Not All Tendons are Created Equal
Have you ever experienced knee pain when beginning a new activity or increasing training volume? Does this pain go away after the warm-up, but come back the day after or when stopping the activity? You may have been of the lucky ones if these symptoms were short lived and went away within a few days. For many, this pain can become a chronic issue and affect everyday activities like sitting, stair climbing, and walking. This chronic condition is characterized by pain in the patellar tendon.
Jumper’s knee, runner’s knee, or patellar tendinopathy are all synonyms for this common condition. It generally affects the adult population ranging from 16-40 year olds, but can affect anyone if a training schedule is not properly developed. The tendinopathy is generally due to overstressing a poorly conditioned tissue, which can eventually lead to tendon dysrepair. Just like your muscles, bones, tendons, and ligaments also have to be trained to meet the demands you are putting on them. The reasons for pain with this condition is poorly understood, but it is believed that the brain and central nervous system play a big role in sensitization of the tissue. Once this process begins it is hard to reverse, which is likely why symptoms can last anywhere from a few weeks up to 2 years.
No matter the activity, whether you are increasing your training volume, load, surface, or equipment the degenerative process may begin. The importance of ramping-up training or allowing appropriate time for tissue adaptation can not be overstated. This is why this injury is more prevalent at the beginning of a sporting season or training regimen. Have you ever wondered why marathon runners are very calculated in their training regimens in terms of increasing mileage? This condition is one of the reasons, as all tissues take time to adapt. Remember, the preseason is what prepares your body, and may be the most important part of the season to reduce injury risk.. Check out our upcoming blog in the spring on how to prevent training injuries.
As always, better outcomes are seen with more timely interventions versus the wait and see method. Treatment is generally aimed at reducing pain, reconditioning the tissue, and improving proprioception in the joint and surrounding tissues. Eccentric and heavy slow resistance exercises have been shown to be the most beneficial in treating this condition, and certain protocols have been established. Since everyone’s tendon quality and pain levels may be different, it’s essential to ensure you are starting at the right level for your state; if the tendon is stressed too much during recovery, the tendinopathy cycle will repeat itself and may become worse. Remember, there is no established timeframe for recovery, so being patient with recovery is important. The good news is that you can usually continue training, but it is best to consult your physical therapist about possible changes in impact training, training load, or training volume. Cookie cutter approaches to treatment won’t work, so be sure treatment is properly adjusted to meet your needs.
Bryan Esherick PT, DPT
As heart health awareness month comes to an end, we want to highlight the wonders of cardiovascular exercise – help clarify exactly what it is – and remind you to keep your heart healthy all year long.
Cardiovascular exercise – or cardio – is defined as any activity that gets your heart rate up. Now, that’s a pretty wide definition which is great because that means you can choose from a ton of different activities – some that you might enjoy more than others, and that means you’ll be more apt to get your body moving more. You could choose anything from: running; dancing; using the elliptical; rock climbing; swinging a kettlebell; playing tennis, basketball, soccer, football; practicing martial arts; taking classes like zumba, kickboxing, or jazzercise… and the list goes on and on – even sex can count! The idea is to choose activities you enjoy, and shift your mind from thinking it needs to be something you don’t like doing.
The benefits are cardio are huge. Most people immediately associate cardio as a weight loss tool, and it’s true that it is a big benefit. But there are so many other wonderful benefits to highlight as well.
Here is a list of health benefits you may have not have associated with cardio:
- improves mood
- fights depression
- relieves anxiety
- improves cognitive function
- stimulates nerve creation
- boost self esteem
- builds social relationships
- improves cardiovascular health
- lowers risk of all causes of mortality
- decreases risk of heart disease
- improves blood pressure
- lowers cholesterol
- relieves pain as exercise increases pain tolerance
There is also some evidence to suggest that regular exercise effectively slows how quickly our bodies age by helping to repair the little proteins at the end of our DNA strands – called telomeres – which can help to keep us younger and fitter longer. Perhaps we have found the Fountain of Youth after-all!
