PhysioWorks, Sports and Wellness https://physioworkshsv.com High quality, individualized and evidence-based Physical Therapy for Huntsville, Madison, and North Alabama Wed, 04 Apr 2018 14:29:28 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.5 https://physioworkshsv.com/wp-content/uploads/2015/10/cropped-favicon-32x32.png PhysioWorks, Sports and Wellness https://physioworkshsv.com 32 32 Sam’s Story: How to Know When is Safe to Return to Sport After ACL Reconstruction! https://physioworkshsv.com/sams-story-how-to-know-when-is-safe-to-return-to-sport-after-acl-reconstruction/ https://physioworkshsv.com/sams-story-how-to-know-when-is-safe-to-return-to-sport-after-acl-reconstruction/#respond Fri, 16 Mar 2018 21:04:02 +0000 https://physioworkshsv.com/?p=4436 ACL Injury and Reinjury – A Concern for the Parent of an Athlete

Imagine for a moment that you are the mother of a talented high-school basketball player. He’s currently a junior, is passionate about basketball and motivated to pursue it as far as he can. But, he’s just suffered a second ACL tear and reconstruction on his other leg – just three months after he was released to play again following his first ACL reconstruction! Now he’s recovering, and nearing the point where his surgeon may release him to play again, and you’re feeling nervous. In the last year he’s had major injury and surgery on both of his knees, and you know he’s at an increased risk of re-injury to both of them, let alone what he might feel like as he gets older due to earlier onset of arthritis. How can you help him avoid re-injury and reach his full potential as a player?

Sams Story How to Return To Sport Safely After ACL Surgery in Huntsville Alabama

Sam – ACL Injury and Surgery x2 – Where to Turn?

This was the situation an Ardmore mom was in when she first called me a few months ago. Her son, Sam, is a junior at Ardmore High School. In August of 2016, he tore his left ACL and meniscus while playing basketball, and had bone-patella-tendon-bone (BPTB) ACL reconstruction. He was released to return to play about 6 months after his surgery, but only 3 months later (9 months post-surgery) suffered a right ACL tear. Sam’s mom started researching what could be done this time to help Sam recover better and stay injury-free. That’s when she found the information on my website about how the landing error scoring system (LESS) can identify those at risk of ACL injury and better help reduce injury risk, and she gave me a call.

Diagram showing what occurs at the pelvis, hip and knee when the gluteus medius and other abductors are weak

This diagram shows a) normal lower extremity (LE) position when standing on one leg. It shows increased hip adduction due to weak hip abductors (b). It shows compensation leading to a valgus deformity and force (c)

When I first examined Sam in September of 2017, he was 3 ½ months post-surgery and had been receiving PT treatment at another local clinic. Although he’d been going to therapy twice a week, he was much weaker than I expected and was in no position to be doing the LESS screening. He had not been doing much home exercise as part of his previous PT treatment and had not done any significant single-leg weightbearing work. His single leg squat mechanics were quite poor, with his knee collapsing in and his pelvis dropping (see diagram from previous blog article showing how this risks ACL tear). My manual tests showed his quads and hamstrings to be strong; this was confirmed a week later with a machine-based test (isokinetic dynamometry) that his doctor ordered before releasing him from his care. But just because he was released from the doctor’s care, Sam’s mom knew she didn’t want him to just jump right back into playing basketball; in order to avoid re-injury, a more careful and controlled return to sport was needed. Below, I will outline the specific plan of care that I took Sam through to improve his strength and biomechanics prior to giving him the go-ahead to return to playing basketball below; but to understand this better I first want to go into a little more detail about ACL tears and reconstructions as these are important to understand as part of this process.

Time is a Healer, But How Long?

Many patients are queued to expect a return to sport at 6-months, mostly because a fair number of professional athletes are seen to do this. Friends who’ve undergone similar injuries, the media, and pressure/desire to not miss a playing season reinforce this trend. However, even a fair amount of professional athletes suffer re-tears – and they have many resources at their disposal that students and the general population just doesn’t have – such as time and access to top-notch PTs, trainers, gym equipment, and doctors. Since student-athletes aren’t surrounded by such a team of experts and resources, we have to assume their recovery should take longer. However, it’s also not just a matter of adding recovery time. Time alone doesn’t take into account progress in strengthening and improving biomechanics and how they interact with a healing knee. Instead of just waiting an arbitrary amount of time, there are objective criteria that we can use to help gauge progression and readiness to return to sport.

To understand this better, let’s delve a little deeper into ACL tears and reconstructions. I’ve written before about the epidemic of youth ACL tears and how they can be prevented. The ACL is an important ligament that provides stability and controls rotation at the knee. When it tears, people can experience instability on that leg; it can be a devastating injury physically and psychologically. There are two options to treat an ACL tear: reconstruction or rehab. Most of the time for athletes under 40, reconstruction is the option of choice. I use the word ‘reconstruction’ vs. ‘repair’ as there is not yet a proven way to repair the remaining ACL. (There is some promise in the ACL BEAR Trial at Boston Children’s Hospital.) Instead, the surgeon must construct a new ACL. Over the years, various tissues have been used, some less successful (synthetic) and others more successful (ligament and tendon) for the graft. The non-synthetic, ligament and tendon, grafts can either be from the patient (autograft) or a cadaver (allograft).

In competitive athletes under 40, the gold standard is considered to be a bone-patella-tendon-bone (BPTB) autograft – this is the surgery that Sam had after each of his tears. Some surgeons will use hamstring grafts, and there is also a development towards quad tendon grafts (check out this blog by PT and recent ACL victim Laura Opstedal on her decision process around graft choice.) In the case of a BPTB ACL reconstruction, the surgeon has to drill a tunnel through the tibia and femur in the angle/plane of the original ACL. They then place one bone end of the graft in the tibial tunnel with a screw and the same to the other end in the femoral tunnel. There is great skill in this surgery, and in the research, they are always trying to move towards a reconstruction that more closely mimics the anatomy of the original. Outcomes can be poor when the reconstruction angle is too vertical, the ligament is too tight or lax, or for many other reasons, so surgeon selection is important!

Once a patient has the surgery and comes out of the operating room, they are not immediately able to do everything they want. The first thing that patients typically notice is feeling like they cannot fire their quads, which gives a huge feeling of instability. As swelling settles and the quad gets stronger, the knee starts to feel more normal. I find that often younger patients recover their quads quicker and feel back normal sooner than others. However, that does not mean that the knee has finished healing or that it’s ok to go back to playing sports! Something very important and amazing is happening, and we need to protect the knee while it does!

While the bony part of the BPTP heals pretty quickly (like a fracture), the tendon portion of the graft dies! Yes, it dies, but then it starts to be infiltrated with new blood vessels and nerves, and here is where it gets cool. The graft starts to take on the structure of an ACL! Yes, from day one, there is a process of death of tendon cells and then growth and development of ligamentous cells. We call this process ligamentization and during it we have to strengthen the knee and the hip, gain control of the leg, BUT ALSO protect the maturing ligament. When the ligament is not well protected before it has matured, there is a chance it will retear. This is a big topic of research1 and debate as the timeframes of this maturation process vary in the research.

The results of Clae’s et al Systematic Review – Showing uncertainty in length of time for the ligament to mature.

There is certainly a wish to return to sport quickly due to various reasons and pressures. However, if you return too quickly you risk retear. A study in 20122 found that a young athlete who returns to sport within 1 year is 15 times more likely to suffer a second ACL injury than a healthy athlete with no medical history of a knee injury. The same group in 20143 published further findings that elevated risk remains evident within two years of returning to activity when an athlete is approximately 6 times more likely to sustain a second injury than an uninjured counterpart. This has led this group of authors to suggest4 we should wait till 2-years post ACL surgery for return to sport! I suspect that two years may be overly conservative for most people, while 6-months will be too soon for the majority; in reality, recovery time will be dependent upon the individual and their progress.

How Sam Followed And Trusted The Criteria

Keeping this in mind, I stressed to Sam and his mom the importance of a criterion-based approach to determining when it was safe for Sam to return to basketball, and provided him with a set of exercises and goals for us to reach. At each appointment, I was testing and measuring several key metrics that helped to show me how his strength was progressing and whether he had met criteria to move to the next progression. As he strengthened, I progressed his home exercises to keep him challenged and moving closer to reaching his goals. After 4 visits spread over three months (6 months and 10 days post-surgery), he was ready to be tested against what would be one of the final criteria for return to sport: the Cincinnati hop test. Two of the four hop tests are shown below from one of Sam’s appointments:

But here was the twist with Sam: normally for the hop test we want the performance of the injured leg to be within 90% of the uninjured leg. But in Sam’s case, he had recovering ACL’s on both knees! Thankfully, some recent research5 provided helpful benchmarks – They found normative values for basketball and football players for the hop tests at both high school and collegiate levels for males and females. As you will see in the chart below, Sam performed pretty well, being within the average of the high school athletes for some of the hops (2/4 on right, 3/4 on left) However, I wanted him to perform better, so I progressed his exercises and training and at the next appointment he was much better – close to the average male hop test for a high school athlete. He was still having some consistent right knee pain and left shin splints, and I was still concerned that he was not ready to return. I could see Sam was disappointed with this, and he felt strong, so I used a further test to help illustrate my concerns: he was to do single leg squats up and down from the chair. On the left leg he could do 23, and on the right only 12. Research6 shows that having the ability to do 22 or more after ACL surgery correlates with significant improvement in quality of life 3 years out from surgery. So, he was on the cusp of return to sport, but he still had weakness that could negatively impact his life. I saw him again in late January (nearly 8 months post-surgery) and he did much better in hop testing.

