Non-contact based knee injuries are common and preventable during youth, collegiate, and recreational sports participation.   You may ask, “How can I reduce my risk of knee injury?”   The short answer is through focused strength and conditioning.  And you may also be wondering, “Am I at risk for this type of injury?”

An example of a non-contact knee injury is when an athlete lands with poor knee control then twists in the knee in such a way that the anterior cruciate ligament (ACL) is sprained or torn.  Simply put, these injuries are characterized as a plant and twist mechanism of injury.   Females are at a higher risk than males due to inherent alignment differences.  Additionally, decreased balance, decreased lower extremity flexibility (i.e. tight IT Bands), and weak leg strength put you at a higher risk of non-contact knee injuries.

As mentioned above, strength and conditioning is the short answer to the question of injury prevention, however, other steps are pivotal in this process:

1.  Assessment – In the ideal world an athletic trainer, physical therapist, or skilled sports medicine professional should perform a biomechanical, strength, flexibility, and functional assessment.  However, this is not always possible.  One way to perform a self-assessment is as follows: perform squats, lunges, and single leg balance exercises in front of the mirror.  If these are challenging, you note weakness on one side, or your knees go out to the side or in during the movements, then you are at a higher risk of knee injury.

2.  Program Development – Once the assessment takes place, it will be important to pick 3-5 findings from the assessment to work on through the exercise program.  Trial and error is part of the process.  It is important to find exercises that are challenging, but successful performance of the exercise is possible (see the examples below).

3.  Exercise Program – Three typical exercises that can be performed in an effort to prevent knee injuries are band walks, single leg balance on an unstable surface, and squat variations.   See Dr. Looney’s blog on “Runners’ Supplemental Six Pack” for more information about these exercises.  Please be advised many other exercises can be performed with multiple variations.  Exercises of this nature are used often in reducing existing knee pain too.

If you are currently experiencing knee pain and would like to reduce risk for further injury, consider scheduling an appointment with a physical therapist.

Dr. Merson is a Physical Therapist at Boston Sports Medicine

What do you mean stop running?! Working out?  I’m an active person!  It will drive me absolutely bonkers to rest and do nothing!  Ok, admit it.  How many of you out there have avoided seeking treatment for those aches and pains out of fear that we will tell you to stop doing all things active and fun?

Believe it or not, the physical therapist’s goal is not to turn you into a couch potato!  In fact, it’s the exact opposite.  One of the most rewarding things for me is when I receive an email or card from a past patient telling me how excited they are about their recent race time or competition. Trust me, getting you back on your feet and back in the game is definitely my goal.

Ok, so how?  It’s true that in recovery sometimes we need to take a step back in order to move forward.  I believe in looking at the total picture.  That “picture” is not only made up of my goals and objectives, but also your goals and objectives.  My job is to work with you to evaluate areas that need improvement and areas that are not working as they should.  I look to address the injured area, but also look to find the cause or source of the pain – the “why is this happening” factor.  In most cases, I find the use of hands-on treatment to optimize tissue healing and restoration, combined with the use of modalities and a custom-tailored treatment plan is most effective.  This is not all that different from most other physical therapists’ line of thinking.

Unfortunately, I find many are scared to reintroduce the activity that caused the injury.  I believe this is often the missing link to full recovery.  Research tells us that newly healed tissue needs to be exposed to gradual increases in stress to adapt and prepare the tissue to be strong enough to withstand forces generated from activity.  So wouldn’t it make sense that gradual, re-introduction of sport specific activity (of course, under the guidance of a physical therapist) during the recovery phase be ideal?  I think so.

So, the key is not always to stop the activity, but to reduce and gradually return to where you left off.  Now the exact amount of reduction is obviously going to depend on the severity of injury.  Would I be lying if I told you that I never tell a patient they need to stop running for a little bit? Yes.  However, I can tell you that most of my patients continue some sort of fitness throughout therapy, and many of them don’t stop their activity at all!

I consider myself lucky to work with such a fun, active population and with a team of great practitioners.  So if you find that you have questions or an annoying pain that’s lingering, call a PT.  Contact us before it becomes a bigger issue.  It may be something that we can quickly address and get you back on your feet and in the game.