The secret is to find something you enjoy and like doing, and stick with it. For me, it is martial arts. I’ve trained in it my whole life and get my cardio from Brazilian Jiujitsu and running. Bryan plays hockey and likes to use the rowing machine, while Dongjin plays soccer and Megan opts for aerobic dance. Think about what gets you moving – and of you’re not moving, give us a call and let us help you get started. Who knows, you just might find a new passion or hobby that will help keep you fit for life.
–Sam Spillman, DC
The knee joint is the most vulnerable and most common snow sport related injury. The good news is there are steps you can take to condition and prepare your body for winter sports such as skiing.
Things to do in preparation for your ski trip:
- Core and lower extremity exercises (listed below)
- Training your cardiovascular fitness- many injuries occur as a result of fatigue
- Proper equipment that is appropriate for your height and skill level
- Take a skiing technique class before hitting the slopes
Preventing Injury on the slopes:
- First off warm up your body before hitting the slopes each day
- Proper technique: Hands and weight forward, legs parallel and hips, knees and ankles flexed equally
- Stay on trails that are marked for skiing safely
The following are exercises should be preformed several weeks before you plan to ski. All of the exercises should be attempted for 1 minute and increase the time as you improve.
Standing on one leg reach the other leg toward an imaginary clock face. Repeat on other side.
With both feet close together bend your knees and jump side to side while maintaining a straight spine and a flat back as well as even weight in both feet.
Start from a squat position with feet close together jump from diagonal to diagonal landing on the balls of the feet.
Side to side skaters
Stand on one leg and take a large step to the with the other leg and then take another large step back to where you were. Make sure your pelvis stays level and your knee does not buckle inward.
Check out the full video for these fun and helpful exercises!
Rotator cuff is a term that many people fear when mentioned by a healthcare provider. This fear is usually warranted but, if a partial tear, can usually be treated conservatively if caught early. This fear may come from not knowing about conservative measures that can help. On the other hand, when conservative management fails or the tear is more significant, surgery is generally indicated. The goal of this blog is to help answer many of the questions you may have when a healthcare provider mentions that your rotator cuff may be the cause of your shoulder or arm pain. A brief description of the function of the cuff and the pathology will be followed by a look at the road to recovery and what to expect as you go through the weeks of rehabilitation.
The cuff’s main purpose is to improve shoulder stability by actively pulling the arm bone into the shoulder socket with arm motion. It does this through a concert of contractions of the 4 muscles that make up the structure. Each muscle works intricately with the other to provide the most stability possible: Even when one muscle is not working properly, it can lead to issues. Without the rotator cuff, the shoulder generally becomes unstable which can lead to further tearing or other injuries affecting the shoulder joint.
Tears are fairly common and can affect people of all ages. They occur most commonly in patients in their 50’s and above, likely due to tissue deconditioning and other age related changes. Tears also occur frequently in overhead throwing athletes. Cuff injuries generally occur gradually over a period of time where symptoms begin to evolve and worsen. Warning signs of tears include deep, dull shoulder pain, trouble sleeping, and an inability to move the shoulder through its full range of motion. Labral tears and biceps tendinopathy are common concurrent injuries that may also be addressed.
Surgery vs. conservative management will generally be decided on a case by case basis and based on failure to conservative treatment, imaging results, signs and symptoms, and quality of life reported by the patient.
Here is what to expect when surgical repair is indicated.
Day 1- week 2: Surgery is generally performed at an outpatient surgical center. Most repairs are done arthroscopically meaning a small camera will be inserted with tools on the end to complete the repair. A local nerve block as well as general anesthesia is used during the procedure so you will be asleep the entire time. The nerve block will also help to ease pain for the hours following surgery and likely into the next day. This usually only requires 2-3 small incisions in your skin. You will return home the same day following the surgery. Pain killers are generally prescribed to help ease pain, and they should be taken to make you more comfortable.
The next 2 weeks are used to allow the repair to heal properly and is the maximal protection phase. During this time your arm will be in a sling and you will likely sleep in a recliner to protect the repair. Moderate pain is a normal experience during this time so be sure to ice and take any medication as prescribed.
