follow up as his schedule allowed to continue to improve any remaining functional deficits.


          As expert clinicians, we are expected to be able to treat both simple and complex cases, perform detailed yet directed evaluations, demonstrate pattern recognitions, and have a wealth of knowledge of conditions to perform differential diagnosis.  However, the knowledge and preparation an expert clinician should possess cannot be limited or contained in a box.  Often, clinicians are forced to adapt to new information on unforeseen exposure.  In this case, a patient with a motor neuron disease that is so uncommon that very few in the physical therapy field are aware of it, came to my clinic with an atypical presentation.  Having performed the lumbar and lower extremity scan many times, I was quickly able to recognize that this patient did not show the normal signs and symptoms of radiculopathy or lumbar pathology. 

          Furthermore, I determined that this patient probably did not exhibit an atypical presentation of a common condition.  For example, while receiving mentoring during this Fellowship, my mentor and I evaluated a patient with lateral thigh pain.  While I hastily suspected the lumbar spine, I learned about a potential entrapment point for the lateral femoral cutaneous nerve just above the iliac crest.  Like much of the valuable knowledge and experience I had gained during mentorship, I was previously unaware of this entrapment site.  Still, I was able to recognize that this patient could have an atypical presentation of a common condition.  This Fellowship Program also furthered my ability to recognize patients that require attention outside of the scope of physical therapy practice.  Had Robert come to our clinic as a direct access patient, I would have immediately referred him to a physician. 

          Since Robert was under a physician’s care and he presented with functional impairments from an undiagnosed condition, I used my training to develop an individualized treatment plan for Robert both before and after his diagnosis was confirmed.  The expert clinician may be occasionally challenged by an unfamiliar diagnosis or presentation.  Fellowship and other training can assist in making that clinician adaptable to apply previously learned material and experiences to the creation of a treatment plan for a new diagnosis. 

          The particular difficulty that this case provided was a lack of clinical or empirical evidence for treatment of benign focal amyotrophy.  Several searches uncovered some literature that mentions the words physical and occupational therapy, but little other treatment was specified.  One might assume that since self-limiting, individuals with benign focal amyotrophy do not require physical therapy.  However, physical therapy is a critical component in the recovery of people diagnosed with Guillaine-Barre Syndrome and other self-limiting diseases.  Physical therapy is not limited to conditions that it is the primary treatment of choice such as whiplash or tennis elbow.


          This capstone project involves the application of skills and knowledge possessed by a Fellow in training to a topic not previously highlighted in physical therapy literature.  Limitations included the lack of considerable literature, especially pertaining to treatment, and a sample size of one patient.  While preparing for this capstone project, one intervention I would have implemented was muscle stimulation to the lumbar multifidus.  Still, it was a very valuable experience to treat a patient with such a rare condition and assist in his progress and regaining of functional mobility.  It is often difficulty for a young and active patient to understand their condition and why they can’t perform at the level they were accustomed.  As a physical therapist, part of our job is to help return that function to the best of our ability and provide understanding and education for the patient.  Both before and after confirmed diagnosis, Robert appreciated the education he was provided and he fully bought into his treatment plan.  He showed some progress which was uncertain given his diagnosis.  Fortunately for me, Robert presented to my clinic after I have performed much of the requirements for Fellowship training, including mentoring hours.  While my mentor did not specifically prepare me to treat someone with benign calf amyotrophy, I was prepared to adapt and care for a patient with a condition that I could not reasonably be trained for, which I believe is one of the chief purposes of Fellowship training.


  • Cintas, P. (2017). Motor neuron diseases: Benign focal amyotrophy. Revue Neurologique, 173(Motor neuron diseases), 338-344. doi:10.1016/j.neurol.2017.03.016
  • Felice K, Whitaker C, Grunnet M. Benign calf amyotrophy: clinicopathologic study of 8 patients. Archives Of Neurology [serial online]. October 2003;60(10):1415-1420.
  • Hamano T, Mutoh T, Kuriyama M, et al. MRI findings of benign monomelic amyotrophy of lower limb. Journal Of The Neurological Sciences [serial online]. June 1, 1999;165(2):184-187.
  • Chilibeck P, Cornish S, Schulte A, et al. The effect of spinal manipulation on imbalances in leg strength. The Journal of the Canadian Chiropractic Association.  September, 2011; 55(3): 183-192.
  • Pettman, E. The Facilitated segment.  The North American Institute of Orthopaedic Manual Therapy. October, 2005; Volume IX, Issue 5.
  • Cameron, M. Physical Agents in Rehabilitation: From Research to Practice (Second Edition).  Saunders.