Dr. Looney is a Physical Therapist at Boston Sports Medicine

]]> http://bostonsportsmed.com/active-recover/feed/ 0 http://bostonsportsmed.com/get-health/ http://bostonsportsmed.com/get-health/#comments Fri, 27 Jan 2012 08:00:51 +0000 admin http://bostonsportsmed.com/?p=1483 by Katherine Hartsell, PTA

The glittery dust of New Year celebrations has long settled, and for many of us, lofty resolutions have already been buried underneath the winter snow, the business of life, and by the very habits that we were hoping to transform. Two months into 2012, new goals and pursuits, however committed we were to them on January 1^st, begin to slip off their pedestals and attending to them might feel like a burden. A recent health article in Time Magazine confirms that by mid-February, the New Year’s gym surge crashes and that only 10% of well-intentioned folks actually achieve their new healthy visions. Such statistics illustrate that the “old self” can’t just magically change with the calendar year. In a longing to be new and improved, we miss the step of seeing ourselves at our starting point and we feel defeated when greeted by the inevitable obstacles that are akin to any process of change.

When patients come to Boston Sports Medicine, an initial evaluation is conducted by his or her primary physical therapist. This assessment is crucial because it identifies the all important starting point. Goals are then developed and a plan of action is put into place. Fluctuations, improvements, and setbacks are all acknowledged and a constant assessment supports the process of change.  In a similar way, starting points are also highlighted in the yoga classes I teach. I encourage students to spend the first few moments of class observing their baseline.  Without this step, I have found that students are lost even before they begin.  The most common scenario is a student rushing into class late, numb to their anxiety and unaware of the shallowness of their breath. They enthusiastically plunge into the practice, and ten minutes later, they are completely wiped out. Conversely, when students take a moment to observe their starting point, they can shape their practice accordingly (perhaps using a slower pace or a more conservative effort), while still working on longer term goals – a particular pose, a deeper breath, a stronger core, or a more relaxed brain. At the end of class, the process begins again- a quiet moment to observe, followed by a recommitment to intention.

The New Year is of course a popular time to set new goals, but February has proven to be a popular time to abandon them. However, we never have to wait until the next year to recommit to something that we want to bring to our lives – be it a regular exercise program or a healthier eating pattern. Both physical therapy and yoga work well because they acknowledge that obstacles will show up and that the opportunity to begin again, shift the approach, or change the plan is always there. When you find yourself on a plateau, stuck in rut, or sliding down a slope of habit, give yourself a break, because this is the landscape that often accompanies change.  After your break, invite yourself to begin once more. Happy New Year. Again.

Katherine Hartsell is a Physical Therapy Assistant at Boston Sports Medicine

Over the past several years there has been quite a discussion in the medical community regarding glucosamine and chondroitin sulfate supplements. I hear so many patients talking about whether or not to take the supplement and asking me what they should do. So here’s the low down on the supplements and their progress in clinical trials.

Let’s start with a short overview of the arthritic process in discussion as well as the basics of glucosamine and chondroitin themselves. These supplements are being studied in the improvement of pain, joint space integrity and cartilage quality of major joints such as the knee and hip in cases of osteoarthritis. Glucosamine is an amino sugar found in and around the cartilage cells. The body produces glucosamine and sends it to connective tissue and areas of the body populated with cartilage.

Chondroitin is a separate substance from glucosamine, they are often bundled together for purpose of supplementation but can also be purchased separately. Chondroitin sulfate in the simpliest terms is a chain of types of sugars, the technical term is glycosaminoglycan. It functions as a structural component of cartilage, helping to resist compression forces, which would narrow the joint spaces. It is manufactered from sources such as shark and cow cartilage.

The theory behind taking these supplements and frequently combining them together is that the body will be more apt to build and repair cartilage if more of these building blocks are available for use.