ACL hop testing numbers for Sam

Further Testing to Make Sure Sam Was Ready to Return to Sport

He still had some transient knee and shin pain, which gave me a slight pause, but with only two games left of the season in which he will likely see minimal playing time, and would be similar to recent practice, he had my blessing to return. This turned out to be true when I saw him for follow-up in March, and he was still having a little pain after practicing for longer periods. The hop tests showed good power and control, but he was still lacking endurance. To help illustrate this I had him do a hop test where you hop side-to-side between two points 40 cm apart for 30 seconds. On one side Sam managed 36 and on the other 32. The aim is to be within 90% of the other side and close to the norm (55 for males, 41 for females)7.

To highlight this further, we initiated some drills using an app called Clock Yourself which showed he had good reaction and control, but he found endurance challenging. He was due to start a development ball program and I very strongly recommended that he needs to continue to build strength, endurance, and should be a great position to enjoy playing development ball through the spring and hopefully have a standout season as a senior. Should he do these things, he gives himself every opportunity to play collegiate basketball, but more importantly to have as healthy a knee as possible as he moves through life.

What Huntsville And Madison Parents And Athletes Need to Know!

Navigating an athletes’ return to sport can be a challenging, evolving, multifactorial equation. Part of the equation is made easier by research such as I refer to in this and other blogs. The patient’s outlook, the support they experience from their family, and the level of trust they develop with their healthcare providers are also key factors. In Sam’s case, he had supportive parents and we developed trust from the first session. One part of the equation that can be challenging depending on the therapist is an understanding of the patient’s sport and relevant professional experience. I have been fortunate to have treated collegiate and professional basketball players in my career, so I knew the levels that Sam needed to achieve if he wanted to have the opportunity to go down that route.

If you are looking to return to sport after injury or surgery, research your rehab options and who you will work with. I have worked with high school, collegiate, and professional athletes in various sports, with injuries from ACL to labral repairs, to rotator cuff repairs. Please call me if you have questions that I might be able to answer or if you want to find out how to work with me.

References:

  1. Claes S, Verdonk P, Forsyth R, Bellemans J. The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med. 2011;39(11):2476-83.
  2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med. 2012;22(2):116-21.
  3. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567-73.
  4. Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports Med. 2017;47(2):221-232.
  5. Myers BA, Jenkins WL, Killian C, Rundquist P. Normative data for hop tests in high school and collegiate basketball and soccer players. Int J Sports Phys Ther. 2014;9(5):596-603.
  6. Culvenor AG, Collins NJ, Guermazi A, et al. Early Patellofemoral Osteoarthritis Features One Year After Anterior Cruciate Ligament Reconstruction: Symptoms and Quality of Life at Three Years. Arthritis Care Res (Hoboken). 2016;68(6):784-92.
  7. Gustavsson A, Neeter C, Thomeé P, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778-88.
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Do you have pinchy hip? https://physioworkshsv.com/do-you-have-pinchy-hip/ https://physioworkshsv.com/do-you-have-pinchy-hip/#respond Thu, 22 Feb 2018 23:00:02 +0000 https://physioworkshsv.com/?p=4419 Pinchy hip or groin pain is a relatively common issue. Running, squatting, getting down on the floor to play with your kids, can all trigger groin pain. Say you’re a recreational athlete – maybe a runner, Crossfitter, weightlifter, basketball, softball, or soccer player. Or maybe you’re a mom/dad/grandparent of young kids, a gardener, or love doing DIY projects around your house – the onset of groin pain can really curtail or stop you from doing those things you love. It can even get to the point where it hurts just to rise from sitting, get in and out of your car, or go up and down stairs. It’s an injury I see fairly frequently in my practice, and many of my patients do get better with therapy. But what if it doesn’t? Or what if your doctor performs imaging and recommends surgery?

Recently, diagnosis and surgery for a particular source of groin pain called femoroacetabular impingement (FAI) have increased significantly – surgeries have increased 400% over the past decade! In order to understand the reason for the increase, a panel of experts convened and published guidelines in the British Journal of Sports Medicine (BJSM). In this blog, I want to discuss hip/groin injuries, the BJSM guidelines, and how FAI, in particular, can be treated.

Hip anatomy and impingement:

The hip and shoulder have a couple of similarities; They are both ball and socket joints, and they both have a labrum (a ring of cartilage around the socket that deepens the joint). However, that is where the similarities end. The shoulder is a shallow ball and socket with relatively weak ligaments. This allows for great motion, which in turn asks much of the muscles to provide stability. On the other hand, the hip has a deep ball and socket which allows significantly less movement. Its ligaments are strong and it is very stable. With this, it is very rare to hear of hip dislocations but is more common in the shoulder. We also hear of shoulders and hips having impingements with the idea that there is a painful catch between the ball and the socket and other structures such as the labrum. There are also other sources of groin pain such as the hip flexor tendon, the femoral nerve, and hernia. The guidelines by BJSM seek to help to increase diagnostic accuracy to help ensure the best treatment. The guidelines require three features to be present for an FAI diagnosis: symptoms, clinical signs and imaging findings.

Symptoms:

The main feature of FAI is pain in the groin that is related to motion or position. Pain might also be felt in the back, buttocks, abdominals, or thigh. There may also be clicking, catching, locking, stiffness, restricted range of motion or giving way. The pain is typically severe and limiting. Injection of an anesthetic into the hip joint under imaging guidance can be useful in helping to determine if the above symptoms are likely from an FAI or not.

Clinical Signs

One of the concerns of the BJSM panel was that there is high variability in how different clinicians apply and interpret tests. However, they felt that several things should be considered in a good examination:

  • Hip range of motion – will typically be limited
  • FABER (Flexion, ABduction, External Rotation) test will likely be positive (This still does not mean the problem will be FAI).
  • Tenderness in surrounding musculature
  • Gait. Walking, or running depending on level of patient.
  • Hip muscle strength – weakness often found
  • Single leg control – e.g. single leg squat.

The video below runs through several of these:

Imaging Findings:

No doctor or therapist has X-Ray vision! For FAI to be considered a true diagnosis, you need imaging. This is different from the latest guidelines on patellofemoral knee pain (anterior knee pain) which only require symptoms and clinical signs for diagnosis. The imaging findings of the hip will help us to see if there two major anatomical variants:

  • Cam lesion – This is where there is either a flattening or convexity of the head of the femur (The ball). This means the ball is not as circular as it should be, is more cam-like, which will potentially cause impingement and pressure.
  • Pincer lesion – This is where there is an overgrowth of the acetabulum (The socket) which again leads to opportunity for impingement.

Illustration of the normal hip, cam lesion, pincer lesion and mixed lesion.

Illustration showing how the lesions will increase the chance of impingement during hip motion.

The initial imaging should be X-Ray, which essentially shows bone and space and will also show any other findings such as a fracture. To visualize the hip in 3-dimensions and to see the soft tissue (tendon, muscle, labrum, or ligament problems), advanced imaging such as MRI, MRI arthrogram, or CT scan should be used if planning on surgery. So, the first time you see the doctor for this issue you will likely only have X-Ray and would then go onto advanced imaging if conservative measures have failed.

Three positive components = FAI

When these three components are all positive, the expert panel concludes that a patient likely has FAI. This is important, as we know there are a significant number of people, even sporting, have no pain but have “pathology” on hip imaging. For example, 81% of asymptomatic (no pain, catching, etc) professional hockey players have some form of pathology on hip imaging. So, could the “pathology” actually be a physical adaptation to the sport? We don’t have an answer yet, but the above should give caution to jumping to surgery based off of imaging findings when perhaps the other two components are not so clear. A recent study in 2016 found that 92% of FAI surgical decisions were based on imaging, but only 56% were based on the three components. Only 44% had described previous failed conservative treatment or worse still only 18% described failed physiotherapy as a reason for surgery! Hopefully, with these guidelines being published in the past year we will see a shift in the approach of healthcare professionals to this issue and therefore a change in these statistics.

How best to treat FAI?

So what are the treatment options? At this point there is not clear evidence for what treatment is best for each specific patient, i.e. are there some who should skip straight to surgery. The panel makes a recommendation for physiotherapy-led rehabilitation and they agree surgery is an option. Let’s quickly consider each option and what they involve:

Rehabilitation:

The rehabilitation needs to help control the position of the pelvis (the socket) relative to the ball. As you can see in the video below, if I have a significant anterior pelvic tilt, there is an increased chance of impingement. This chance would be increased if there is already some form of bony lesion of a tear already reducing space. So we need to assess when this might occur in the tasks that they find painful. For example, a runner who has excessive amounts of pelvic tilt may need to work on correcting this using various strengthening and cueing strategies. Another example would be someone lifting weights and using excessive hip flexion as they have a restriction elsewhere (e.g. ankles). We would work to correct this by correcting form, as well as strength deficits (wherever found in the trunk and lower extremity), and improve mobility where it was lacking.

Manual therapy can also be useful in FAI using a technique called mobilization with movement (MWM). To do this, I use a belt that provides a force along the length of the femur. We previously thought that we were decompressing the joint, but now we know this is only happening to a small degree. We do not really know the mechanism, but when it works (which this technique seems to do regularly) it is having an effect on the nervous system and pain. This allows the muscles around the hip to work better helping the patient regain function and have ongoing pain relief.

Surgery:

Surgery can be either arthroscopic (keyhole) or open, and typically involves removal of the excess bone and fixation of other findings (e.g. labrum tear). Arthroscopic hip surgery has been shown longer term to give a better quality of life versus open surgery. Surgery for FAI has certainly been shown to be effective for return to sport (RTS) at 87%, and 82% RTS at the same level. Another study showed 94% of runners returned to running at an average of 8.5 months after surgery. It also showed good outcomes at 2 years for both pain and function. There is a ~10% conversion rate to hip replacement, but some of these people probably should not have had the surgery in the first place (perhaps even had not met the three components in the guidelines?!). However, a recent paper published from research in the military found no significant difference between a surgical and non-surgical group at two years and ⅓ had not returned to active duty.

