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Patellar Tendinopathy: Not All Tendons are Created Equal

Have you ever experienced anterior knee pain? The likely answer is yes, and it can be quite debilitating! There are a variety of causes for anterior knee pain including patellar tendinopathy (tendonitis), chondromalacia patella, patellar tracking issues, and more serious injuries like ACL tears. This blog with focus on patellar tendinopathy.

What is Patellar Tendinopathy

So, you may be wondering how this condition starts in the first place. It is usually the result of overloading the tendon before it has time to adapt. By not allowing for a gradual increase in training load, the tendon faces more stress than it is capable of tolerating. Generally it affects the adult population ranging from 16-40 year olds, but can affect anyone if a training schedule is not properly developed. Once the condition has developed, it can take anywhere from 2 weeks to 2 months to fully resolve. 

Biological signs of the injury include up regulation of cells that create the tendon, ground substance, nerves, and blood vessels. One hypothesis for why the tendon becomes painful is the in-growth of nerves and blood vessels; picture packing all of these substances into a compact area. The brain and central nervous system may also play a big role in sensitization of the tissue. Pain with this condition like serves more  as a “danger signal” to allow the human to know something is happening in that area of the body, and is likely not a signal of tissue damage. Think of this as a warning sign to slow down and let the tendon adapt.

Diagnosis of Patellar Tendinopathy

Functional movements that usually become painful with patellar tendinopathy:

  • Going down stairs hurts more than going up
  • The deeper the squat, the more the pain
  • Sitting for long periods
  • Running, jumping, and walking hills hurts

Other hallmark signs of the condition:

  • Pain in the front of the knee just below the kneecap
  • Pain “came out of nowhere and progressively got worse”
  • Recent change in training load
  • No catching, locking, or giving-way

 

 

Real Life How it Happens

Now that we’ve gone through all the logistics of this condition, lets look at a real life example of how this can happen with running. Picture this: It’s winter, the weather isn’t great for running so you’ve been inside running on a treadmill. You have been consistently running 5 miles with no pain throughout 4x’s a week.

Then BOOM. March hits and its 60 degrees out with the sun shining. New shoes are unboxed and you can’t wait to get outside and hit the pavement. You start running outside with the same mileage, but now you’re running 5-6x’s for 6-7 miles a week because you can’t resist how nice its been outside. One morning you wake up to walk to work or class and you notice that as you’re walking down hill your knee is bothering you a little (nothing serious 1/10 pain). Over the next few days you notice the pain is getting a little worse (2-3/10 pain with stairs, hills, and now its even bothering you a little with running). Now you’re concerned because its starting to affect running.

So let’s break that story down and see how training may have overloaded the tendon before it was able to adapt:

  1. The obvious, moving from 4x’s a week to 5-6x’s a week and increasing mileage
  2. Moving from a treadmill which absorbs some shock to pavement
  3. Flat to hilly terrain
  4. Even to slightly tilted or cracked sidewalks
  5. Going from a consistent speed or cadence to one that is likely more varied
  6. Change in temperature

Wrap-Up

As you can see, outside of the obvious, there are a lot of other variables that need to be accounted for to allow the tendon to adapt properly. No matter the activity, it is important to allow adaptation to training volume, load, surface, or equipment. The importance of ramping-up training or allowing appropriate time for tissue adaptation can not be overstated. This is why this injury is usually more prevalent at the beginning of a sporting season or training regimen.

Treatment

As always, better outcomes are seen with more timely interventions versus the wait and see method. Treatment is generally aimed at reducing pain, promoting tissue adaptation and healing, 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 some 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 level of tissue irritability. If the tendon is stressed too much during recovery, the tendinopathy cycle may repeat itself and may become worse.

Remember, there is no established time frame for recovery, so being patient with recovery is important. The good news is that you can usually continue training during rehab, but it is best to consult your physical therapist about adjusting impact training, training load, or training volume.

Bryan Esherick PT, DPT

So you tore your ACL…now what?

Anterior Cruciate Ligament (ACL) ruptures are one of the most common injuries in sport. Most occur without contact, and occur far more often in female athletes than in males. There are many ways to injure the ACL; maybe you’re a soccer midfielder who got into a 3-way tackle at practice. Maybe you’re a goalie who went to clear the ball and felt your plant leg crumble underneath you. Or maybe, if you’re really unlucky, you stepped in a pothole walking home from a game. Regardless of the scenario, when an ACL ruptures you will feel a pop, likely feel your knee “go inward”, and experience immediate swelling.