One of the most recent and well-referenced studies was performed by a branch of the National Institute of Health known as the National Center for Alternative and Complementary Medicine. This study utilized a large sample size; pitted placebo vs celecoxib vs glucosamine with chondroitin added supplement. The glucosamine with chondroitin supplement and supply used throughout the study was assessed by the FDA to ensure purity, dosage, quality and consistency. Joint changes were monitored through the study with X-rays. The results stated that glucosamine and chondroitin did not improve joint integrity or subjective pain with any statistical significance and actually equaled the placebo results. The study did indicate that the length of time for dosing was in months, a more long-term study may indicate statistical significance. Other reputable studies done recently had a smaller sample size than this one and often did not use adequate controls such as FDA monitoring of the supplement. I mention the FDA monitoring of this study as an important component as the FDA does NOT regulate supplements of any type.

So, in summary at this time there is no clinical proof that glucosamine and chondroitin can decrease pain and assist in cartilage repair in any joint of the body. There is encouragement in longer-term studies, which are under way. There are also no significant side-effects to taking these supplements, which makes them a safe choice for over the counter use. A typical dosage should be 1200 to 1500 mg daily, in case you decide to try this much-discussed supplement yourself. However, no supplement can take the place of working with your health care provider to eat right, exercise and manage your arthritis in a safe manner tailored to your knees.

As I always say to my patients, “If I could cure arthritis I would have my own private island with a fruity drink and a cabana. Until that time, I can certainly improve where you are at now and teach you how to maintain the best level of function possible.”

Dr. Clark is a Physical Therapist at Boston Sports Medicine

Hundreds of people in Boston and the surrounding towns are handed a prescription for physical therapy (PT) from their doctor each day.  Some may have had PT in the past while others are new to this type of treatment.  Regardless, the first question you should ask yourself is which PT clinic is right for me?

There are a substantial number of outpatient PT clinics in any given area.  It is helpful if you understand what to expect in physical therapy and determine what your goals are beforehand.  Ask yourself, what could make or break a clinic for you?  Is it the therapist’s level of experience; the time the therapist spends with you each visit; the accessibility of the clinic, or perhaps the type of equipment the clinic has available for your rehab?  For outpatient PT, many doctors have a preferred provider list of clinics in your area.   You can take that information and go online to find ratings of each of the clinics and determine if thay have expertise in treating your particular injury.   If your doctor doesn’t have a list and is unable to recommend a specific clinic, you can do your own search using Google and other search engines.  The best recommendation can come through a friend who has past experience with a Physical Therapist.  When you find a clinic that you believe suits your needs, you should call and inquire into how they can cater to your needs.  A site visit is most always welcomed.

Find out what you are comfortable with and how far the clinic will go in making you comfortable.  If you have a difficult time walking and moving around independently you may want to see how many patients each therapist sees per hour.  If a therapist is treating more than two patients at once it may not be the place for you. Are you uncomfortable being treated or doing exercise in an open area around other patients?  If not, you can ask if they have private treatment rooms available.  Ask how long a patient typically waits before being seen.

Are you a very active individual with a certain goal in mind?  Do the therapists specialize in treating athletes?  Find out what equipment is available that may be necessary for your recovery.  Most PT clinics have all the standard modalities for pain/swelling reduction and function but some clinics are very small and resources for higher level strength and agility are limited.  Others can be set in a very large area, possibly even a gym with greater variety for treatment.

On the contrary the larger clinics typically have more therapists working at the same time, therefore creating a more hectic environment.  If you are looking for a personalized and quiet atmosphere, you may want to find a smaller clinic where only 2 or 3 therapists work in the office.

If you’re still not sure, the next step would be to visit the actual clinic and check it out for yourself.  You can call and set up a time to stop by at your convenience for a site visit and to meet the staff.  You can take a brief tour, chat with the therapists, and see the clinic in operation.  This will give you a good sense if it is right for you.

Trust your gut, don’t hesitate to ask questions , be picky, and do your research.  In the end it will be worth it when you’re back to being yourself!  They are all somewhat different, but there is a clinic out there that is right for you.

Stacy Choquette is a Physical Therapy Assistant at Boston Sports Medicine

Running can be both a strenuous sport and pleasurable pastime for individuals of all ages. Many say there are few substitutes comparable to the challenge or even the “high” one can attain from running, but research offers an alternative which is not only safer, but equally as taxing on the cardiovascular system.