So, even if there are some less promising findings that have been published, if you had it and two years out are feeling great, you would probably recommend it! However, there have not been any papers comparing the surgery with a sham (fake surgery), so we don’t really know what the outcome would be if surgery had not been undertaken. It may be a while till we get this sort of study as only 25% of surgeons are willing to participate in a well-designed study comparing surgery and conservative care. Getting this type of study is important as we have recently seen how the common knee scope for a degenerative joint is now strongly advised against in new guidelines as it performs no better than conservative care at mid (6-month) and long terms (2-year) when compared with rehabilitation. Knowing that there is a high number of people with “pathology” and no problems, it is arguable that some of these surgical patients got better due to enforced rest after surgery more than the surgery itself. This may be particularly true if we consider that cam and pincer lesions could just be physical adaptations to activity and sport.

What if I was the patient!

It is not my place to tell you what to do, or to try and tell the surgeon what to do! All I can do is provide education and then practice the best physical therapy I can, based off of the best research evidence. However, if I had groin pain and it was diagnosed as FAI, based on the above information, I would want to try a good course of conservative care. This may initially involve relative rest and appropriate analgesia and anti-inflammatories. If the pain persists more than a week, then I would seek out physical therapy to progressively increase activity, load the muscles, and improve my control of movement.  If the pain is still not settling, I might accept an injection into the joint as it might significantly reduce my pain and is to some degree diagnostic. If the injection provides relief, I would again try the physical therapy as described above – i.e. load the muscles/joint and improve control. If running was something that provoked my pain, I would review my technique (video analysis is great for this) and would make gait changes (e.g. cadence, stance width, correction of pelvic drop). If I felt I had exhausted these options, (this might be a year-long process), I would consider surgery and I would try and find the best surgeon possible to do it!

If I can be of any further help please let me know. I have treated hip surgeries from several local doctors and also from Dr. Byrd in Nashville who is one of the pioneers of arthroscopic hip surgery. You can contact me by email or by phone. You are also welcome to sign up for our e-mail list to stay up to date on the latest research as we get it!

 

References:

  • Gupta A, Redmond JM, Stake CE, Dunne KF, Domb BG. Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center. Am J Sports Med. 2016;44(1):74-82.
  • Ross JR, Bedi A, Clohisy JC, Gagnier JJ, Larson CM. Surgeon Willingness to Participate in Randomized Controlled Trials for the Treatment of Femoroacetabular Impingement. Arthroscopy. 2016;32(1):20-4.e23.
  • Nwachukwu BU, Rebolledo BJ, Mccormick F, Rosas S, Harris JD, Kelly BT. Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes. Am J Sports Med. 2016;44(4):1062-8.
  • Levy DM, Kuhns BD, Frank RM, et al. High Rate of Return to Running for Athletes After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Capsular Plication. Am J Sports Med. 2016;
  • Mansell NS, Rhon DI, Meyer J, Slevin JM, Marchant BG. Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up. http://journals.sagepub.com/eprint/XzicCn4qThfrDUtFtDCe/full. Accessed Ahead of Print The American Journal of Sports Medicine February 22, 2018.
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I Want a Scan Doc! https://physioworkshsv.com/i-want-a-scan-doc/ https://physioworkshsv.com/i-want-a-scan-doc/#respond Fri, 19 Jan 2018 21:24:10 +0000 https://physioworkshsv.com/?p=4373 When we have an injury or pain it is very tempting to want to know exactly what is wrong!

“Why can’t I just have an x-ray or MRI so that we are certain it is only a sprain!”

I understand this wish, but if we imaged every little pain or injury, our medical care would be even more expensive than it currently is. There are even circumstances where imaging can have negative consequences! So, the gatekeeper to imaging needs to be responsible and judicious. This blog we’ll look at the main types of imaging that are used in orthopedics and sports injuries and give you some idea of when and why they are used.

Radiograph (aka, X-Ray)

People often use the term X-Ray interchangeably with a radiograph. You are having an X-Ray in the sense the body absorbs X-Rays, but the image we see at the end is a radiograph. The different structures of the body absorb certain amounts of X-Rays which gives us the nice (or nasty!) picture. This is a simple 2-dimensional picture and can be taken in different positions to give us the view we want.

Radiographs simply show bone and space. With contrast (injected or consumed solution), they can show other things, such as blood vessels and food traveling down the esophagus (In the form of a live x-ray called a fluoroscopy).  

Normal knee radiograph xray medial and lateral compartments

Image 1: A normal knee- green line marks the joint line of the femur (thigh bone), the two blue lines the joint line of the tibia (shin bone). You can clearly see good space there, indicated by the two marron vertical lines. The two yellow and purple vertical lines demark the lateral and medial (outside and inside) compartments.

Sometimes I hear people say that they had an X-Ray and were told they have worn cartilage – this is not really true as you cannot see cartilage on an X-Ray; instead they are making an inference that there is less space and therefore less of the soft tissue (cartilage) that should be there. While this might be true if you opened up the knee, it may not be the most helpful thing to tell the patient. They walk away from the appointment thinking they have a horrid arthritic knee when in fact, that may not be the cause of their pain! X-Ray has become a formality in medical and chiropractic care when it should not be. X-Rays are harmful, so they should be used only when necessary. In musculoskeletal care, they should be used when there is a concern of fracture or other significant pathology. If someone likely has a soft tissue injury, e.g. muscles, tendon, ligament, or disc, it likely is not appropriate. This principle has been considered with ankle sprains in the form of rules to help decide if there is a risk of a fracture and benefit of a radiograph (see our blog on this here). It has also been looked at by professional groups as part of the Choosing Wisely campaign which many countries take part in. The in 2017 as their first contribution to this campaign stated:

 

Chosing wisely on imaging

*(Red flags are symptoms of significant pathology that need an immediate intervention – e.g. include neurological deficit such as weakness or numbness, any bowel or bladder dysfunction, fever, history of cancer, history of intravenous drug use, immunosuppression, steroid use, history of osteoporosis or worsening symptoms.)

 

As you will see in these example of imaging and low back pain there is a consensus amongst the medical, chiropractic, and physical therapy organizations that certain things need to be met in order for imaging to be ordered and be useful. Some of you will read this and may realize that you have had imaging that is unnecessary. I have seen this in my patients, which is why I think it is good to publicize the result of these campaigns. I have even had patients who have had recent good quality X-Rays that were taken elsewhere, who have gone on to visit a local doctor and be told by support staff they need to have a new X-Ray using their equipment… The doctor might not be aware of this, but the X-Ray was ordered without a doctor having seen the patient! Rant finished, let’s look at the other imaging options that are out there:

Nuclear Medicine Imaging (CT, PET, SPECT scans)

In a Computed Tomography (CT) scan, many X-Ray measurements are taken to provide us with slices or a cross-sectional representation of the body. Positron Emission Tomography (PET) and Single-Photon Emission Computerized Tomography (SPECT) scans are also forms of CT scans, but use different forms of radiation than an X-Ray. Each of these technologies has their use in various types of medicine and industry. In orthopedics, CT scans are typically used for imaging fractures that are more complex and will require surgical fixation. Whereas a radiograph gives us a 2D view of the fracture, the CT scan gives us a 3D view which can be viewed in 2D or can be looked at in a 3D model. This allows us to see the route(s) that a fracture takes through the bone. In a fracture that is fragmented (comminuted) it helps visualize the fragments of bone and helps the surgeon plan how they will put it back into a normal anatomic position and what hardware they will need to use. Like X-Rays, nuclear imaging may also use contrast dyes to help identify other issues. These scans are used in other conditions in medicine from cardiology to oncology.

 

Bone scan tibial stress fracture

Image 2: A bone scan (Scintigraphy) of a stress fracture of both tibia!

Acetabular fracture CT scan

Image 3: The arrow on this CT scan shows a fracture to the acetabulum (the socket of the hip). This a 2D slice of the body a little below the waist looking from the head to the toes.

3D acetabulum CT

Image 4: A 3D model using CT data of an acetabulum fracture – we can see a complex fracture with lines in the front and the back of the socket.

Magnetic Resonance Imaging (MRI)

MRI uses a magnetic field, radio waves, and computation to determine the alignment of hydrogen atoms in the various tissues of the body. NOTE, there is no radiation involved! The main risks are if someone has metal objects or implants in their body, so they should make sure they tell their provider about this as this might make this an inappropriate scan. The alignment of hydrogen atoms is detected as a signal, and the differences in the signals give us our image. Some signal differences also indicate a pathology. As with CT scans, a contrast agent can be used to help better visualize/diagnose certain issues. MRI scanners in human medicine are typically either 1.5 or 3 T (Tesla), which denotes the strength of the magnet. The stronger 3T magnets give better resolution (detail) of the scan. One of the challenges of MRI scan is that they take significantly longer than X-Ray or CT scans and are performed in a tunnel which can be claustrophobic. To help those who struggle with claustrophobia, open-sided MRI machines have been developed, but they have weaker magnets, so the images are less detailed. To reduce the time the MRI takes, slices can be thicker, but this can also lead to things being missed if they are between slices. When scans are being performed, various sequences are taken. These sequences are produced by altering parameters such as the time between radio wave pulses and the time for the pulse to be sent and the echo to be received. Two of the most common sequences are T1 and T2. T1 sequences are typically very good for looking at anatomy. T2, on the other hand, is great for looking at pathology as fluids show up as a bright signal or hotspot.