Plantar Fasciitis: Stretching vs Strengthening and Stretching only a 2-study comparison

Reviewed by Mark Boyland PT, DPT, CSCS

Plantar fasciitis is a common diagnosis with symptoms including pain at the heel, difficulty walking, and increased foot pain usually for the first few steps in the morning or when walking after a period of immobility.  While there are many treatment options available we will review two studies which examined primarily exercise interventions on the treatment of plantar fasciitis pain. Effects of Strengthening and Stretching Exercises on the Temporaspatial Gait Patterns in Patients with Plantar Fascitis: A Randomized Control Trial and Effect of a home-based stretching exercises on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis. Both study participants were educated by a Physical Therapist on proper execution of these exercises and received a written home exercise program with instructions on how to perform and progress exercises.

The study which compared strengthening vs stretching group had 84 participants, a sizeable group, whereas the stretching only study had only 20 participants.  Participants were selected if they had only plantar fascial pain without other systemic conditions or other forms of lower extremity pain.  The strengthening vs stretching group was monitored for 12 weeks whereas the stretching only group was monitored for just over 3 weeks.

Interestingly enough the general pain, time of the worst pain, gait parameters, and muscle strength improved regardless of stretching only or strengthening only in either study.  However, there was limited changes on multisegmental mobility of the foot before and after interventions and there were no significant between group differences in any of the noted parameters.  However, both studies had significant decreases in pain from baseline to the first 2 weeks with progressively improving symptoms in following weeks, though not as significant.

Both studies provided the exercise protocols including sets, reps, progressions, and approximate time to complete assigned exercises.  The PMCID will be provided for free article access to review both protocols via Pubmed. The strengthening vs stretching study was a more traditional protocol including 3 sets of 10-15 repetitions of 4 strengthening exercises or 3 repetitions of 30 seconds with 10 seconds rest for the stretches. Patients were instructed to complete these exercises 3 times per day. The stretching vs strengthening study exercises took between 6-10 minutes to complete per session. The stretching only study had 3 stretching exercises which were performed for 20-30 seconds with 10 seconds rest for 10 sets 5 days a week over 3 weeks, the stretching only study took about 20 minutes to complete their exercises.

For Therapists:  Recent research has been guiding us to introduce a progressive loading program to help manage and improve our patient’s symptoms.  These two studies provide a framework on how to provide this progressive loading to your patients and that you have 3 options to provide your patients, pending their compliance/preference for exercise.  There seems to be no agreement between these two papers as to what a minimal/maximal dose of exercise intervention at this time, however 20-30 minutes of dedicated exercise seems to be a good start.

For Patients:  Plantar Fasciitis can be a difficult condition to recover from and that pain improvements can continue for up to 12 weeks after beginning an exercise program.  Your therapist can provide you with a stretching and/or a strengthening program to help manage/improve your symptoms depending on what you feel that you prefer.  This condition can be self-managed at home for the most part and your Therapist should be progressing you on a weekly to bi weekly basis pending your overall symptoms.  However, before you begin self-treating, a Physical Therapy Evaluation is critical to rule out other diagnoses or pathologies


Effects of Strengthening and Stretching Exercises on the Temporospatial Gait Parameters in Patients with Plantar Fasciitis:  A Randomized Control Trial.  PMCID PMC6960082

Effect of a home-based stretching exercise on multi-segmental foot motion and clinical outcomes in patients with plantar fasciitis.    PMCID: PMC7493445

Can Exercise be an Effective Treatment for Concussions?

by Sean Phillips, PT, DPT, OCS

Sports-related concussion (SRC) is a very common sports injury in America and can affect people of all ages. Concussions are a physiological event in which the brain and head are rapidly moved, typically as a result of a hit or sudden loss of momentum. Although the CDC classifies concussions as a mild traumatic brain injury (TBI), the symptoms can be severely limiting and long-lasting. In the article, “Exercise is Medicine for Concussions” by Leddy et al., researchers reviewed the treatment approaches for athletes with concussions utilizing low-threshold exercise intensity for rehabilitation. 

Concussions can produce many symptoms in an athlete, but one of the most common is exercise intolerance. Current research suggests that this is caused by a concussion’s effects on an individual’s autonomic nervous system (ANS), which plays a large role in respiration. When the ANS is damaged, ventilation can be limited in proportion to activity or exercise intensity leading to an accumulation of CO2 in the arterial blood (PaCO2). Once this occurs the cerebral blood flow will also be out of proportion to exercise and produce the intolerance that many people display. 