Week 2-4 Post-op: This is generally when physical therapy is initiated, but some surgeons will wait for 6 weeks before therapy is initiated. During this period in therapy, the therapist will move your arm for you to begin regaining normal motion. You will also begin working on activating the muscles around your shoulder blades. Gentle activation of your shoulder muscles will also start.
Weeks 5-10 Post-op: The goal of this phase is to obtain good range of motion and to be able to stabilize your shoulder throughout the range with your muscles. Range motion will continue to be progressed and active motion will be progressed gradually within relatively pain-free ranges to hopefully reach full range by week 7-8. Range of motion progresses differently in different patients so don’t be discouraged if it takes longer than normal. Strengthening exercises will also progress gradually to gain strength for normal activities.
Weeks 10-20 Post-op: The goal of this phase is to continue progressing strength and stability to prepare your shoulder for return to all prior activities. You will also be expected to become more independent with exercises. Challenging functional movements will be performed later in this stage. Complex movements like throwing will be broken down into parts to practice before performing the actual movement to ensure proper shoulder function. You will likely be weaned from PT and may be discharged to continue with comprehensive home program to continue toward the end of this period. Athletes that need more intense treatment will continue with therapy into the return to sport phase.
Be sure not to perform activities that are too taxing for your shoulder at this point. Your shoulder will be feeling much better, which makes this a common time for re-injury to occur. Although your shoulder is feeling better, that does not mean it is fully healed and ready for full return to all of your normal activities.
Weeks 20+: Typically the safe return to sport phase. You will progress back into your sport or other activities. Continue with your home exercises to continue building strength and stability throughout your shoulder complex.
You can expect to be checking in with your surgeon throughout this process to insure that everything is going as planned. Your therapist should be in contact with the surgeon throughout the process to ensure you are progressing as expected as well.
I hope this blog can ease any anxiety about your upcoming procedure and give you a brief guide for what to expect following a RTC repair. Surgery can be intimidating, but the more you know going into it, the better the outcomes!
We will be following one of our patients through rehab and will post exercise videos and updates throughout his recovery. Be sure to check them out!
Bryan Esherick, DPT
It is that time of year again, the birth of a new year and maybe a new you. Are you making any New Year’s Resolutions? In the fitness and health care communities we tend to focus a lot on losing weight, diet, starting an exercise program. And all those are wonderful things. But I think it is important to focus on what will make your life better. What kind of resolutions will improve YOUR life. Not necessarily what your healthcare provider would choose for you, or your spouse, or your parents. We might want to swear less, or improve a relationship with a loved one, visit family more, get a promotion at work, get more involved with charity, and so on.
Whether you are trying to resist something that is bad for you or start a new thing that is good for you, making a change can be difficult.
I like to start with the end result and work my way backward. For each goal, I like to make it SMART: Specific, Measurable, Attainable, Realistic and Timely. This is a commonly used business idea, but it can be applied to personal goals too. To me, using this method can help really set ourselves up for success.
For me, less screen time in the year ahead is a big goal. You may have noticed that it is more difficult to NOT do something than it is to add a new activity. So instead of setting a screen time limit for myself, I’m endeavoring to fill up my time with other things, so that screen time is less of an option outside of work. I’m making a list of books I’d like to read, and a commitment to do more activities after work. I’ve joined a committee of a local charity and I’m going to attend one evening jujitsu class a week.
So as you make your New Year’s Resolutions, try to spend time planning out how you might achieve your goals, as well as determining what goals to set.
You’ve got this. Happy New Year!
Sam Spillman, DC
Insurance coverage can be a tricky thing to navigate. Do you know what your individual deductible is? If so, do you know about your family deductible and coinsurance for a specialist visit? For most of us, myself included, the insurance specifications have become seriously complex. Many times I’ve intervened on behalf of patients that have met their wits-end while attempting to understand their chiropractic or physical therapy benefit coverage. In an attempt to simplify some of the frequently used insurance terminology, I put together this little cheat sheet to help in minimizing the frustration factor.
A coinsurance occurs when there is cost-sharing between the insurance company and the covered member/family. The insurance company may tell you that your responsibility is a 20% co-insurance and that they will cover the rest of the charges (remaining 80%). Quite often a coinsurance comes in to play after an individual or family deductible has been reached.