MRI shoulder cyst and rotator cuff tear

Image 5: This T2-weighted MRI shows high signal (white in the scan) showing a rotator cuff tear (infraspinatus tendon – white arrow) and a cyst (white arrowhead)

 

People are often aware that MRI gives a really good view of a person’s anatomy and pathology, so this is often the scan people want their doctor to send them for! As we have seen for the choosing wisely campaign, radiographs and MRI are not indicated for people with acute, non-specific low back pain without red flags. Although we want to know, it is not indicated, and may even have a negative effect. The reason it may have a negative effect is threefold:

    1. Significant numbers of pain-free people have MRI findings such as disc bulging and degenerative changes.  Disc Bulges in people with no back painWe might be more likely to have surgery or recommendations based on imaging that might not have been necessary. One example is a 2016 case study in the New England Journal of Medicine1.  that showed an MRI of a large lumbar disc herniation and then a repeat MRI 5-months later that showed it had spontaneously (i.e. no surgery) resolved. We see this in people who have a degenerative meniscal tear diagnosed by MRI, have a knee scope and the statistics show are no better off at two years than if they had not had surgery and worse find they will end up having knee replacement sooner (see our blog on this!).
    2. There is actually a significant variability in the reading of an MRI. This paper2 found that a lady with back and leg pain was sent to 10 different imaging centers over a week and there was large variability in the findings/readings of the scans!…Among the 10 reports, there were 49 distinct findings, and not one was found in all 10 reports! On average, each radiologist made about a dozen errors, seeing one or two things that weren’t there and missing about ten things that were! In the UK I saw many more scans and am by no means an expert in interpreting them, but I have caught miss-readings myself and been in hospital rounds where surgeons have disagreed with the radiologists’ findings.
    3. The nocebo effect – When you are told something about your body it can be positive (placebo), or negative (nocebo). If you are told that you have spinal degeneration that can negatively affect your beliefs about your spine. For this reason, there are actually descriptors that might be more beneficial to use, e.g. “We saw nothing more than the equivalent of wrinkles of the spine on your scan”.

When it is appropriate, MRI is a superb imaging option. In the US, physical therapy programs teach image interpretation, but there are very few situations (military being one) that PTs can order them. In the UK, after the requisite courses, PTs can order all types of imaging and I have been on the side of ordering images out of concern of cancers, fracture, ligament and tendon rupture, which has led to appropriate treatment.

Conclusion:

Seeing inside the body is amazing and under the right circumstances, it is very necessary. However, we do not always need to see inside. What a patient tells us provides most of a diagnosis, the physical examination confirms things and imaging is only needed when something more concerning is going on that needs some type of intervention (surgery, chemotherapy, radiotherapy, etc). In many cases, even in the case of imaging findings that we might call a pathology, physical therapy can be successful in helping people return to activity and resolve pain. If you have an issue, don’t be too eager to jump to imaging, consider if physical therapy might help. Feel free to contact (e-mail, or phone) me to see if physical therapy would be a good option to consider.

 

References:

  1. Hong J, Ball PA. IMAGES IN CLINICAL MEDICINE. Resolution of Lumbar Disk Herniation without Surgery. N Engl J Med. 2016;374(16):1564.
  2. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017;17(4):554-561.

Images:

  1. Beattie KA, Duryea J, Pui M, et al. Minimum joint space width and tibial cartilage morphology in the knees of healthy individuals: a cross-sectional study. BMC Musculoskelet Disord. 2008;9:119.
  2. Kurklu M, Ozboluk S, Kilic E, Tatar O, Ozkan H, Basbozkurt M. Stress fracture of bilateral tibial metaphysis due to ceremonial march training: a case report. Cases J. 2010;3:3.
  3. Flanigan DC, De smet AA, Graf B. Magnetic resonance imaging in traumatic hip subluxation. Indian J Orthop. 2011;45(3):272-5.
  4. Fornaro J, Keel M, Harders M, Marincek B, Székely G, Frauenfelder T. An interactive surgical planning tool for acetabular fractures: initial results. J Orthop Surg Res. 2010;5:50.
  5. Awh MH, Stadnick ME. MRI challenge. Sports Health. 2009;1(2):180-3.
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How Much?! Typical PT Costs in the High-Deductible Era https://physioworkshsv.com/how-much-typical-pt-costs-in-the-high-deductible-era/ https://physioworkshsv.com/how-much-typical-pt-costs-in-the-high-deductible-era/#respond Wed, 10 Jan 2018 21:26:13 +0000 https://physioworkshsv.com/?p=4360 How much is physical therapy care in huntsville and madison county physioworks sports and wellness inc

We recently went through open enrollment for our family health insurance.  We had been on a traditional PPO plan, but over the past three years, we have also had the alternative option of a high-deductible health plan (HDHP) tied to a health savings account (HSA). This year the HDHP became more attractive due to bigger contributions from my wife’s employer, so we revisited our decision. This required going back and looking at past healthcare expenses and trying to predict future ones. As we look at our situation (a family of four), even with two family members having conditions that require ongoing specialized medical care and imaging, the high deductible plan looks to now be a better fit. So, starting this year, we have a much greater incentive to be informed of the true costs of our healthcare decisions.

I know that many of you are making the same decisions – increasingly, employers and individuals are moving to high-deductible plans with HSA accounts. Even on PPO plans, the trend is for higher and higher deductibles. PT is definitely one of those healthcare expenses that can hit you in the pocketbook! So, now that we have more incentive to ‘price-shop’ our healthcare, how can we do that without sacrificing our health and quality of care?

I believe that being a smart consumer is positive for both the patients and the employer. Historically, consumers haven’t given too much thought to the provider they use or the pharmacy that they fill their prescription from a cost perspective. In our case, we usually had a $5 copay for a 30-day medication supply, so unless we looked at our insurance explanation of benefits (EOB), we had no idea what the medication cost, what insurance paid, and even then we had no idea of cost differences between pharmacies. However, more tools are starting to become available to help us as consumers make informed choices. One that my family will be using this year is GoodRX, which lets you price compare your prescription medications between different local pharmacies – we found a $100+/month difference in the price of one medication that one of my family members is on!

In the physical therapy world, it is harder to price compare. First of all, under the traditional in-network model, the PT will have no way to tell you exactly what codes will be billed to your insurance until you have been examined. The amount charged from visit to visit may also vary, especially if you see more than one provider due to the way clinic scheduling works. Also, what pricing information is publicly available is fragmented making it difficult and time-consuming to check prices. However, as an insured person, my insurance company does provide me with a tool on their member site that can at least help. Some insurers have tools that are publicly accessible and others are inside member sites, so hopefully, your insurer can provide you with some data. This tool had been promoted in open enrollment to help employees price shop, and doing so for physical therapy I was amazed how great the variation is from clinic to clinic. However, even with that information, there are still things that make it hard for a consumer to understand. So, here is a breakdown and some notes that might help. (Note: These numbers are hypothetical estimates informed by average pricing information that I found through internet searches; they are intended to give a ballpark idea of the price ranges for PT, not exact pricing for any specific providers or negotiated insurance rates. The numbers provided here are intended to reflect negotiated rates; i.e., the amount due after the bill has been processed by your insurance company.)

 

Physical Therapy Average Costs, evaluation, therapeutic exercise, electric stimulation, manual therapy

Notes:
1. Evaluations are untimed codes, which means that that the above amounts could get charged for any amount of time the therapist spends doing the evaluation. The quicker the evaluation, the more time there is to provide other treatments whose codes are typically timed. These codes are typically billed when a certain time is spent on a service. Many insurances follow Medicare billing principles, so with exercise, 1 unit could be billed after 8 minutes, and a second could be billed after 23-min, so essentially 15-min of exercise averages $88, 30-min would average $176. Some insurances do not follow Medicare rules which allow for more aggressive billing.
2. The electrical stimulation that most people get at the end of therapy is classed as “unattended” which means the patient can be hooked up and left on it, while the therapist sees another patient (and bills both!). Theoretically, all the above are supposed to be skilled procedures by a physical therapist, so although an aide can set up the basics (e.g. getting the patient comfortable and positioned), the therapist should be the one performing any of the above treatments. This also means that legally an aide should not be taking someone through an exercise program, which is then billed to insurance.

 

With that knowledge, let’s compute the cost of a hypothetical evaluation (first PT visit) as performed in many clinics around the country. The patient will be with the therapist 40-45 minutes and will be in the clinic for 60 minutes. Evaluation (the talking and the physical examination) takes 20min, the therapist does 10min of manual therapy, 15min of exercise and puts them on electric stimulation (during which they might write notes, or in many clinics will move on to treat someone else):

Physical therapy evaluation cost example

 

Let’s also consider a follow-up appointment where 15min is spent on manual therapy, 30min on exercise (2 units) and the session is completed with 15min of electrical stimulation (unattended):

 

physical therapy follow up costs

 

Assuming you only need evaluation and a follow-up it would total $780. With the shift to high deductible plans, you may not have hit your deductible (The average individual deductible across the US is $1,696 for any sized company, and is $1,205 in Alabama)! The policy my family is moving onto has a $3000 family deductible that has to be met before it will then pay 80% of the charges (coinsurance). Typical PT in the US is 2-3 x a week for 4 weeks, so with evaluation costing $410 and follow-ups costing $370 each, you may have been billed somewhere in the range of $3000-$4480. For anything more than 2x a week for 4 weeks I would have hit the deductible with the increased visits being subsidized by coinsurance. Even with insurance paying some of the cost at that point the larger amount for 2x a week for 4 weeks would have only been reduced to $3296. Visits add up quickly and when you are seeing the dollar amount instead of a copay you might be shocked! It is even more shocking when you consider there is no research showing superior results being seen over so many visits in such a short space of time.