Walking on an inclined treadmill can be the aerobic equivalent to running. Using a 10% incline at 4.5 mph as a goal, individuals will not only challenge the the heart, but preserve the hip and knee joints as the program carries a low injury risk. Beginners to this program should start at low levels of intensity and progress the program as tolerated. Beginning at a 5% incline at 3.0mph is a good place to start, and over time you will find that you can work your way up to the goal of the 10% incline at 4.5mph. You can also begin by trying the workout for 10 – 15 minutes, and eventually try to hit the 30 minute goal. It is possible to work at 85% of your maximum heart rate and burn hundreds of calories at this intensity level.

In addition, the protocol is great for patients who have either acute or chronic low back pain, as back pathologies often inhibit one’s ability to run. Adding an incline to the treadmill will shift the body’s center of gravity forward, calling upon the spine extensors to keep the body erect.  Over time, this will strengthen the muscles of the back and improve their endurance. Adding this workout to your life can potentially reduce back pain you may experience from long car trips or standing for several hours at work because it prevents the back muscles from fatiguing quickly.

Furthermore, the inclined treadmill workout is an alternative for individuals with plantar fasciitis, as the incline limits or softens the heel strike. This will not only decrease pain, but provide a stretch to the Achilles tendon.

Personally, I add this program into my life 3-4x/ week to stay healthy.  After 4 knee surgeries in high school and with a current meniscal tear, I find myself still unable to run on a treadmill and not challenged enough with an elliptical. I now use this inclined walking protocol to stay in shape and keep weight off. Best of all, I can do it all without any knee pain.

Remember to consult your doctor before engaging in strenuous physical activity. Give it a try and walk your way to a healthier life!

Dr. Barrett is a Physical Therapist at Boston Sports Medicine

The majority of patients I see with neck pain have jobs that require them to sit in front of computers all day.  Holding a static position in poor postural alignment for hours on end at your workstation can wreak havoc on the structures in your cervical spine. Your head, which weighs 8-12 pounds, sits atop your spinal column with the forces of gravity pulling down on it all day. Think of what this can do to the support structures underneath it.

The position of your low back is directly connected to neck alignment. Try this: sit up straight right now. If you did it correctly, the first thing that happened was that your hips rolled forward and you created a small arch in your low back known as lumbar lordosis. Then your chest came up and your shoulders rolled back, and lastly your head followed, creating another small but important backward arch in your neck known as cervical lordosis (loss of this lordosis causes extra tension on the spinal cord).  Your chin should not protrude forward or be tucked down. You should be looking straight ahead. Seated posture starts from the bottom up, literally. Therefore, a good desk chair with rigid lumbar support is essential. If you don’t have one, get one. Even if your company can’t pay for it, you should spring for a new chair. How much money did you spend on your dining room furniture? On your living room furniture? How many hours per day do you spend sitting in that furniture? And how many hours per day do you spend sitting in your desk chair at work? Now do you think it’s worth spending money on your desk chair? If you still can’t afford a new chair, add-on lumbar support cushions, whether makeshift or prefab, are a decent short term solution, but they might shorten seat depth by too much and throw alignment off, so choose wisely.

Arm position at your desk is of utmost importance if you have neck pain. The weight of your arm can cause traction on the brachial plexus, a network of nerves that sprouts from the cervical spine and branches off in different directions down the shoulder, elbow, forearm, and eventually into the hand. When your shoulders are slightly shrugged up, they begin to cause upward compression on the cervical spine. When they hang down, they apply traction on the nerves. Ideally, your elbows should be bent at 90 degrees and your wrists should be straight on your keyboard, not cocked upward or bent downward. Your mouse should be even with the keyboard—don’t let it get away from you! You do not want to reach forward for the mouse. Laptop computers are horrible for people with neck pain. They force you to look like a praying mantis—this is not good posture for the human body! If you work on a laptop for more than 20 minutes at a time, you should get a peripheral mouse and a peripheral keyboard and only use the laptop monitor, set up higher on a desk so that the monitor is at eye level, essentially mimicking a desktop computer.