Example: Your opthamologist visit is $400 and Optima informs you that you have a 20% coinsurance after meeting your $200 deductible. Currently, you have met $0 of your deductible. Your responsibility would be: $200 of the deductible and then 20% of the remaining $200 specialist visit charge = $40.00. The total you can expect to pay for the visit is around $240.
A copay is a set fee that you are responsible for each time you visit a doctor. There are usually tiers or copays where a primary care doctor is typically less than the copay you may have for a specialist. Some plans have a copay due in addition to a co-insurance.
The set amount an individual or family must reach before transfering over to coinsurance coverage for medical services. Some plans have relatively low individual and family deductibles of $200 – $500 while other plans have larger $5000 – $9500 deductibles. Once you have met your deductible you may only be responsible for a fraction of the percentage of your medical care, referred to as a co-insurance.
Out of pocket maximum or stop loss
This is the absolute maximum a covered member or family will pay out of pocket for medical care including copays, deductibles and co-insurance for a defined period of coverage (usually a calendar or a contract year)
At the start of this holiday season, we’d like to give thanks for Balance(d). I named my practice Balanced because I believe in a measured approached to things – to the body, to patient care, and to life. It serves as a reminder to me as much as I hope it does for my patients. Last year I wrote about the importance of balance during the holidays, and you can read about it here. This year, I thought I’d share how I keep my balance during the holidays. Keeping your holidays stress free is great advice, but I want to talk a bit about how you actually do it.
For me, as an introvert, I’ve learned it is really important not to over schedule myself. If I do, it can really wear me out. So I keep track of my schedule in a calendar, and when I consider any invitation I look at the time slot and see what’s around it. If attending the event doesn’t leave me any recharge time, or there’s too much travel time, or if it means I’ll miss too much of my exercise plans, it’s likely a pass for me. Of course for those with children, schedules can be more complicated. You just have to keep your mind on the balance.
Another consideration around the holidays is food. I love food. You can often hear me talking about cooking, restaurants, and value-driven ingredients. To balance food around this time of year, I try to keep lunch light and very healthy – especially if I have plans for dinner or a party later. Then there are the oh-so-tempting sweets that pop up everywhere during the season. So, I eat a healthy snack before I head out since counting calories doesn’t work for me. When I am trying to relax and enjoy a party the last thing I want to think about is how healthy the food is I am eating. Filling up a little on healthier foods before I go can also help ease the guilt along with the managing how much I eat. I gain weight easily if I’m not careful, so I tend to stick with my plans.
I’m a big proponent of exercise, as many of my colleagues in the healthcare field are. If you’re trying to keep from gaining weight, or if you’re trying to lose weight during the holiday season, you’ve got to pay attention to your diet the most. However, exercising during the holidays will also help keep your weight in check as well as help to alleviate stress and keep you in a better mood overall. Of course, if you’re on a set plan for a competition, stick with your plan. If you’re like most people, you exercise more because you should and less because you love it – or perhaps you don’t exercise at all. Time is a big factor for those who don’t, but it doesn’t need to be all or nothing. The key thing is to keep your body moving. If during the holidays, you drop from four days a week to three, that’s a good trade-off. Another way to make the most of your time is to consider high-intensity interval training to make your exercise shorter but more intense. You’ll still build muscle, improve your cardiovascular function, and get all those wonderful stress relieving chemicals – going hard for 10-15 minutes can be as useful as an hour of moderate exercise on the bike or a long walk.
So, take these tips and find your balance this holiday season:
- Look at your calendar frequently and make sure you aren’t overloading yourself and the family
- Stick to a healthy breakfast and lunch and have a healthy snack so you don’t have to watch too much at a party
- Keep up with some amount of exercise, even if it’s less than you normally do
Sam Spillman, DC
The balance system is one of the most important systems the body uses. Throughout the day it helps us to drive a car without getting dizzy; slip on a slick surface without tearing ligaments; go up and down stairs without looking at every step; and walk down the sidewalk without tripping on uneven cracks. Balance is a complex masterpiece that can be honed to help every person function at their highest level. Have you ever wondered how gymnasts balance on the balance beam, or hockey players skate on ice while handling the puck, or how skiers tear manage to slalom downhill without falling? It all has to do with practice and creating a balance set to fit their unique sporting needs. There are three different balance systems that work together to create a wholly balanced world.