I often hear HR departments and insurance companies tell people that it is cheaper/better to stick with in-network providers. This is not necessarily true as it makes an assumption that out-of-network and in-network providers will do the same things. This is not the case and is why PhysioWorks is an out-of-network provider! Knowing some of the numbers from my time working as an in-network provider for a large local company, I set my cash rate at what I considered to be a fair value for my clients and for myself. At $135 for 60-minutes, if I saw someone for 12 visits it would only total $1620, but I do not typically see people on those schedules! On average, I see my patients 5-6 visits over a 6-month period using a highly tailored plan of care. Using those numbers, my patients’ out-of-pocket costs for a plan of care likely average ~$800.

 

physical therapy cost in madison huntsville alabama physioworks versus the rest

The table uses the numbers in our other examples; your actual numbers may be different.

 

The differences in these numbers are huge! However, with the assumption that it is cheaper to stay in-network, the first question I am asked when people call me is: “ Are you in-network with my insurance?” If people give me the chance to explain things and also look at our reviews they start to see our business model is very different and that it yields results. Once our clients experience the highly-tailored personalized care that we provide, they often tell me that they see our service as a fantastic value at a bargain price! If you are considering physical therapy or any other form of healthcare, do not just look at the dollar value. As with any other decision (car purchasing, restaurant choice), consider the overall value of the service. I hope the above helps you to consider the value of physical therapy! If you have any questions send me an email or call.

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Medical Misinformation – Be Careful What You Read & Trust! https://physioworkshsv.com/medical-misinformation-be-careful-what-you-read-trust/ https://physioworkshsv.com/medical-misinformation-be-careful-what-you-read-trust/#respond Wed, 03 Jan 2018 21:10:37 +0000 https://physioworkshsv.com/?p=4352 Does coffee cause cancer?

Put down that cup of coffee! A recent research study says….

No, wait. It’s ok. Coffee is actually good for you; a new study showed….

But EGGS – eggs are bad. Will ruin your cholesterol…

Oh, hold on, the latest research shows that eggs are ok after all….

I’m sure all of this sounds very familiar – medical “information” is constantly coming at us, on the news, social media, our favorite TV show host…and it will make your head spin if you try to listen to it all. We’ve all noticed the constant yo-yo on whether certain favorite foods and activities are “good” or “bad” for our health. What is going on?

Medical misinformation careful what you read and trust!

If you have met me or been reading my blog for long, you will know that I read a lot of research papers and that I try to back up my medical decisions and advice with research. That is why I take the time to include the relevant references in my blog posts! But with all the conflicting advice out there, how do I know what to believe and what to ignore?

There are many papers out there; In fact, the National Library for Health has some 17 million trials tagged “human”, and a further MILLION articles are added each year. Much of this research is useless, creates misinformation, or worse, can be used to push certain agendas. It is challenging to look at papers in an unbiased manner and assess their quality; their study design, the appropriateness of their conclusions and recommendations. There is no way that I, or any medical professional or researcher, can stay on top of ALL of that information, but it is important to at least be able to evaluate the quality and reliability of the medical research that we do consume and allow to shape our practice. This is what I try my hardest to do so!

A recent paper1 looked at this issue. It came up with 4 major problems we have with research publication which is shown in this graphic

Four issues of Medical Missinformation

In order to evaluate the quality of a particular research paper, one needs a knowledge in research statistics and how to properly design an experiment. For instance, factors such as the sample size, length of the study, whether a good experimental control was in place are crucial. Also relevant is whether the research was carried out on lab tissue, humans, or animal subjects. Sadly, many times those attention-grabbing headlines touting the latest “cancer-causing” (or cancer-curing) food, etc, don’t tell you any of those things – if you dig deep you might find out that the research was in rats, at much higher dosage levels than human normally would (or even could) experience, or that the research was simply some cells responding in a petri dish and may be decades away from actually being a conclusive result that anyone should base their decisions on!

This is why I take my professional reading seriously and strive to be careful about evaluating the quality of the research that I bring to you on my blog. My educational background has equipped me with the basic knowledge and tools I need to critically review sports-medicine research, and my goal is to break that information down into something useful and applicable for my clients and my readers!

Do you have any questions or topics that you wish I could cover in a future blog? Let me know! I would love to hear from you and report back on the current state of the research. No matter where you find your health information, I would encourage you to consider it with a critical eye; before you let the information coming at you from all directions start to change your lifestyle decisions, consider the source and the quality of the underlying research behind the headline!

Reference:

  1. Ioannidis JPA, Stuart ME, Brownlee S, Strite SA. How To Survive the Medical Misinformation Mess. Eur J Clin Invest. 2017;
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Gloria’s Story – Elbow Pain Gone Naturally: No Injections, or Surgery! https://physioworkshsv.com/glorias-story-elbow-pain-gone-naturally-no-injections-or-surgery/ https://physioworkshsv.com/glorias-story-elbow-pain-gone-naturally-no-injections-or-surgery/#respond Thu, 07 Dec 2017 23:19:04 +0000 https://physioworkshsv.com/?p=4337 Gloria came to see me because she had been struggling with pain on the inside and outside of her elbow for over a year. These problems are often referred to as “tennis” or “golfer’s elbow”, as tendon pain in these areas is commonly seen in these sports. However, in Gloria’s case, her elbow pain was preventing her from doing her gardening, and some of her fitness routine (pilates and weight-lifting). She went to see an orthopedic surgeon, who prescribed an oral steroid,  referred her for physical therapy, and scheduled a follow-up for 5 weeks. If she was not better by then, he planned to give her a steroid injection. After reading our online reviews, Gloria contacted me. We discussed her case over the phone and she scheduled an evaluation.

On examination, Gloria was found to have a full range of motion through her neck, shoulder, elbow, wrist, and hand. Nerve testing was negative, but all tests for lateral and medial elbow tendinopathy (tennis and golfer’s elbow) were positive. The insertions of these tendons at the elbow were also quite tender. I could not detect any notable weakness except when the arm was raised above the horizontal, which was consistent with her history as she struggled with heavier, fast loads in positions distant from the trunk.

Typically, if left untreated, the average recovery time for tennis elbow is about a year. But at the time I first saw her, Gloria had had the problem for more than a year and it persisted, so it seemed unlikely that the problem was going to resolve on its own. Research indicates that exercise is helpful for tendon pain, but our understanding of how to treat tendon pain is rapidly evolving, and often we don’t yet have a definitive answer for how to best treat a specific tendon injury. But thankfully, a recently published paper1 gives some guidance on the best practice for tennis elbow. Long combinations of isometric, eccentric and concentric exercises were found to be effective compared to other exercise combinations 8-weeks after treatment had started (longer-term data is not yet available; rest assured I will be keeping an eye out for any updates as new research is published!)). So, I recommended we start with these exercises specifically targeting the elbow tendons. Gloria also had weakness in the shoulder above the horizontal, so it made sense to also strengthen the shoulder and trunk. I also recommended heavy load strengthening exercises for these.

During the evaluation, I tried a manual therapy technique called a “mobilization with movement” (MWM) and it gave some instantaneous relief. When a client has been experiencing debilitating pain for a long time, it can be hugely relieving to experience the instantaneous reduction or even elimination of pain that manual therapy treatments can sometimes provide. However, the relief they provide is only short-term – still helpful to provide comfort and reduce potential need for medication or injections while the body heals, but they do not actually heal the injury in and of themselves. Gloria and I discussed the need to avoid her becoming dependent on passive treatments like manual therapy and that true long-term recovery would come from an active, exercise-based approach. This empowered Gloria to be in control of her own recovery, rather than dependent on frequent appointments with me.We also discussed that having had pain for a year, recovery could be slow and would be influenced by changes in how her body processes pain (not just structural tendon tissue changes at the elbow).

Gloria also asked about the injection the doctor had proposed doing only five weeks after starting therapy. Current evidence does not support injecting steroids into or around the elbow tendons as an early treatment and could lead to worse outcomes. If she was significantly further down the road and had tried other less risky conservative options the potential risk of a steroid injection might be worth considering. But given that we were just starting a physical therapy plan of care that I expected to take at least a matter of months, I recommended that she delay any injections until we determined whether PT was helping her to recover.  You can read my summary of some recent research2 on this topic below in the footnote* below, but here is a spoiler: “The physical therapy group had less use of pain and anti-inflammatory medicines, and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids)”.

Gloria returned 3 more times, for a total of 5 visits over a period of 5months. At discharge, she felt 98% better. Her only pain was occasional and was in a motion that she did not often experience and was not that notable, and will likely resolve as she continues to be active and improve strength.

If you have a problem that has persisted and is keeping you from living your life the way you want, send me a message or give me a call! If you are on the fence about physical therapy due to doubt, or past experience, we offer no-risk FREE screenings where we can meet and I will do some brief examination to determine if I can help you. If I can’t help I provide recommendations on which health professionals you might want to consider seeing.

Footnote:

*We have blogged about tendinopathy before, and the research is pretty clear that many of the “quick fixes” don’t address the true issue, or can even be negative. Current physical therapy research does not support the use of traditional treatment such as ultrasound, friction massage, and in some cases stretching (compressive tendinopathy). The research is also against more modern treatment such as assisted soft tissue mobilization (using a metal tool on the tendon to scrape already degenerative tissue!). In medicine, steroid injections have often been used because tendinopathy had been considered an inflammatory problem. However, these injections have not been found to be very effective as tendinopathy is a problem of cellular degeneration due to poor load management. The main degenerative change is to the collagen within tendon cells (We want healthy collagen as it makes tendons stiff so they can withstand load). The reason steroids are not particularly helpful is that when injected, they slow down the turnover (regeneration) of collagen cells. It seems that steroid injections are actually not good for tendons! A recent study2 compared steroid injection with placebo injection or physiotherapy. They found that 1 year following steroid injection patients had worse outcomes than those who had a placebo injection. Those who had the steroid injection were also more likely to have a recurrence of symptoms. The physical therapy group had less use of pain and anti-inflammatory medicines and had the lowest level of recurrence at 1 year (Recurrence of 5% for physical therapy, 20% for placebo injection, and 55% for corticosteroids).