While there are several clinical tests that a physical therapist can use to determine the status of your ACL, the gold standard for diagnosis is MRI. Once an ACL tear is confirmed on imaging, the gold standard of treatment is still surgical reconstruction.  Research is coming out now suggesting that some individuals can “cope” with intensive rehab, but what we see in the literature is that this only occurs for about 25% of patients who sustain an ACL rupture. If you are going to return to a high-level contact sport – and especially if you’re female and under 30 – your best bet for returning to optimal performance is a reconstructive surgery. 

While it’s a common injury in sport, it’s also an emotionally difficult one; it’s likely your season will be over. Athletes will usually feel grief grief over suddenly not being able to do the thing you love,  anger at watching your teammates continue to thrive and perform in your sport, and fear that you’ll never be the same again.  

 These are all normal feelings to have, but in excess, they’re actually going to prevent you from making a solid comeback. So, here are some steps to take to get your head back in the game, and some information for you so that you know exactly what to expect after you’re wheeled out of the operating room. 

First: Know that it’s going to be okay. 

While an ACL rupture is likely a season-ender, it doesn’t have to be a career-ender if you find the right orthopedic surgeon and a physical therapist who specializes in sports. How many of you watched Megan Rapinoe this year in the world cup? Did you know she tore her ACL – for the THIRD time – in 2015, and was back on the field for the Rio Olympics? . Yes it takes a long time and a lot of hard work, but know this: you WILL play again. 

 Second: Learn about what’s going to happen in the Operating Room.

Surgeries are scary,  but the good news is that sports medicine surgeons perform this operation all the time. Choosing your surgeon is important – you want someone who is board-certified in sports medicine and who does this operation regularly. It is more than okay to ask your surgeon how many ACLs they have reconstructed! Choose your surgeon well – make sure they have LOTS of experience with this operation and make sure that they share your goal of getting back with your team – and you will be just fine. In the operating room, the surgeon will make a small incision and will first debride, or clean up, the inside of your knee. She will likely remove the torn portions of your old ACL.  Then, she will take a portion of one of your tendons – either your patellar tendon (front of your knee), hamstring tendon (back of your knee) or quad tendon (just above your kneecap) and creates a “graft” by re-inserting the tendon into the joint, such that it will act like a new ACL. 

 Third: Get your dang knee straight!

 After you wake up from surgery and make it home from the hospital, you’ll likely be sore, but it’s important to get that knee moving. Check with your surgeon about specific precautions and limitations, but in most cases physical therapy should begin 1-5 days after your surgery. The most important thing in the early phases of rehab is to regain full range of motion, especially extension. Without full range of motion, strength gains will be hard to come by. The earlier you start working on this, the less painful and difficult it will be over time! 

Fourth: Train Hard. 

Find yourself  a physical therapist who specializes in sports rehabilitation. Your physical therapy sessions should feel progressively harder and harder, and your PT should be stressing your cardiovascular systems in addition to getting you strong. If you’re not sweating during your sessions and have mild DOMS afterward – and if you’re not eventually doing things that look and feel like your sport – find a new PT.

Lastly: Be Patient. Play the Long Game. 

 You’re six months out from surgery, running intervals, doing box jumps, and feeling GOOD. So…why can’t you play? The sports medicine and rehab research overwhelmingly and unequivocally shows that for every month you wait to return to play after that 6 month mark, you decrease your risk of reinjury by 50% . That’s huge. Even if your ligament has healed and you’re passing your return to sport tests, the extra three months to get fitter and stronger matter so much to keeping you in the game.   You can reduce your risk of re-injury by waiting until you are stronger and fitter than you were even before your injury. Your physical therapist should be guiding you there and encouraging you every step of the way.