This is the feeling that we have in our feet, and is sometimes intertwined with proprioception. Somatosensation and proprioception are defined as how the sensors within the skin on our feet, joints, muscles and tendons sense where we are in space. These sensors constantly give feedback to different parts of the brain and brain-stem to correct movement, and ensure that the proper muscles are contracting to stabilize and move our body. This system can be disrupted by nerve damage (often called peripheral neuropathy), which often occurs with diabetes and some artery diseases. It can also be disrupted by pain, which is why anyone who has had an ankle sprain will tell you that they sprain the ankle over and over after the first injury. This is because the system is disrupted in the presence of pain so the ability of the ankle muscles to contract and prevent further sprains is impaired. When this system is disrupted due to lack of sensation or pain, the body relies on the other two systems below.
Simply put, vision gives us our picture of the world and integrates with the other systems to adjust muscle activity and movement to match what we see. We rely most of our vision during balance.
The vestibular system is an integral part to the balance system. It activates postural muscles throughout the day and also helps us move our eyes independent of head movement. This allows us to focus on one thing while there may be a lot of other things going on around us – think about reading a street sign while driving on the highway, for example. If both of your vestibular systems were non-functioning (you have two, one in each ear), the horizon would bounce up and down instead of being still when walking. Mismatches in information within this system is usually what causes motion sickness. The reason people get nauseous with motion sickness is that the brain has trouble with deciding which input to use – vestibular, somatosensory, or vision. Nausea is your brain’s way of saying: we need to sit down and take a break so I can figure this out. When this system is not functioning correctly, patients generally experience dizziness – defined as feeling off, light-headed, or spacey – and vertigo, which gives the sensation that the world is spinning around you. This system is most important for balance at night when vision can be eliminated.
Balance may not be as straightforward as it seems. It requires a lot of input and processing within our nervous system to work well. The good news is that our balance system can adapt to use one part of the system more than the other through training and practice. The bad news is that as we age, we generally lose sensation in our feet and vision leading to increased risks for falls.
We can help you find your balance before issues develop. Give us a call for your balance screening today!
Bryan Esherick, DPT
Inflammation can strike at any time. Anti-inflammatory drugs can be helpful, especially for new injuries and certain inflammatory-based pathologies. However, our bodies experience new episodes of inflammation (both beneficial and detrimental) all the time. So, using natural remedies is a safer way to decrease those frequent bouts of non-beneficial inflammation.
Here are a few natural remedies to try before you reach for a pill.
- Exercise: Even just 20 minutes of exercise can have anti-inflammatory effects on the body’s systems.
- Add powerful anti-inflammatory spices to meals: Give turmeric, cinnamon, and ginger a try. Turmeric can be sprinkled on variety of foods, cinnamon can be a great addition to your oatmeal or tea in the morning, and ginger brings a nice twist to a smoothie.
- Reduce red meat consumption: Recent studies show red meat can actually bring on inflammatory effects on the body. Chicken, salmon, and other foods high in Omega 3’s can be great options to prevent inflammation and get the protein you need.
- Eat more foods with anti-inflammatory properties: Fruits, vegetables, nuts, and legumes are your friends. Be sure to include multiple servings of these throughout the day to allow your body to be at its best.
Remember, your body is your greatest asset. Take good care of it, and it will take care of you for years to come!
Bryan Esherick PT, DPT
Treatments come in a variety of options. Opioids (oxycodone, hydrocodone, etc.) are often prescribed as treatment for an episode of pain patients are experiencing. If you haven’t been the recipient of these directly, there’s a good chance you know someone who has. They’ve been widely prescribed as they had always been considered both safe and effective. However, in the wake of an opioid epidemic, we want to remind our patients that there are safe and effective treatments that let you avoid the drugs – and without the side effects, That said, there are instances where these types of drugs are appropriate – post surgery or serious injury – and with proper management may be used safely. However, we want to use this platform to highlight our approach to more conservative treatments that can effectively alleviate pain.