References:

  1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13-19.
  2. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-9.
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From Failed ACL Reconstruction to Podiums and Mountaintops! https://physioworkshsv.com/from-failed-acl-reconstruction-to-podiums-and-mountaintops/ https://physioworkshsv.com/from-failed-acl-reconstruction-to-podiums-and-mountaintops/#respond Tue, 24 Oct 2017 22:31:28 +0000 https://physioworkshsv.com/?p=4315  

2017 Heel and Crank - Number 1 in age group post ACL - way to go Jeremy!

Number 1 in age group – way to go Jeremy!

Do you know someone who has had an injury or surgery and has not fully recovered? Have they been unable to do what they could before, or do the things they want? Sadly, it is my experience that there are many people who are in this boat and have not found a solution. The reason for this is likely to be different in each case, with some assuming it is their lot, or worse being told that the lack of progress was a risk of their surgery.  I have seen many of these people and, with the freedom, my practice at PhysioWorks provides, have been able to step back, review the case holistically, and take a different approach. In many cases, this has helped them to progress further than they had previously, and in the best instances make a full recovery.

In this blog, you will get to hear the story of Jeremy, a 33-year-old who had an ACL tear, surgery, PT, a second surgery, more PT, yet was still unable to get back to the things he loved – running, cycling, hiking, and weight training. When I first saw Jeremy, he was part of the 20% of ACL reconstruction patients who had not returned to sport. Over the course of nine PT appointments, spread over a year, Jeremy has returned to doing all the things he loves, even placing 32nd and making the top of the podium in his age group in his first ever duathlon – the Heel and Crank in April 2017! He then went on to complete the Assault on Mount Mitchell, a 102 mile, 10,000ft ascent!

The video below shows Jeremy’s progression with running. You can really see how his biomechanics have improved over time, making him a stronger, faster runner, with less future injury risk.

 

 

As you read Jeremy’s story, you might wonder about an old injury that has bothered or restricted you – email me about it! I would be happy to listen to your story and explore whether my approach can help you.

 

Completed the 2017 Assault on Mount Mitchell - Go Jeremy! Post ACL rehab success!

Completed the 2017 Assault on Mount Mitchell – Go Jeremy!

 

A More Detailed History:

 

The Injury And Surgery:

Jeremy was an active 33 year old – he cycled, ran, hiked, and rode dirtbikes. Unfortunately, in January of 2014 he came off of his dirtbike and hurt his knee. Examination and MRI revealed an ACL rupture and meniscal tear. Shortly after, he had an ACL reconstruction (ACLR), using the central third of his own patella of the same knee (technical term: patella autograft). This patella tendon tissue over time turns into ligament tissue that very closely matches that of the original. The meniscus was torn in the outer third, in the so called red-zone, which meant it was repairable with two anchors. The red zone means there is good blood supply and it will heal, versus a tear in the white zone of the meniscus, which is considered irreparable and  is typically trimmed off. The surgeon must have also found an area of cartilage damage, where the bone was essentially bare, because a microfracture procedure was also performed. Microfracture involves small holes being drilled into the bone to stimulate bleeding, the release of stem cells and subsequent cartilage regrowth.

 

Post Surgery, a second surgery, and post surgery again!

Jeremy followed the typical ACL rehab protocol at another local PT clinic associated with his surgeon. He did well with respect to basic normal activity (i.e. walking, stairs, slopes) and felt good enough to try some hiking that same August. However, following the hike, his pain levels started to increase and he started to have issues getting his knee fully straight, had pain going from sitting to standing, and also pain when walking on slopes. Going hiking at this stage should have been ok if the strength and range of motion is available, so it is likely that one of these was not quite where it needed to be (but I cannot travel back in time and see!). A year after the initial surgery he continued to have issues, so he underwent a scope of the knee to remove scar tissue. He did therapy as recommended by the doctor, saw some improvement, but still could not return to running or sports – meaning at that time, he was part of the 20% of people who had not returned to some form of sport.

I’ve written before about ACL injuries (here and here) because we’ve seen such a dramatic increase in them in youth sports in recent years, and because the sad fact is that many athletes do not make a full recovery after ACL rupture. Typically, recovery back to normal activity (walking, stairs, etc) is fairly uneventful. This is normally as far as your insurance-covered PT treatment will take you. But return to sport after ACL reconstruction is challenging – even many professional athletes don’t make it back to their pre-injury performance. Statistics show that about 80% of ACLR patients return to some form of sport, 65% return to the same sporting level and only 55% return to sport at a competitive level within 1-2 YEARS post ACLR1

 

Two Years Later – Jeremy’s Assessment at PhysioWorks

Jeremy was unwilling to accept this outcome, so in April 2016, he contacted me and came to the clinic for an evaluation. As I do with every patient, we began with me listening to Jeremy’s story and understanding his goals and frustrations with his current lack of progress. In fact, some of this process started before Jeremy walked into my clinic – my online paperwork system meant that I had already read about his history and goals before we met for his first appointment, and I could immediately zero in on the key issues, ask clarifying questions, and quickly develop an in-depth understanding of not only where Jeremy was at that moment, but the entire history of his injury and recovery to date. Sometimes patients can become frustrated as they move from provider to provider, having to tell their story again and again, and over time the accuracy of the story they tell may reduce. This can be a big problem in an on-going case like Jeremy’s, where small clues about what was going on even before an injury can really be helpful in understanding the big picture and the underlying issues that will need to be corrected for a full recovery to be possible. Taking the time to understand a patient’s issues and where they’re at in terms of processing and dealing with injury, pain, and loss of function is incredibly important. For this reason, it is not uncommon that half of my 45-minute examination time is spent talking to the patient. In many cases you can do most of your diagnosis by talking, and the physical examination is just a confirmation. I find that this approach is particularly helpful for people with complex problems, and they often tell me they have not really felt anyone has truly listened to them before. (As a healthcare professional, hearing this always makes me sad!)

In Jeremy’s case, this approach led not only to understanding the history of his injury, but also of his history of chronic low back pain since 2003 that could have some connection to his poor recovery. The persistence of back pain had been diagnosed as coming from his sacroiliac joint (SIJ). He would have flare ups from time to time, which were significant and disabling, even affecting his confidence in exercising and doing what he wanted to do in the gym or in rehab.

During our initial conversation, I told Jeremy the findings from a couple of questionnaires I had him complete. These questionnaires are validated to help understand the full effects that ACL injury can place on an individual, and both showed that there was a significant affect on not only his sporting interest, but his life in general. One showed that instead of what should be a normal 0%, he had a 44% on the emotion score. This does not mean he was a blubbering wreck! Instead in the ACL literature, emotional aspects of ACL injury can include feelings of loss, physical dependency on others, fear of re-injury, lack of self-confidence, and mood swings2. Often people are unaware of the impact that such an injury and surgery can have. Thankfully, Jeremy was not willing to accept where he was at; he realized the issues it could have for his lifestyle and he wanted to make progress.

Only once I had a clear understanding of Jeremy’s history and goals did we move on to physical examination. My primary findings were gluteal (butt) weakness, quad tightness on the injured side, and persistent loss of muscle mass and control/balance in the leg that was injured. He also still had soreness at the patella tendon incision, indicating that there was a tendonapathy, even two years past the surgery!

All of these issues could be successfully addressed through a tailored home exercise program. When possible, this is always my preference, as it requires the patient to be an active participant in their recovery, as opposed to potentially becoming dependent on passive “hands-on” therapy treatments like mobilizations, manipulations, stimulation, etc. Creating a situation of dependence is not something we wish for and is particularly harmful when there is a persisting problem where the individual is desperate for a solution. Also, I knew that with a case like Jeremy’s, the recovery would likely stretch over months, even a year, rather than weeks. Prescribing the right therapeutic exercises would allow his therapy appointments to be spaced out rather than every few days, keeping the treatment affordable and not overly intrusive into his time and life. I expected each session would consist of progression of exercises and tapering of visits. Jeremy and I discussed that in order to be successful, he would have to work hard and be committed. This may sound like a no-brainer, but to commit to changing how you do things for an extended period and changing habits can be difficult! During the last 15-minutes of our hour-long evaluation, I walked Jeremy through about half a dozen exercises. I explained how to progress them over the next couple of weeks and to contact me if he had concerns. Instructions for the exercises were given via an online portal which had videos, photographs, and suggested ranges of repetitions and sets. (Click this link to see what this looks like!) This form of delivery has proven to be popular and helpful as many patients have told me about their frustration of being given stick figure drawings or simple picture print-out that they then lose or do not understand.

 

Jeremy’s progress:

I will not detail each of the follow ups, but Jeremy saw me a further eight visits through March of 2017. The chart below gives some highlights of the visits:

First three visits post ACL

At this point Jeremy was very happy with the progress and decided to write us a review! However, he had more goals he wanted to meet, including comfort on century bike rides and running. Our rehab continued along the original plan.

Further visits post ACL and return to running and cycling

The Final Result!

As you can see, at his last appointment (March 2017) Jeremy had made excellent progress. He had met all of his goals and has a very good approach for continuing to move forward. He is also very pleased that his back pain has not flared up recently which he would have expected it to do so. None of his sporting interests require a significant change in his plan, but I feel confident given his strength and previous hop testing that he should be able to do these as long as they are approached sensibly (i.e. the way all people should approach a new sport – gradually!)