If you have questions about how to prevent ACL ruptures, or whether we’d be a good fit for your pre- and post-operative rehab following this injury, reach out to our sports specialist Dr. Wason: [email protected]

What You Need to Know about Stress Fractures

A more accurate term for a stress fracture is “bone stress injury” (BSI).  This is because bony stress injuries occur along a continuum based on how much loading the bone is being asked to sustain.  When caught early, that dull ache at the front of your shin, for example, might just be what we call a stress reaction: there is edema (fluid) in the bone marrow, but no visible fracture line.  If a stress reaction isn’t caught in time and/or the athlete continues to run through the pain, the bone can be stressed to the point of a partial fracture, what we call a “stress fracture”. Usually, pain with a stress fracture is significant enough that the athlete cannot continue to run through it. However, in cases where the bone continues to be loaded beyond what it is capable of tolerating, a stress fracture can widen and deepen and eventually progress to a complete break in the bone. Again, this is rare because most athletes will voluntarily stop their training due to intolerable pain with a stress fracture. 

Who gets stress fractures?  Bones respond to impact. Moderate amounts of impact activity, such as walking, running, and jumping – when progressed appropriately – are actually GOOD for your bones. Bones actually cannot get strong and dense (aka, strong enough to resist fractures and stress fractures and reducing the likelihood of osteoporosis in your later years) without some impact loading.  The best way to go about this – if you’re not already a runner or involved in a running/jumping based sport like basketball or soccer – is to schedule a visit with a sports physical therapist who can help create a program for you to safely and effectively load your bones. 

 

However, when it comes to loading your bones, it’s very easy to have too much of a good thing.  HIgh volumes of load, or increasing your load very suddenly, will “stress” the bone and eventually cause it to crack. Generally, stress fractures occur in athletes who run – cross country, track, marathoners, as well as running-based sports like soccer and lacrosse – and in athletes who jump.  They also occur commonly when an athlete is transitioning from a nonweightbearing sport like cycling or swimming into more running. A stress fracture is typically preceeded by a significant increase in impact activity beyond what the athlete is used to. 

 

Stress fractures can also occur in the absence of an increase in training load. However, the reason is always due to an increase in stress on the body.  This can be physical stress in the form of training load, but can also be emotional/psychological stress (for example, making the transition from high school to college), or metabolic stress from not eating enough. Bones, just like muscles, need fuel to build themselves up and keep from breaking down. For more information on the relationship between energy balance and bone health, see our last post on relative energy deficiency in sport! 

 

A clinician will usually be able to determine whether or not they suspect a stress fracture based on the patient’s history and on several clinical tests. However, imaging is necessary to rule these in or out. Despite being a bony injury, most stress fractures will NOT show up on X-Ray; MRI is the gold standard for diagnosis. 

 

Following diagnosis, a stress fracture will usually require a period of unloading depending on severity. Stress fractures in the foot and ankle will usually require a walking boot; stress fractures higher in the leg will require crutches. THe length of time on crutches is entirely dependent on the severity of the fracture.  During this time, most athletes will be allowed to cross-train in the pool (swimming or deep-water running) or on a stationary bike – again, depending on the severity of the injury. 

Most stress fractures take 6-8 weeks to heal. A common misconception, however, is that once the bone is healed the athlete is clear to resume running.  While it’s true that after the bone has healed, the athlete can resume LOADING the bone, this does not mean they are ready to run. With every step you run, your leg has to absorb forces that are FIVE TIMES GREATER THAN YOUR BODY WEIGHT. Starting at this amount of load will likely just lead to a second fracture.

 

This is where physical therapy comes in! A sports specialist will be able to design a gradual loading program for you, involving progressing walking speed and distance, improving global lower body and core strength, and eventually, progressing plyometric activity in order to guide you safely back into running. This way, you can return to your sport stronger than you left it, and with full confidence that you will not experience an injury like this again anytime soon.  Additionally, a female athlete specialist (like Dr. Wason!) can help coordinate the resolution of any risk factors you may have, such as your training volume, your fuel intake,body image issues, and your menstrual cycle status (for more on how your menstrual cycle affects your bone health, see our previous post on RED-S). 

 

If you are a runner or running athlete and you: 

-have been diagnosed by a physician with a stress fracture

-have had a bone stress injury in the past and are struggling to return to training

-are having pain with training and suspect you might have a stress fracture

-just want to avoid a bone stress injury

 

Send an email to Dr. Kate with any questions or concerns or to set up an appointment!

[email protected]

Relative Energy Deficiency in Sport

Most everyone reading this has heard of eating disorders. Somewhat less of you, but still a lot, will also have heard of the Female Athlete Triad.  But likely few will know what RED-S is. RED-S, or Relative Energy Deficiency in Sport, actually encompasses and expands on the female athlete triad and is essential for you to know about if you are an athlete, a parent of an athlete, or work with athletes in a coaching or healthcare capacity. 