As physical therapists, chiropractors, and massage therapists, we look to provide that first-line treatment for acute and chronic injuries alike – including: manual therapy; joint mobilizations; massage and soft tissue release; targeted therapeutic exercise; and health education. Let’s take a closer look at these distinct areas.
Joint Manipulation and Mobilization
Manipulation and mobilization are used throughout musculoskeletal health by chiropractors, physical therapists, and some osteopathic doctors. Despite popular belief, the aim of these treatments is not to put a bone back in place. Treatments like this work with the nervous system to affect pain (through release of endorphins), muscle tension (through reduction in pain and thus reduction in spasm), and proprioception (your brain’s sense of your joint position). In my opinion, 95% of cases require exercise to reinforce the effects of the manipulation. In other words, mobilization and manipulation gives your body a window to exercise with less pain so that you can correct the issue at fault and increase muscle tone. However, it does not correct the underlying cause of the pain independently. These are powerful pain relieving tools that can be employed to aid in your recovery from pain, especially in the spine.
Generally massage is thought of as a relaxation and stress reducing technique, but it can also be used as a powerful pain relieving and recovery tool. Therapeutic and sports massage are given in order to improve recovery through reduction in muscle tone and improvement in blood flow. Relaxation in muscle tone allows the muscle to receive the adequate nutrition is desperately needs to heal. Think of a muscle as a sponge; when it is squeezed out (overactive) it is not able to receive the water (blood) it needs to function. We see this happen often in cases of back pain associated with sustained postures, and receiving occasional massages would help alleviate this chronic paid in a more effective and cost-effective treatment. Massage also releases endorphins through a healing touch and targeted techniques, which helps to ease pain and creates a relaxing therapeutic environment for the body to heal. Your chiropractor or physical therapist may also use targeted soft tissue techniques to promote healing and pain reduction.
Therapeutic exercise is used widely by physical therapists and chiropractors as well. Movement encourages the body to release endorphins, reduce tissue tension through increased blood flow, promote healing through cellular processes, and prevent chronic pain from fear of movement. Exercise can be used as a means for tissue to adapt and heal to specific stresses it will encounter through daily activities. We use therapeutic exercise not only as a pain relieving mechanism, but also as a way to introduce stress to healing tissues in a controlled manner. If the tissue is not properly loaded over time, it can be substantially weaker than it was prior to the injury causing recurrent injuries. The best example of this phenomenon is chronic ankle sprains. Without proper rehabilitation, ankle sprains are likely to keep occurring as the body is unable to fully heal the tissue prior to sustaining a second, third, or fourth injury. Another common misconception is with arthritis. Many people stop moving because the arthritis is causing too much pain. On the contrary, our joints need to be loaded in order to provide nourishment to the joint surfaces. Without movement, joints can continue to degrade and become more painful. Remember, movement is your friend and is ultimately what will keep you feeling happy and healthy for years to come.
Education about a particular condition should not be taken for granted. It is the responsibility of your healthcare provider to educate you on your conditions, the treatment options, and expected recovery prognosis. Please don’t hesitate to ask your provider questions – fully understanding your condition is a key element to complete recovery. Education about pain can also be invaluable for the patient, which is why our office strives to provide pain education to help contextualize thoughts and beliefs about pain. Sometimes education is the stepping stone to preventing a patient from progressing to a chronic state of pain. For this reason, our office doesn’t just treat your condition, we help you understand it.
As you can see, there are many alternative treatment options for pain relief – and with far fewer side effects – than prescription drugs. It is important when seeking care for pain, that you explore all options landing on an course of treatment. Second opinions can often be helpful when you are unsure if a certain treatment is right for you. Trying a more conservative option first may save you time and dangerous side-effects from other riskier alternatives.
Our office uses all of the above techniques, and when necessary, uses other techniques including modalities and dry needling. Our goal is to provide our patients with the most comprehensive, evidence-based treatments to ensure the fastest and most complete recovery path from injury. We ensure that each patient is treated individually, as every patient has different needs from the healthcare system. Still have questions? Give us a call to learn more. We’d love to help you become the strongest version of your best self!
Bryan Esherick PT, DPT