As we already showed in the summary Jeremy was able to place 32nd out of 295 people in his first ever duathlon and then was able to make a a 102 mile, 10,000ft mountain ascent on a bike! He does not feel any particular restriction in his activity and is able to pick and chose what he wants to do rather than having his life dictated by an old injury.

Have you been struggling with an injury, or from a surgery that you cannot get over? Do you need a different and more tailored approach? Send me an email if you have questions about your problem; I would love to help you!

 

References:

  1. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-52.
  2. Olofsson L, Fjellman-Wiklund A, & Soderman K. From loss towards restoration: Experiences from anterior cruciate ligament injury. Advances in Physiotherapy. 2010; 12: 50- 57.
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Up close and personal: Total knee replacement in the US vs. the UK https://physioworkshsv.com/up-close-and-personal-total-knee-replacement-in-the-us-vs-the-uk/ https://physioworkshsv.com/up-close-and-personal-total-knee-replacement-in-the-us-vs-the-uk/#respond Thu, 19 Oct 2017 16:02:17 +0000 https://physioworkshsv.com/?p=4302 knee replacement components

This is what goes in the knee!

One month ago, I had the opportunity to return home to England for a week to help my mom as she recovered from knee replacement. Of course, I was concerned (as surely any son would be!) about her undergoing major surgery, but my concern was also based on seeing a variety of outcomes for people after knee replacement. I wanted to go and make sure everything went well; I joked with her that I was going to make sure she was behaving herself!

From hearing the experience of friends and family, you may have mixed opinions about total knee replacements (TKR/TKA). They are typically a good surgery, but I have seen some that recover in a very straightforward manner and others that really struggle. TKA should be undertaken when quality-of-life is being significantly affected by pain, difficulty in function, and has not improved with rehabilitation. This was certainly the case for my mum. When someone decides to have a TKA they are expecting a significant improvement in quality-of-life. Many find this, but imagine what it would be like to struggle to get the knee moving after surgery, or have ongoing pain. I have seen patients like this and it feels to them like they have swapped one problem for another. There are a myriad of reasons for this from medical complications, surgical errors, to poor rehab and patient compliance. My goal was to make sure Mum did not struggle and was able to reap the rewards I know are possible with TKA.

From the media, most of you will know something about the health system in the UK; It is a socialized system called the National Health Service (NHS). Getting a TKA in this system can take a long time (12 months +), which is not much fun when you are in pain. Fortunately, following retirement, my parents had maintained private health insurance for this very reason and were able to schedule surgery when they wanted. So, her experience in scheduling the surgery was the same as someone in the US. I’ve lived in the US for 10-years, but before that I lived and worked in the UK both in the NHS and private practice, so am familiar with the typical post-surgical treatment of a TKA in each country and setting. In the US, patients would typically experience daily physical therapy while in the hospital and then would start outpatient or home health therapy 2-3 x a week for anywhere from 4-8 weeks or more. This has become the norm and is relatively encouraged by the way insurance and reimbursement works. However, there is no evidence to show that this approach to rehab works any better than others. Obviously, it has been a while since I worked in the UK, but watching Mum’s rehab reminded me how different approaches can work and explains the beliefs I have on rehab and why I have structured my practice the way I have.

Traveling to London

The long process of international travel, but well worth it 🙂

 

After 20 hours of traveling, I arrived in London Heathrow, picked up the rental car (think stick shift and the other side of the road) and drove the 60 minutes to the hospital. I arrived at the hospital the day after her surgery (I spoke with her the day of the surgery via wifi while transatlantic! Pretty cool!). She was doing well, sitting up in the bedside chair, and the biggest problem she was having was some nausea. She had PT daily, working on a simple set of exercises and her mobility. She left the hospital three days after the surgery having proven that she could walk with a pair of crutches and go up and down the stairs. She was discharged with a set of instructions, including exercises, and she was then at home on her own with Dad and I for a period of a week and a half until she started her first therapy appointment. During that period we encouraged her to do her exercises and brought her ice when she wanted it. I did try to see if I could help her move her knee, but she couldn’t relax enough to make it worthwhile so I left the work to her! Essentially, we were glorified cheerleaders. I dovetailed with a visit from my sister (Also a PT!) who stayed with them for a few days, and a week and a half after discharge she went for her first outpatient PT appointment. The therapist was impressed with how she was doing.  They worked a little on improving her walking gait using one crutch and gave her a progression of her exercises. She continued to work at home and had a follow-up PT appointment two weeks later. When I spoke to her today, Oct 17th 2017, four weeks after the surgery, my sister had visited with her family (Easier for them to visit from Scotland!) and Mum had walked 1.5 miles with her one crutch! I am obviously a little biased, but I think that her progress has been exceptional!

 

Mum doing great following knee replacement

My Mum doing great after surgery. First trip out! Also, a rare chance for us all to be together as we live so far away!

 

Obviously, this is only one case, so it does not prove that one approach is superior to another. However, having worked in both countries, I do not feel like I have seen more superior results in the US. The difference in care in the UK, in this case, is not due to the socialized healthcare as some might claim; for example, all of Mum’s care was at a private hospital. (I do acknowledge there is room for improvement in both systems and you are always welcome to ask my opinion!) Instead, the philosophy is different. In the US, most people’s experience of going for PT following TKA involves 2-3 time a week of the therapist making them do the repetitious exercises, the therapist bending their knee, and some electric stimulation and some form of ice therapy. There is a lot of hand-holding and, to be honest, I see overtreatment which can have negative consequences. I see patients who have been pushed too hard by PTs who are worried about a stiff knee, but the aggressive therapy creates pain that itself leads to stiffness! In the UK, the more spaced out appointments ask the patients to be more responsible for their progress. Certainly, there is some risk with this approach when a patient does not report concerns/problems. Even though I am aware of this risk, I still favor an approach that is more similar to the UK approach with all of my patients, as I believe that my patients are smart, able, and don’t need their hand held all the way through rehab. Many of my patients are busy professionals and do not have the time for multiple visits per week! I make sure that there are adequate ways to communicate with me to reduce the risk of unintended consequences occurring between appointments. I believe that where the patient is more involved, they will see more lasting/resilient results. I will qualify this by saying that everyone is different and some people will want the hand-holding, and I am fine with that initially if it is truly needed. However, I feel it is incumbent upon me, and a professional/ethical responsibility, to promote self-efficacy and self-reliance.

When you have been practicing/working any job for a period of time (in my case 15 years now) you can’t always understand why you do everything the way you do. I have tried as a professional to stay up to date on the latest research and that is the biggest guide to my practice. But, my experiences have also guided me, and mine are quite different from most PTs having worked in two countries, various practice settings, and under two healthcare systems. If you think my approach might be a good fit to help you with any pain, injury, or rehab needs, please do send me a message. You can contact me via email or phone. I am always happy to chat!

 

Image Credits:

  • Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh RA, Arnold MP, Friederich NF. Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?. BMC Musculoskelet Disord. 2010;11:167.
  • Google Maps
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CrossFit – Are You Crazy?! https://physioworkshsv.com/crossfit-are-you-crazy/ https://physioworkshsv.com/crossfit-are-you-crazy/#respond Tue, 03 Oct 2017 20:55:15 +0000 https://physioworkshsv.com/?p=4257 I have recently started doing CrossFit at a local box (CrossFit gym), and from the reaction I’ve received from pretty much everyone I’ve told (including my own wife!), it seems that the first thing many people think of is ‘injury’! I’ve received many admonitions to ‘be careful’, and warnings about CrossFit causing shoulder injuries, knee injuries, back injuries….you get the picture. I have wondered if many of those warning me are thinking, “Surely as a PT you should know better!” Certainly, I have seen and rehabilitated some CrossFit injuries over the years, but as a form of exercise, it can provide a great base for people to enjoy life and perform better in their sports. But is it really true that CrossFit is inherently more dangerous than other sports? If it is, why is that? If it’s not, why is there a perception that it is?

Well, thankfully I’m not going into this blind! A few months ago, I had the fortune of meeting Scott and Lori Bean, owners of CrossFit Nomad. Very quickly I was impressed with the care that Scott and Lori expressed for their members. They want to do everything they reasonably can to keep injuries to a minimum. My focus on injury prevention and risk reduction resonated with them, as well, and so we have agreed to partner together to support each other in our goals! I’m now available to Nomad members at the box several times throughout the week (or anytime by phone/email!) to answer injury-related questions, screen potential injuries, and provide guidance on injury risk reduction. In return, I am working out at Nomad as any other member would, working on improving my own fitness (which I have sadly neglected while raising small kids and starting my own business!). This is really allowing me to truly understand and appreciate CrossFit! I want to tell you a little more about CrossFit Nomad in particular, but first let’s look a little more closely at what CrossFit is, and what the research says about CrossFit and injuries in general.

 

Picture of Andrew Walker, Physical therapist doing box jumpat CrossFit

Hard work, great fun, seeing results!

 

CrossFit – What Is It, and Who Is It For?

CrossFit is a form of cross-training exercise – meaning that it is a mix of cardio and whole-body strength and flexibility training. Many of the exercises are a little unusual or maybe things you wouldn’t have imagined yourself doing (or doing again) – like headstands, rope climbing, jerry-jug carries, sled pushes…along with some more traditional weight lifting moves like squats, clean-and-jerks, dead-lifts, pull-ups….

So maybe you’re thinking – good grief, that stuff was hard in high school, I can’t-do that? Stay with me! One of the great things about CrossFit is that all of the workouts can be scaled to your current ability level – and you will still get a great workout. That said, there is definitely the possibility of injury when you’re starting a new exercise routine, so what is the real injury risk with CrossFit?