Through a variety of experimental and observational data, researchers have identified that sub-threshold aerobic exercise can help normalize these levels and reduce a person’s symptoms. Therefore, exercise is essentially “medicine” for athletes or individuals recovering from a concussion. 

This article reviewed two different techniques of finding the proper heart rate dosing for the correct level of sub-threshold exercises. These included the Buffalo Concussion Treadmill Test (BCTT) and Buffalo Concussion Bike Test (BCBT). Once the target heart rate is determined, an individual may be able to safely speed recovery from a concussion. This is most effectively accomplished with consistent supervision from an experienced healthcare professional such as a physical therapist in order to ensure the athlete stays within his or her target levels. 

In conclusion, this article provided evidence for safe and effective ways to reduce or prevent prolonged symptoms from SRC utilizing individualized exercise dosing and monitoring. If you are experiencing any lingering exercise intolerance following a concussion, consult your doctor or contact a physical therapist near you to help return to your normal levels. 


Article: Exercise is Medicine for Concussions; Leddy JJ, Haider MN, Ellis M, Willer BS; Curr Sports Med Rep. 2018 August ; 17(8): 262–270. doi:10.1249/JSR.0000000000000505


A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation

Article summarized by: Evan Peterson PT, DPT

Achilles injuries, more specifically tendinopathies, are one of the most common injuries seen by physical therapists. Achilles Tendinopathy is an overuse injury which typically causes pain at the insertion of the tendon near the heel or at the mid portion of the tendon. This injury has a propensity to last for several years without proper rehabilitation. Typically, the injury is brought on by excessive utilization of the tendon or increasing intensity of training to rapidly. Unfortunately, reoccurrence or re-injury of the tendon is high with too little time in between rehabilitation and returning to usual activities. This specific article being reviewed had the goal of creating a return to sport program for those with mid portion Achilles tendinopathy injuries.

What Is Achilles Tendinopathy?

As described above, Achilles tendinopathy is an overuse injury which has hallmark signs such as swelling, pain, and impaired performance of function. The diagnosis of insertional versus mid portion is based on the distance from the calcaneus (heel). Mid portion is typically located 2-6 cm above the calcaneus whereas insertion is located at the bottom of the heel. Mid portion tends to be the more common of the two at 55-65% of all cases of Achilles tendinopathy. Both are categorized by pain, stiffness in the morning, tenderness to palpation or a thickening of the tendon, and gradual onset of pain and symptoms.

How Do We Treat It?

The treatment of Achilles tendinopathy has been extensively researched and has several systematic reviews investigating numerous interventions. Exercise time and again has shown significant benefits for Achilles rehabilitation, more specifically eccentric exercises. Many other interventions have shown benefits such as orthoses, shockwave therapy, and low-level laser but none as effective as exercise when used in isolation. There has been some evidence that the use of low-level laser or shockwave therapy alongside exercise can help to speed recovery.

What Exercise is Specifically Used?

At the present moment, exercise for Achilles tendinopathy revolves around eccentric heel raise activities with knee both bent and straight. It is suggested each exercise be performed 2x daily for 15 repetitions of 3 sets. This is a model that has been shown effective in the athletic population but has had mixed results in the general population. Therefore, it has been suggested that a more fine-tuned approach is important, considering age, sex, and activity level, in order to properly dose the intervention. More often it is suggested to utilize a numeric pain rating scale (NPRS) to establish the correct loading during exercise.

When Can the Patient Return to Sport?

When attempting to return to participation in sport, it is important to have gradual progression and loading of the tendon with adequate recovery in order to prevent re-injury after return to sport. Re-injury rate in soccer players was shown to be 27% to 44% when returning to sport to soon or with inadequate recovery. The clinician should be aware of symptoms the following day after sport activities that include stiffness, pain, and swelling. These are good indicators of readiness for returning to full activity. Some research advocates for no running or jumping until symptoms have subsided; however, others believe this is not always necessary. Instead there are numerous factors that must be considered when implementing a return to sport program. The level of pain with physical activity should be considered as well as the healing time of the tendon, the strength, range of motion, and functionality of the Achilles, and the physical demands of the specific sport.

Major Principles

The most important aspect of return to sport for Achilles tendinopathy is to progressively load the tendon while considering the intensity, duration, and frequency of the forces placed on the tendon. Before a patient begins jumping and running the patient should have a maximum of 2/10 pain while performing activities of daily living. Rehabilitation should be performed daily, despite having performed plyometric tasks during that day. One of the most important steps in returning an athlete to their sport, is to educate the patient on healing times and instilling a routine to increase adherence as they move closer to participating in sport again. The athlete must also understand the differences between light, medium, and heavy activities. These can be classified by pain during and after the activity performed. These activities are fluid and can change based on the patient’s response to pain.