 

 

 

 

 

 

 

 

 

 

 

 The Female Athlete Triad describes three inter-related health issues that occur specifically for female athletes when their food intake is not enough to support their activity levels. Oftentimes, this imbalance occurs due to disordered eating; intentionally restricting food intake in order to achieve leanness or small-ness which, for better or worse, can be advantageous in sports like distance running, triathlon, gymnastics. Over time, this lack of fuel triggers the body to essentially curl up in a ball and protect itself via shutting down the reproductive system. Your body will always prioritize survival over reproduction; this is why most women with eating disorders will lose their period due to low energy availability. The way this occurs is through alteration of hormone production and circulation in the body. In women, bone health is directly tied to reproductive hormone levels.  Estrogen and progesterone levels are altered, which then has a cascade effect on your bone health. In sum: disordered eating leads to menstrual cycle disruption/hormone dysregulation and sad bones. 

 It seems fairly comprehensive, right? But it actually leaves a lot out, and that’s where RED-S comes in.  This is the new term that we’re using instead of the “female athlete triad” for the following reasons: 

Relative Energy Deficiency in Sport affects men too. 

  Men certainly don’t menstruate and don’t have the same link between bone health and sex hormone profile that women do, but they do still suffer the consequences of not eating enough. As we’ll talk about later, not eating enough can affect ALL your body systems, not just bones and reproduction.  This is one of the main reasons for the change in terminology!

 

The “ED” in RED-S stands for “Energy Deficiency” and not necessarily “Eating Disorder” 

 It’s true that eating disorders are a massive problem in sport. The vast majority of women and girls will at some point and in some way, struggle with their body image and their relationship with food. However, it is also common for athletes to under-eat simply because they don’t know any better. Young women and girls are especially unaware of how many calories they actually need.  I blame diet culture for this – many of us are lead to believe through the media that 1500 calories a day are sufficient. In reality  if you’re active and/or still developing, it most definitely is NOT appropriate. Most female athletes need between 2,000-3,000 calories per day. (If you are curious about your own personal needs, I encourage you to get in touch with a Registered Dietician). As an example, consider the following scenario:

 You’re a college freshman and you’re trying to balance 1) being a member of a sports team 2) classes and homework 3) finding your way around campus 4) making friends 5) being homesick 6) oh and the dining hall doesn’t have anything you like, ugh. 

 It isn’t hard to see how this young woman – and thousands just like her – are not getting enough calories. And it doesn’t mean she has an eating disorder. So that’s another reason for the change in terminology – being energy-deficient isn’t always due to restriction. This is where healthcare providers and coaches can play a huge role in educating girls and young women about what they actually need to consume and how to do so conveniently!

RED-S affects MUCH MUCH MORE than bones and sex hormones

Low energy availability affects every system of the body. It absolutely can lead to low bone density which increases an athlete’s risk of stress fractures.  It will also shut down a woman’s menstrual cycle because with limited resources the body needs to choose between reproduction and survival. However, it also has effects on:

 Mental health: poor regulation of serotonin/dopamine = bad moods, irritability, lashing out, and increased feelings of depression and anxiety. Your body needs fuel to appropriately store and release hormones too!

Energy levels: The term “energy deficiency” says it all. Feeling sluggish, foggy, sleeping excessively or having difficulty with sleep are all potential symptoms of RED-S. Additionally, athletes will often struggle to complete workouts or will feel that a volume/intensity of work that has been typical for them has suddenly become challenging

Cardiovascular health: Your heart is a muscle, and it uses carbohydrates and fats for fuel just like all the other muscles of your body. Without enough fuel, your heart muscle will not be able to work as efficiently. This can change the electrical conductivity of the heart leading to things like arrhythmias – which will disqualify an athlete from participating in sport. It also leads to feelings of fatigue – workouts suddenly feel hard because the heart is having to work with less fuel!

Your musculoskeletal system: If you’re not putting in enough fuel to allow your body to recover, it breaks down more easily. This is true

In summary,  Relative Energy Deficiency in Sport is the new term we’re using to describe when athletes of all genders don’t eat enough to support their activity.