CrossFit Injury Compared to Other Sports

A recent systematic review found that CrossFit’s injury rates are lower or comparable to those for Olympic lifting, distance running, track and field, rugby, football, ice hockey, soccer, and gymnastics. With respect to most commonly injured body part, 25% are shoulder, 14.3% and 13.1% were lower back and knee, respectively. The quality of the research available is not of the highest caliber, but is also not the worst!

What can CrossFit do to Keep Injury Rates Reasonable?

The above research noted that it appears that injuries occur more where supervision is not always available to the athlete, or they do not actively seek supervision. I had often heard from CrossFit athletes that some boxes don’t have great supervision and have more injuries. Some boxes and athletes may even wear pain and even injury as a badge of honor! The paper quotes other research showing that in CrossFit males were less likely to seek help from coaches. That Y chromosome and our testosterone do seem to make us a little more likely to plow onwards without such regard for technique and safety. I have seen this in other sports as well, so I feel pretty confident it is not isolated to Crossfit! Even though males are perhaps less likely to seek supervision, perhaps the mark of a good CrossFit box is one where the coach is paying good attention to those who are not seeking it!

CrossFit Nomad’s Approach to Injury Risk Reduction

 

2nd session – I felt this pale after weighted sled pushes! 200lbs x 40yd repeats! Nauseating, but good sweat!#crossfit…

Posted by PhysioWorks, Sports and Wellness, Inc on Tuesday, August 29, 2017

 

If supervision is key to reducing CrossFit injuries, then Nomad is definitely on the right track. Each new member attends 3-6 private personal training sessions, where you learn the basics of the various techniques employed in CrossFit workouts (or “WoDs” – workout-of-the-day). The focus of these sessions is technique rather than any weight or achievement. (Though, I can attest that they are still really good workouts – I was drenched with sweat from head-to-toe after each one!) I really enjoyed the personal training sessions as although I was broadly familiar with CrossFit I did not know all of the different exercises. So before you ever go to a regular workout session, you are laying a good knowledge foundation to be able to safely progress.

 

Now that I’m going to the regular WoD classes, I continue to be impressed with all the coaches and their attention to detail. The coach who is leading the workout is constantly keeping an eye out on everyone’s form (not doing the workout themselves!). Also, the coaches themselves come to classes for their own fitness and I have noticed them helping even when it is not their class. As a male, I acknowledge that perhaps I am slightly more likely to plow onwards even when wrong, so I have been happy to see that I have received coaching input both when I have looked for it and when I have not! In the past, my natural competitiveness has caused me some injuries, so I am glad that although there is the encouragement to perform and better myself, there is no push for me to do stuff I am not comfortable with.

Exercise for Everyone!

 

 

Overall, I’ve found working out at CrossFit Nomad to be a great experience of challenging workouts and a fun community. If you’re looking for a new way to get in shape and have fun, with a little more variety than your typical “weekend warrior” sports, I would encourage you to check out CrossFit. In fact, whether your thing is running, golf, tennis, soccer, softball, CrossFit is a great way to improve your strength base and improve at your primary sport. Whatever your reasons for starting, just make sure the box you’re at is providing you adequate guidance as you learn the workouts, and don’t push through pain – give me a call or schedule a free injury screening if you have concerns. My experience so far makes me excited to be doing CrossFit and I look forward to seeing where it takes me!

 

Reference:

Klimek C, Ashbeck C, Brook AJ, Durall C. Are Injuries More Common with Crossfit Training than other Forms of Exercise?. J Sport Rehabil. 2017;:1-10.

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Fighting For Your Goals https://physioworkshsv.com/fighting-for-your-goals/ https://physioworkshsv.com/fighting-for-your-goals/#respond Wed, 13 Sep 2017 20:59:34 +0000 https://physioworkshsv.com/?p=4232 What brings you to see me?

One of the first things I ask a current or potential patient is “what brings you to see me?”. People often say what they think I want to hear (pain, stiffness, etc), but the question is aimed at teasing out a much broader answer. What are their goals? How is life is being affected? What do they want to achieve? More than feelings of pain, or stiffness, these are often what our patients really care about, but how often are they given the opportunity to express themselves? Taking time to understand the patient’s true goals ensures that we don’t get to the end of the plan of care with me thinking I am great because they have no pain, while the patient is frustrated because they can still not pick up their grandson, play ball, or whatever the case may be. Asking this question gives us the opportunity for true success! Sometimes the goals of my patients are ambitious and may take significant time to achieve. But, as long as they are realistic, we will discuss how long they might take to achieve and what interim goals we can set to gauge progress. Today’s blog is an example of how understanding my client’s true goals made all the difference in his treatment and outcome.

Pearson’s Story

 

When Pearson came to see me he was 23, had a small lawncare company, and looked like a fit, well-built, and healthy guy. However, he actually was very frustrated because of a long history of shoulder problems that were stopping him from confidently working out his upper body and pursuing his passion of boxing and MMA. Six years ago, he suffered a dislocation of his shoulder. Although the joint spontaneously relocated, he had ongoing pain and feelings of instability. Three years went by, and he went to an orthopedic surgeon – MRI showed a labral tear and a Hills Sach lesion (a small divot in the cartilage on the humeral head). He underwent a surgical repair, followed up with physical therapy, but he continued to have the same problems. I first saw him over a year following the surgery and he was still struggling with the same symptoms. He had returned to the surgeon, but he found visits were relatively short, without any real answer, until they eventually said he had probably torn something else or damaged the initial repair. They wanted to get another MRI and expected him to need another surgery. Given his experience thus far, Pearson was understandably reluctant to go for another surgery. He decided to try something different and reached out to me.

One of the first things that was very evident was that he desperately wanted to get back to MMA/Boxing and was not so concerned with a little pain. However, he was also concerned about causing additional damage to his shoulder and the potential long-term consequences for his future health. This was a perfect segway to discussing his beliefs about pain, how he could monitor pain, and what the potential was for further injury and success.

 

Pearsons Shoulder Problem

 

Moving into his examination, I found he had full shoulder and elbow range of motion. With him laying on the table, I took hold of his arm and passively moved his shoulder joint and found that he had a lot of mobility into external rotation When I did this, there was a look of apprehension on his face. We call this an “apprehension test”, and it suggests some instability of the shoulder. The test is a slow and careful motion, giving a sensation of instability, but in real life, a quick and forceful movement in that direction at the very least might be painful and concerning, but could also cause subluxation or dislocation. The test has an additional portion where I put my hand on the front of the joint and gently push down, providing a relocating force. The relocation portion of the test removed the pain. I then tested shoulder strength and found he was significantly weak in flexion and external rotation of the shoulder. This is quite a helpful finding as we now know that two of the rotator cuff muscles, the supraspinatus, and infraspinatus, should be very active in these two movements. Weakness in these two muscles could explain some if not all of the instability, as the major job of the rotator cuff is to provide stability to the shoulder joint. So I was able to explain that it is entirely possible that the instability he had been experiencing was more likely due to weakness in the rotator cuff than a new or old labrum tear that needs more surgery. I  learned that Pearson did not feel his rehab had gone well prior to or subsequent to surgery, partly due to his attitude at that time, and also due to his experience of in-network physical therapy. As I asked questions about his rehab, it was very apparent that it had never stressed him to the level that he needed to return to boxing and meet his goals.

Given all of this information, I was able to formulate a hypothesis of why Pearson had continued to struggle with shoulder problems – he had weakness in his rotator cuff muscles. I also knew there was a possibility that he could have a labrum or rotator cuff tear, but even if he had a scan showing a tear, research shows that surgery is not necessarily required. I discussed all of this with him and explained that we needed to load the shoulder to strengthen the rotator cuff and build load tolerance to the activities he wanted to do. I instructed him in a simple set of strengthening exercises, provided him with electronic instructions at the PhysioWorks portal, and booked him a follow-up three weeks later. If you have done PT before you may be used to 2-3 x a week, but in my opinion, this is typically not needed. In Pearson’s case, he had been struggling with this injury for several years, and he needed time to reverse the muscle loss. I made sure he had all the tools and information he needed to make progress during those three weeks and kept in touch via phone and text in-between appointments.

 

Pearsons Shoulder Success!

 

After the evaluation, Pearson came for a total of four follow-ups over a five month period. At each visit, we reassessed and progressed the loading exercises. We saw progress at each appointment, and after the second follow-up, we started to add exercises that mimicked boxing and MMA motions (e.g. grappling). The feeling of instability went away, and he was able to get back into training at the boxing gym. Progress wasn’t always a linear progression with each day being a little better – there were some very good days, average days and even some days where it felt like things backslid. However, the overall trend was progression month on month. At the beginning of the year Pearson was in the process of moving out of state, so we held off on any visits and he would contact me when back in town for a period. At the beginning of June, I got a call asking if I would be able to meet him in the boxing gym. One of the great flexibilities my practice brings is the ability to go outside of the clinic and see athletes or workers in their environment, so I was happy to go! I went to Rocket City Rocks Boxing Gym and had the opportunity to review his shoulder and then watch him workout and then spar. His shoulder felt solid and above all, he was able to hit hard. A year before he came to me with a shoulder that felt fragile, and now he had confidence. There were still a couple of areas that felt weak, and we discussed that he just needed to continue to build strength and build load tolerance in those positions. I was great to see Pearson enjoying the sport he is so passionate about! His dream is to take it to a higher level, even to go pro, and his coaches say he has a shot at it! I will be cheering for him all the way!

 

We can help you:

 

If you have a goal that is unmet, an injury that is still an issue, or a surgery that has not given you the results you want, give me a call or an email. I would love to help you!

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