Physical Therapy First

At Physical Therapy First, the therapists are trained to work with athletes or recreational athletes to implement plans of care that allow a person to return to their sport of choice. We utilize the aspects discussed in this article to minimize reoccurrence of injury when the patient feels they are ready to begin participation again. If you are someone who has experienced Achilles pain in the past or are currently experiencing Achilles pain, we here at Physical Therapy First are here to assist you.


A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation | Journal of Orthopaedic & Sports Physical Therapy (jospt.org)

Gut Check on holistic treatment of Parkinson’s

Summarized by Mark Boyland PT,DPT, CSCS 

This was an interesting perspective paper due to the implications it has on how we can potentially test for Parkinson’s earlier and opens up avenues for treatment methods in a holistic style incorporating diet and nutrition in addition to exercise and pharmaceuticals.  While this perspective primarily focuses on Parkinson’s Disease, the paper also mentions potential effects on other conditions including Alzheimer’s and Huntington’s.

Parkinson’s is the second most common neurodegenerative disorder.  It has been primarily thought to be a brain disorder.  However there have been suggestions that changes in the gut microbiome, gut dysbiosis, could be linked to Parkinson’s.  Common symptoms of gut microbiome disruptions include constipation and increased inflammation.  Neurodegenerative diseases such as Alzheimer’s, Huntington’s, and Parkinson’s gut dysbiosis has been linked to cognitive impairments/reduced performance and motor dysfunction. Motor dysfunction includes postural instability and gait impairments. The authors indicate that dysbiosis can be improved with exercise, which calls to question how? 

First, we must understand how dysbiosis can affect the brain.  The gut biome regulates immune function, signaling of neurotransmitters including dopamine (over 50% of dopamine production comes from the gut), and metabolism support.  If there is disruption in our gut (dysbiosis) the impacts include increased inflammation, decreased neurotransmitter signaling, and deregulates metabolic function.  This perspective paper suggests that Parkinson’s can begin at the gut level and that as the condition progresses it impacts the motor system progressively.

As mentioned previously, exercise can restore the gut microbiome.  In those without Parkson’s having higher exercise capacity (aerobic/muscular strength) has been associated with higher bacterial diversity and reduced gut inflammation.  Restoration of the gut microbiome comes with both aerobic and resistance based exercise.  There are some differences in the benefits provided by each exercise modality however resistance exercise has been less studied at this point. 

Exercise to promote physical capacity may not be the sole factor for improving patient outcomes however.  For those with Parkinson’s exercise is now integral to their care but could be related to learning new skills which helps to keep the brain plastic (neuroplasticity). Additionally, as we begin to exercise more we also tend to eat a greater variety of healthy foods which could promote holistic changes as well. 

The gut and its bacteria are the recent quick fix hot topic but may have implications for our future in prevention and care of neurodegenerative conditions and maybe more.  Further research and study is required to establish a better understanding of the gut biome and it’s relation to our health at this time. Fortunately, improving gut health can be as simple as completing regular exercise and meeting the daily activity recommendations of the AHA as opposed to taking an unknown pill or supplement.  Eat well, stay active, be well

Direct link to article: https://doi.org/10.1093/ptj/pzac022

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels

Article Reviewed by: Evan Peterson PT, DPT

“Return to sport” (RTS) has been a topic of discussion throughout the physical therapy community and has been researched for a variety of sports related injuries. One of the most common injuries looked at is ACL reconstruction or other lower extremity injuries. Not as widely discussed in return to sport is for athletes with shoulder injuries. In response to minimal high-quality evidence or guidelines to direct the return to sport decision making process, The Athlete Shoulder Consensus Group convened. Their goal was to create guidelines for clinicians, athletes, and coaches in order to provide the best quality care following shoulder injury. This particular statement was ascertained through the use of several rounds of questionnaires to obtain a consensus for rehabilitation in athletes. Following these surveys, the group had an in person discussion to solidify the results of the questionnaires. The consensus that was established is categorized into 4 main points. 1) Managing injury risk 2) Managing and progressing load 3) Shoulder injury rehabilitation and 4) evidence to support RTS decisions.