If you spend 15% or more of your time at work on the phone, you need to have a headset. Shoulder rests do not cut it. Whether they are short phone calls or long ones, each time you squeeze the phone between your ear and shoulder, you side bend your neck, compressing one side of the cervical spine. If your company can’t pay for a headset, buy one. You must have the right tool for the job. If you were a carpenter and you needed to bang nails into the wall and you didn’t have a hammer, would you use a rock? No. You would go get a hammer. So get a headset!

For those of you who work on two computer monitors simultaneously, I recommend placing those monitors as close together as possible, and when switching back and forth between the two, swivel your chair slightly instead of turning your head.

Click the link for a diagram of correct seated posture for computer work.

If you are still unsure about your workstation, use your cell phone camera and have a coworker snap a side view photo of you seated at your desk, and bring it to your Physical Therapist.

Dr. Ullman is a Physical Therapist at Boston Sports Medicine

Since I have the opportunity to work with such an active population of physical therapy clients, an issue that continuously surfaces for me is that of recovery.  Over and over again, patients come in with an injury and their first response is, “I didn’t want to come in because I knew you would tell me not to run/bike/row, etc.”

When an athlete ends up at physical therapy it is most likely due to pain and associated symptoms such as swelling and lack of motion.  This pain often leads to the inability to perform a function.  This function is often a sport.  For most athletes, the inability to participate in this sport is what has most likely led them to the office.

Pain is your body’s way of telling you that something is wrong.  Pain receptors let us know that we are doing harm and we should stop the activity that is causing it.  As an example, imagine if you put your hand on the stove burner and you didn’t feel pain?  You would have no way of knowing to quickly retract your hand because you were doing your body harm?  Pain is a defense mechanism, and it is a great one.  It is a mechanism that should not be ignored.  Without it we would be in big trouble.

A client should think of their physical therapist as an ally in the process of return to activity. Being an athlete myself, I understand how difficult it is to stop the exercise you enjoy doing.  Many people are training for competitions, some exercise for stress relief and to stay in shape.  This exercise becomes very important both physically and mentally to the client, and he/she doesn’t want to be told to stop.

When in this situation with a patient, I find it is very important to let the patient know that I understand the situation, have been there before, and my primary goal is to get them back doing what they want to do.  Often this process involves rest.  Not rest forever; not never returning to the beloved activity; but temporary rest to let the body heal and recover, a process that it wants to do naturally.

Again, the physical therapist is your friend in this quest, not your foe.  With rest, the proper stretching, strengthening, modalities, and manual work you will be back doing the activity you enjoy.  Being patient from the start will get you back to where you want to be much faster than fighting with a body that needs rest and recovery.

 I often tell my patients that pain free alternative exercise is ok.  For example, the elliptical machine vs. running.  One also must keep in mind that when returning to activity your body must be eased back in a pain free manner.  For instance, a cyclist that takes 3-4 weeks off to rehab a knee injury, should not go back to cycling at the same volume and intensity as she was riding before the injury.   A good physical therapist will work with the athlete to provide a protocol for safe return to activity with the proper amount of rest and recovery.

In summary, pain is your body’s way of letting you know something is wrong.  It is a defense mechanism that is very important.  Quite often when in pain from a given activity, rest and recovery is needed.  A physical therapist will be a partner and ally in your safe return to the activity that you love.  Don’t avoid us, and don’t be scared of us.  We are here to help.

Sara Bresnick is a Physical Therapist at Boston Sports Medicine

Are you a victim of the “Mummy Tummy” or chronic low back pain post-pregancy? As a Physical Therapist, I have come across many postpartum women who have a diastasis recti, or separation of their abdomen. Most women that I have found the separation on were not even aware that they had this deficit. The diastasis recti can also be a cause of low back pain, even after mommies have the lost all their baby weight.

Diastasis recti is a separation of the right and left side of the rectus abdominis muscle. Normally, the left and right sides of the muscle are joined by the linea alba which runs down the middle of the abdomen.  See this link for the image.