Motor Control, Part 2

Our bodies are built to do what our brains ask it to do. If you ask it to move in a particular way, it will do it, but it may not always be exactly how we imagined it. Think about watching people pick up an object from the ground: There are many different ways to do this, and your body will choose the best one suited for you. If you read part one of this series, you should now have a better understanding about what motor control is. Here in part 2, we’ll discuss how motor control may cause and be affected by pain.

 

Issues in motor control may be a likely culprit if part of a certain motion is pain free but other parts painful. From an observational standpoint, issues are usually evidenced by “jerky” or “ratchety” motion: Compensation patterns are also usually noted like moving from the hips when asked to flex in the lower back. Not everyone with these issues present with all of these characteristics, but it is likely to see at least one if this is contributing to the painful experience.

 

Now that you know a little more about what  motor control is and how to spot it, you may be wondering how it can lead to pain and dysfunction. Depending on who you ask, you may get a different explanation! In my opinion, there are two different schools of thought on the subject: Pain causing motor control issues, or motor control issues causing pain. I’m personally a believer that motor control issues are caused by pain via a complex interplay of different systems. 

We know that pain can affect a lot of things including activity level, social interactions, movement, mood, etc. When pain is present in an area it begins to affect proprioception and muscle activation, both of which are required for pain free control of movement. When the muscles and nervous system aren’t communicating optimally, pain and movement difficulties begin to occur. This leads to a cyclic pattern between pain and movement. Rather than put it in words, there is a graphic below that describes this cycle. Keep in mind, the arrows can go in both directions on the graphic, and one does not necessarily cause the other.  So although it may be a case of which came first, the pain or the motor control issue, either pathway leads to a continuous cycle of pain and discomfort and needs to be disrupted with intervention. 

 

So although motor control exercises should be a component of treatment in some conditions, it is not the magical cure to any musculoskeletal issue. It should be combined with other treatments including active therapeutic exercises and manual therapy.  When we work with clients that we believe have issues with motor control, we focus on performing slow purposeful movements. It’s like taking baby steps and learning how to walk, or move your shoulder, properly again. Purposeful thoughtful movement allows the nervous system to begin communicating with the muscles more efficiently. Overtime, this will begin to improve motor control and break the pain cycle above. 

 

Unfortunately, without a specific injury or examination, we cannot go into much more detail than that in terms of treatment. Please reach out if you have any questions on this topic and check out our instagram and facebook for some motor control exercises you may be able to do if you are experiencing pain. 

 

Bryan Esherick PT, DPT

[email protected]

Motor Control

Motor control: What is it and how does it affect you?

 

Aching shoulder or neck? Feeling a catch when you move that causes pain?  Motor control issues may be affecting how you are moving without you even knowing it. It can affect people of all ages and can affect many different parts of the body from head to toes. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


I want to preface this blog with the comment that there is no one right or wrong way to move! Generally, movement variability is necessary to maintain a healthy movement system. Motor control is a buzzword that gets thrown around a lot by movement professionals today. It describes how the body, through a complex link between the nervous system and muscles, is able to control movement through a range. Motor control is not how accurately a movement, like a squat, deadlift, or lifting a box is performed.

 

All the movements that we perform throughout the day require fine tuning by the nervous system. For example, as you raise your arm, for every 1 degree of arm movement your shoulder blade needs to rotate 2 degrees as well as tilt forward and move away from your rib cage. In addition to this your rotator cuff needs to contract just enough to keep your shoulder in its socket. You can imagine that to control this small amount of movement, there needs to be a constant feedback loop supplying the brain with a barrage of information.This is just one example of how amazing and precise our movement has to be to create movement.

 

So how does this feedback loop work? Your brain gets information via nerves carrying signals from proprioceptors and other specialized sensors hidden throughout different tissues. These cells are specialized receptors found in muscles, tendons, ligaments, and even the joint capsule. They generate and relay information about stretch, tension, muscle activation, joint angle and positions to give your brain a representation of what the body looks like in space. The brain then uses this information to finetune and adjust movements as needed. 

 

Now that you know a little more about what motor control is and how it may be affecting you, you may be wondering how to spot it and what you can do to fix it. Stay tuned for the second part of the blog which will be posted in mid-January 2020. 

 

Bryan Esherick PT, DPT

Hip Pain – Part 2

Did you catch our last  blog? If so, you’ve probably got a pretty good idea about what FAI and labral tears are. Hopefully this will make it easier for you to talk to your physician and physical therapist about your healthcare. There’s a lot of options out there, but everyone involved – patients, surgeons, and rehab professionals alike – agrees that targeted sport-specific physical therapy is essential to a full recovery, with or without medical intervention. 