Managing Injury Risk

One of the first ideas brought up in managing risk is to understand the risk factors and predispositions athletes my have for each sport, as each sport involves different types of shoulder mechanics. Some risk factors have been pulled out that encompass many shoulder related sports include: loss of ROM, strength imbalances in rotational planes, change in load, player positions, level of sport (i.e. amateur or professional), previous history of shoulder injury, and psychosocial aspects. Attempting to screen athletes to prevent injury has not shown good evidence; however, it may be important for the RTS decision making process.

The consensus agreed that injury risk can be managed with both primary and secondary prevention programs. Primary programs should be initiated at young ages, particularly in overhead athletes, to allow decreased injury rates and increase the likelihood of adhering to healthy shoulder programs. It is recommended that secondary programs begin soon after injury. The article discusses general principles for training, including sport specific exercise, multiple joint exercises, emphasis on team training, and programs that take no more than 15 minutes at a time. They suggest these programs should be done at a minimum of twice per week to encourage adherence and self-efficacy.

Managing Shoulder Specific Loads in Athletes

Two types of load exist in the shoulder athlete. There is the external load such as a swimming pool’s resistance or the number of pitches in a game. Then there is the internal load, which is the physiological forces placed on the shoulder. It has been difficult to determine which of these factors is most important when managing load and currently there is no measure in order to determine the internal load. External load is much easier to measure (for example, number of pitches thrown); however, in games such as handball it is hard to have a “pitch count” due to the more chaotic nature of the game. At the consensus meeting, it was proposed to utilize a rating of perceived exertion scale to measure the internal load the shoulder. A combination of perceived exertion of the shoulder and overall fatigue of the body are good indicators to help assess a patient’s overall load. One study supported the idea that decreased external shoulder rotation strength or scapular dyskinesis is an indicator of decreased tolerance for load during sport.

Key Principles for Quality Rehab After Shoulder Injury in Athletes

Experts at the consensus meeting agreed that rehabilitation programs should emphasis on:

  • Improving sport specific mechanics
  • Challenging the patient in rehab at the limit of their capacity
  • Building resilience in patients’ ability to load at the physiological and physiological level
  • Multi-disciplinary decision making

The Key principles proposed are as follows:

  • Let Irritability Guide Rehab Process
  • Address Glenohumeral Range of Motion Deficits Using Active Therapy
  • Address the Scapula but Do Not Screen for Dyskinesis
  • Injury Tolerated Exercises
  • Introduce Plyometric Activities Early
  • Retrain the Brain/ Expose Shoulder to Fearful Positions Safely
  • Sport Specific Tasks
  • The consensus suggested objective repeated measures on a weekly basis to assess response to rehab

Return to Sport

The authors suggest that “Return to Sport” is a continuum consisting of three aspects: Return to participation, Return to sport, and Return to performance.

  • Return to Participation: the athlete is continuing rehabilitation, but participating in modified training in their sport at a level lower than their usual; they are not physically or psychologically ready for regular sport activities.
  • Return to Sport: the athlete can return to their sport but is not performing at an optimal level or their desired level
  • Return to Performance: the athlete is performing at their usual level without any restrictions

6 Domains to Consider when Returning to Sport

  • Pain: pain may be present when returning to participation but should not be present in return to performance
  • Active Shoulder Joint ROM: this is a sport specific criterion and should be evaluated as such. For example, pitchers require much more rotational ROM as compared to a collision athlete (i.e. football)
  • Strength, Power, Endurance: the importance of each is sport specific; however, the importance of overall strength in internal and external rotation as well as shoulder stability is crucial for return to sport
  • Kinetic Chain: be able to identify issues outside of the shoulder including the elbow, wrist, and thoracic spine
  • Psychological Readiness: athletes must be able to demonstrate confidence in muscle testing or activities that cause collisions before returning to participation and sport
  • Sport Specific: if possible compare to norms of other athletes in sport to determine readiness for play


One of the major takeaways from this consensus is that there is room for improvement in how we measure athlete performance in rehab and how to prevent injuries from happening/reoccurring. This consensus did however highlight the importance of multidisciplinary and all-encompassing approach for an athlete to return to their sport following injury.

Here at Physical Therapy First, therapists are trained to assess for shoulder abnormalities and detect faulty mechanics in those who have shoulder pain or sport injury. We also look to work with the patient and all involved with their care to prevent future injuries while returning to a high level of performance.


Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Haugsbø Andersson S, Horsley I, Whiteley R, Cools AM, Bizzini M, Ardern CL. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels. J Orthop Sports Phys Ther. 2022 Jan;52(1):11-28. doi: 10.2519/jospt.2022.10952. PMID: 34972489