Diastasis recti is commonly seen in women due to either pregnancy or obesity. In pregnant or postpartum women the diastasis is caused by the stretching of the rectus abdominus muscle during the growth of the uterus. Women who have experienced multiple pregnancies are much more susceptible to acquiring this defect.

I always test and measure for diastasis recti on all of my female patients that present to physical therapy with low back pain. Most women are unaware that Physical Therapists can help with this condition. There are many exercises, manual techniques, and taping techniques that I use in order to help my patients. With physical therapy treatment, the separation can actually grow back together over time.

There is a relatively easy way for you to check for diastasis recti. Start by lying on your back with your knees and feet flat on the floor. Relax your whole body. Place your fingers (palm facing you) about 3 inches above your belly button. Slowly lift your head, neck, and shoulders off the floor while you press down with your fingertips. If you feel a gap that is more than 1.5 fingers wide then you most likely have a diastasis. Do not be alarmed, this is perfectly normal and can be treated conservatively in physical therapy. There are two other important places to check for diastasis as well with the same procedure; right at your belly button and 3 inches below your belly button.

A lot of women ask, should I wear a belly binder or abdominal wrap to help the muscle grow back together? My answer to this is, YES, this certainly can help. The popular Tupler technique encourages women to wrap or bind their bellies to help draw the muscle back together. In my experience as a Physical Therapist, this wrapping technique is more helpful when there is a larger separation (4 or more fingers). The wrap or binder helps with awareness of your abdominal muscles and to actually support your lower back. HOWEVER, the wrap or binder should NOT be used as a substitute or replacement when exercising the abdominals. The idea here is not to just relax the abdominal muscles and let the wrap or binder do the work. This idea can be better explained by your Physical Therapist.

Women commonly ask, which exercises should I avoid when I have a diastasis recti? You should avoid sit-ups, crunches, twisting, and straight leg raises when you have this deficit. Again, your Physical Therapist can provide further education for certain exercises and activities to avoid.

If you are postpartum OR have been experiencing low back pain try this test on yourself. If you find a diastasis contact a Physical Therapist in order to begin treatment to help correct this deficit.

Dr. Mohns is a Physical Therapist at Boston Sports Medicine

The role of the physical therapist in delivering health care to you is changing! Now most patients, depending on your insurance company, can come directly to the physical therapist (PT) after an injury without a doctor’s visit beforehand. This means you get to the people who are going to help you most more quickly, and we call this direct access. A good article was published recently examining the effects of direct access to the PT, and the abstract can be viewed at http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01324.x/abstract. The study reviewed over 62,000 claims comparing patients in an outpatient setting ages 18-64 who were “self-referred” (came directly to a physical therapist) and “physician-referred” (got a prescription and was sent by a physician to do PT).

 The major findings of the study were that self-referred patients ended up having fewer visits and lower costs of care among all ages, genders, injuries, and severity. Self-referred patients used 86% the number of visits that physician-referred patients used and cost 87% of the physician-referred group. Additionally, the self-referred group had lower overall healthcare use outside of physical therapy, including physician visits, diagnostic testing, or surgery. This means that the insurance is paying less overall, which will eventually cost the patient less in insurance premiums if the general trend is allowed to continue. More importantly, the physical therapist does not replace the physician’s role in the healthcare realm but only provides a different point of contact to begin the healthcare process. The study reported most of the self-referred group still were in contact with a physician during and after PT even though they did not initially consult a physician. Previously, there was concern that the physical therapist was not qualified to adequately diagnose a person’s injury, would not know how to refer to the appropriate source, or overuse resources without a physician referral. The study concluded “concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overrated.”

 This is very significant for the profession of physical therapy. It now becomes more of the patient’s decision to go to a physical therapist rather than waiting to be sent by a physician. Insurance companies have already begun to encourage trying physical therapy prior to other healthcare due to the low cost and the effectiveness of PT alone now. Thomas DiAngelis, the president of the American Physical Therapy Association’s Private Practice Section, stated regarding the article, “When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care. We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it.”

 Dr. Lingerfelt is a Physical Therapist at Boston Sports Medicine