“Calm stuff down, then build stuff back up”.  This quote from Greg Lehman, a dual-doctorate physical therapist and chiropractor,  basically sums up how a physical therapist works to help you get past your hip pain and back to your sport.  First – and we know athletes in particular need to hear this – the rehab process generally needs to start with a de-load.  Taking time away from the activities that aggravate your hip is necessary to allow the joint to calm down and get out of an inflammatory state. However, it’s important that you stay active in ways that don’t aggravate your hip to avoid weakness and deconditioning (and to keep you sane, of course).  If you have pain with running, for instance, try swimming or cycling; If you’re struggling to play a full 90 minutes of soccer, try decreasing your time on the field or avoiding drills that you know will flare things up. The decrease in load through the joint will help it calm down. If your physical therapist is familiar with your sport,  they can take a look at your training plan and/or talk with your coach to determine what might look like for you, and for how long. 

 

 

 

 

 

 

 

 

 

 

A physical therapist can also help decrease joint irritation with manual therapy.  Especially when FAI is at play and stiffness is present, a PT can use their hands to move the head of the femur away from the acetabulum, creating space within the joint. This allows fluid to pass through the joint more easily – carrying in nutrients and carrying out waste and inflammatory cells (movement does this too, hence staying active!).  Painful joints can also cause muscles to tense up, so a physical therapist can help release and relax those muscles. On the other end of the spectrum, some labral tears occur due to too much motion of the joint versus an impingement. In these cases, joint mobilization is not a good idea, but soft tissue work can be great as the muscles around the joint tense up to protect it. 

Manual therapy (and similar adjuncts like dry needling and cupping) feels good, but the secret sauce of physical therapy is targeted strength training. This is how we “build stuff up”.   Pain tends to shut down muscle function around the joint. This is your body’s way of protecting yourself (“it hurts, so don’t move!”). Strength training can get those muscles activated again, and research shows that strength training can actually help control pain.  Your PT should be working one-on-one with you to find exercises that feel good, and don’t aggravate your symptoms. 

Once you have a baseline of pain-free strength behind you, you and your PT will work together to gradually progress you back to your sport. We call this “graded exposure” to movements that become more and more sport-specific as your pain decreases and you get stronger. For most sports this means increasing the range of motion you move through, increasing the load you’re using during training, and progressively increasing your impact activity. We monitor how you feel for 24 hours following an increase in activity to make sure your hip is happy with the load, and just keep climbing the ladder from there. This is why it’s so important, as an athlete, for you to see a clinician who specializes in sports rehab. They are the only ones who understand the demands of your sport and know how to appropriately progress you back to meeting those demands on a regular basis.

If you are struggling with hip pain that’s significantly impacting your ability to train and compete, contact our sports specialist, Dr. Kate. She’s been through this too, and is here to help!  

You can email Kate with any questions or comments: [email protected]

Hip Pain

If you’re young and athletic and are experiencing pain at the front of your hip, know that you’re not alone. Anterior hip pain is actually a very common experience among runners, triathletes, soccer and hockey athletes, as well as dancers and gymnasts. 

 

Like other parts of the body, pain at the front of your hip can mean a lot of different things.  For runners and soccer players especially, repetitive impact activity can lead to a stress fracture of the femoral neck or shaft – which presents as pain at the anterior hip with running, walking, and jumping. Soccer and hockey players are also susceptible to groin strains, or pubic bone pathology due to the strain on the inner thigh during that sport. A diagnosis that’s common among all of these sports, and many more, is femoroacetabular impingement (FAI) and labral pathology.  

 

The hip is a ball and socket joint, formed by the acetabulum – the “socket” – on the pelvis -and the head of the femur, on your thigh bone.  The joint is surrounded by a rim of cartilage called the labrum (heard this term before? There’s one on your shoulder joint too!), which helps the joint absorb shock and also deepens the socket, creating more stability through the joint. 

 

hip painFemoroacetabular impingement – FAI – can be diagnosed with an x-ray.  Essentially what impingement means is that ball-and-socket joint isn’t fitting together perfectly, and there are three ways this can occur. First is “pincer” impingement, which means that there is an outgrowth of bone on the socket. This leads to the acetabulum and femur coming into contact too early in the range of motion.   Second, there is “cam” impingement, which means there is a bony growth on the head of the femur, meaning that it cannot glide in the socket without “catching” or “pinching” on the labrum. Lastly, it is actually most common to have a combination of these. 

 

FAI can occur without labral pathology, and labral pathology can also occur without FAI; but, frequently, they do occur together. Labral tears can cause a significant amount of pain, however it must be said that just because a tear is seen on imaging does NOT mean this is the source of pain. There have been several studies showing that when imaging the hips of young, active individuals who don’t have hip pain, up to 70% of them have labral tears. 

 

SO…you’ve been diagnosed with FAI and/or a labral tear. Now what? 

 

Luckily, there has been an explosion of medical interventions for hip pain, as well as significant improvement in the way rehab professionals treat.  

 

Injection Therapies: An orthopedic surgeon may choose to inject the joint with a corticosteroid to decrease any inflammation in the joint. Alternatively, some surgeons can do “regenerative injections” – either Platelet-Rich Plasma (PRP) or bone marrow aspirate concentration (BMAC), both of which serve to stimulate healing of the labrum and cartilage. 

 

Surgical Interventions: There are several arthroscopic surgical techniques that can be used to correct FAI and repair labral tears.  For FAI, the surgeon may perform an osteoplasty – essentially shaving down the bony outgrowths so that the joint surfaces can roll and glide on each other smoothly.  Surgeons can also use sutures or anchors to secure torn portions of the labrum back to the acetabulum; this can significantly decrease painful clicking and catching. In more involved cases, the surgeon can also take cadaver tissue and create a brand new labrum for the patient.  

 

It is important to note that these medical interventions, advanced as they are, do not guarantee pain relief.  Surgery in particular CAN be extremely helpful, and as such it is still considered the gold standard treatment – but like we talked about earlier – pathology does not always equal pain. Therefore “fixing” or eliminating the pathology does not guarantee elimination of pain.  Surgery should be considered a last result option, if injection therapy and high-quality sports rehab do not help. 

 

Speaking of sports rehab….stay tuned for our next article to learn how we help our athletes with hip pain back to the playing field – with or without surgery!  Have questions?Email me at [email protected]

Kate Wason, PT, DPT

Arthritis: Take back your life

What is it exactly, and how can you get back to the things you love? Unfortunately, we hear the phrases above far too often. If you have arthritis and have had an x-ray to confirm your diagnosis, you’ve likely heard one or two of these troubling phrases. The truth is, sometimes these are a poor choice of words. I hope aim to provide you with some peace of mind, by explaining what arthritis is, the reasons why it develops, and what you can do about it.

What is Osteoarthritis?

Osteoarthritis (OA) is a condition that has been affecting an increasing amount of the aging population. It typically affects the larger, weight bearing joints in the body, but can also be found within the smaller joints of the hands, feet, wrists, etc. Development occurs when the cartilage begins to wear down over time. This can lead to increased loading of bony tissue, poor movement mechanics, or even the growth of new bony tissue usually called bone spurs. 

Since arthritis usually becomes painful, it is typically associated with a decrease in activity level. This decrease, which I’m sure most of you can attest to, is out of fear of making things worse due to something a doctor or friend has told you. Interestingly enough, reductions in activity can actually increase symptoms, pain, and progression of the disease. Although it is counter-intuitive, it’s true! 

Whats the deal with my cartilage?

Cartilage helps our joints absorb forces and move smoothly. Did you know that the cartilage in your joints is actually 10x’s more slippery than ice?! This is what allows our joints to flex and extend without much effort. So, whats the number one thing you can do to keep your cartilage healthy? Move! Every tissue in our body is highly specialized and needs certain stimuli to thrive and survive, and cartilage is no exception.

Lets think about the knee for example: Compression and sliding of the joint surfaces create a sponge-like mechanism for the cartilage. When compressed, metabolites are squeezed out and when relaxed the cartilage expands again taking in nutrients. It’s just like a living breathing tissue! When activity is stopped or avoided, this process no longer occurs which can exacerbate the degenerative process leading to worsening arthritis. So what can movement do for your cartilage?

  • Movement stimulates the cells that make cartilage to reproduce, which allows these cells to create more cartilage.
  • Movement promotes tissue nourishment.
  • Movement reduces the amount of metabolites within the tissue.

Why else should you exercise for arthritis?

Just like cartilage, muscles are important for protecting joints as well. They function to not only help us move and stabilize our joints, but also to help dissipate forces going to the joints. Without adequate strength, these forces need to be absorbed by other structures (think cartilage in our joints). This is another reason why avoiding activity with arthritis can actually make the pathology worse. 

People with OA are often told to avoid certain activities including squatting, running, etc. However, I believe this is the opposite of what should be done (see above). OA develops over a long period of time, not after one set of squats. Continuing to squat, run, or any other activity is not going to independently speed up the degenerative process.

That said, there are some ways to begin activity to help set you up for success:

  1. Slowly ramp up activity within your pain tolerance to allow the cartilage to mature and adapt  
  2. Build a strong base of muscles to be able to dissipate the forces being placed on the joint 
  3. Find activities that may be lower impact to build strength before loading the joint (water aerobics, swimming, etc.)
  4. Find a great PT to help you along the path to recovery and improvement of function

You should always discuss your options and activities with your healthcare provider before starting any new regimen or treatment. If your skeptical, we challenge you to try increasing your activity slowly, stick with it for one month, and see how you feel. I’m willing to bet you may find you have less pain. 

If your not sure where to start, feel free to call to book and appointment or reach out to me at [email protected] to get started!

Here’s a great article that discusses the benefits of exercise for OA and may be a good reference for where to start. I promise it is an easy read!

Chronic Back Pain

Chronic back pain is caused by a number of different contributors, and is defined as back pain that lasts longer than three months or that occurs episodically.  It can affect people of all walks of life, regardless of age or physical condition.  

The medical community doesn’t understand everything about chronic back pain yet. Questions persist on why some people have it and others don’t; or why some episodes last longer than others; and why imaging results don’t always paint the correct picture. Imaging and blood work may even show things like lumbar degeneration or disc herniation, though these findings don’t prove useful because these positive findings often don’t come with pain or other symptoms at all. On the other hand, so many people with chronic back pain will receive no positive findings from blood work or imaging at all. 

The good news is that backs are just like any other body part, and the will heal.

We do have a good understanding of some common causes of chronic back pain as well as an understanding of how pain can manifest itself.  Many people experience going to bed feeling fine and waking up with significant back pain. This can be caused by swelling of a disc as it re-hydrates during the night.  Another common trigger is doing something simple like reaching for the milk carton and the back suddenly spasms. This is the result of poor motor control and the spasm is a protective mechanism.  Sometimes it is more obvious and we experience pain during an effort of some kind like sneezing or lifting something heavy. However focusing only on the possibility of what has been “damaged” can lead us into unnecessary imaging, inappropriate treatments and much higher healthcare costs while still not solving the underlying problem. 

Pain is defined as an unpleasant physical and emotional sensation that we experience when injured OR when there is a threat of injury and no actual tissue damage present. 

It is a protective mechanism our brain uses to keep us from getting hurt.  It has biological components, psychological components and sociological components. Unfortunately, we can get stuck in a loop where we get very good at experiencing pain and our brain tells us our back is hurting even when nothing has been done to injure it. This short video does an excellent job of explaining further.

If you experience this, here are some things to consider. 

  • Your back will heal- just like an arm or an ankle. If you twist your ankle one year, and then several years later you do it again, you don’t become fearful of having a ‘bad ankle’.  The same holds true for your back.  
  • Move around as much as you can as pain allows. Moving is better than resting. If it isn’t resolving quickly, considering seeing a chiropractor or physical therapist. They are trained to help relieve your symptoms and give you the tools needed to reduce the likelihood of future episodes, and help you learn to better manage such things on your own. 

If your chronic back pain is constant and not episodic, then a multi-modal approach is best, especially if it hasn’t responded well to individual treatments. There is excellent evidence for a multidisciplinary approach as well as solid evidence for exercise therapy and spinal manipulation. You can read the full guidelines from the American Academy of Family Physicians here.

You should have a team that includes a pain management physician, a chiropractor or physical therapist and a mental health therapist that work with you to help with your symptoms. A psychologist trained in Cognitive Behavioral Therapy can be very helpful in these situations. If you’re having chronic back pain and have questions, please feel free to email me at [email protected]

Samuel S. Spillman, DC