WE ARE NOW OFFERING TELEHEALTH VISITS TO IMPROVE SAFETY AND ENSURE CONTINUITY OF CARE
In order to keep our patients safe who still wish to be seen in the clinic, we have established new guidelines and requests for patient care. :
1. If you have traveled outside of the country, please do not request or attend an appointment until you have surpassed the minimum 14 days of quarantine. The same applies if you have traveled to a domestic ‘hot zone’ NY, CA, LA, etc.
2. If you are feeling unwell (whether you think its allergies or not), please reschedule your appointment. No cancellation fees will apply during this precautionary timeframe.
3. If you are over 60 years of age or have any underlying health conditions, please reconsider attending your appointments at this time. You have an increased health risk associated with this virus and we would like to minimize that risk, if at all possible.
4. Upon entry and exiting our clinic, please sanitize your hands with the sanitizer located near the check-in kiosk.
5. Please be cognizant of our social distancing measures. Our waiting room allows 6ft of distancing as does our treatment area. Our providers will adhere to maintaining 6ft of distance whenever possible during your treatment.
6. We will be keeping windows and doors propped open as weather permits to allow constant air flow and to prevent our patients from repetitively touching door handles etc. Please dress appropriately as the clinic may be cooler than usual.
7. Our providers may wear masks and will be wearing gloves when performing any manual therapy on our patients.
As we remain open, the safety of our patients and staff is our number one priority. We have made changes to cleaning of the clinic space and equipment as well as to our scheduling policies during this time. Thank you for your patience and understanding during this trying time.
Abby Wambach. Golden Tate. Morgan Brian. Colin Kaepernick. Sue Bird. RGIII. Mia Hamm. Allen Iverson. Tom Brady .
What do these individuals have in common, aside from being highly accomplished professional athletes?
They were multi sport athletes all the way through high school. That means they played one sport in the fall; another one in the spring; some of them a third, still different, in the winter; and likely took summer as an off-season where they remained physically active – playing kickball with friends, jumping in the lake, riding bikes around the neighborhood – but weren’t formally training for a sport.
As a sports specialist physical therapist, parents are constantly asking me when, and whether, their child should specialize in a certain sport. I understand -when you notice that your child is good – even exceptional! – at something, you want to help them develop that as best you can, as soon as you can. You also generally have the ability to do so, with school teams, travel teams, and local leagues in abundance.
So when SHOULD a young athlete specialize in one sport? As late as possible. Here’s why.
Risk: Overuse Injury
Repetitive stress is one of the primary causes of sports-related injury. Despite how we usually consider children to be “spry” and “resilient”, they are actually much more susceptible to certain kinds of overuse injury than adults because 1) their skeletons are not fully developed and 2) they are not able to build muscle strength and hypertrophy the way adults are. When a young athlete participates in the same sport year-round, they are only developing one set of skills, one set of movement patterns; this can lead to increased risk of injury outside their sport too. Additionally, repetitive movements like pitching a baseball, bringing the shoulder through a swim stroke, or striking a soccer ball actually involve higher forces going through the body than you might think. This puts extra stress on the athlete’s still-developing muscles, tendons, bones, and especially growth plates.
It needs to be said too that the number one risk factor for sustaining a sports injury is….having had a previous sports injury! Overuse injuries, while they’re rarely a career-ender (but can be!), are in many ways setting the young athlete up for a tough ride in their sport.
The developing brain of a young athlete is not meant to focus on a singular task day after day, year after year. Quite the opposite – children and adolescents need variety in order to thrive and grow, both mentally and physically. The more specialized a young athlete becomes, the more likely they are to become frustrated and, well….burned out. Did you think burnout was just for medical students or adults working desk jobs they hate? Think again. When kids do too much of one thing, and experience too much pressure from coaches and parents, they will fold, and it is harder for them to recover than it is for adults with fully developed brains.
Burnout is a huge problem that has dire health consequences for young athletes. Involvement in sport has endless benefits, from learning how to work as part of a team to keeping a person’s heart and lungs healthy to controlling their weight. If an athlete becomes burned out by their sport at a young age, they are much less likely to ever participate in sport; and are even less likely to continue with physical activity. This puts them at risk down the road for obesity and cardiovascular health issues. You can see how this is not just a problem at the individual level, but at the societal level as well. The key to keeping young people involved in sport all through life is VARIETY.
Reward of Waiting: Athletic Prowess
You read the names I listed above. There are countless more. The more variety a child has in their athletic activity, the more comprehensive their athletic development. Athleticism is not the same thing as having skill at a particular sport. Athleticism refers to strength, power output, speed, agility, reaction time, and endurance. Sport-specific skill refers to things like refining your pitching biomechanics, honing the accuracy of your shot on goal, working on your running form, gaining confidence with tackles. Sport-specific skill, of course, is important for performing well and reaching the highest levels of a particular sport BUT, this should be built on a foundation of athleticism. Skill work is the steering wheel, athleticism is the engine. Build the engine first; and the best way to do that is variety. Running cross-country in the fall is a great way to build endurance so that you can play the full 60 minutes of your lacrosse game in the spring without needing a sub. Playing soccer in the fall helps build that sprint-endurance capacity you need for your finishing kick in the 800m spring outdoor track season. Riding bikes through the neighborhood with your buddies all summer allows you to rest and recover from a tough spring season while still keeping you active. Sport variety, with natural periods of exertion and rest, help your athlete grow from a curious child into a strong, athletic adult.
Reward of Waiting: Growing a high-functioning, well-adjusted adult.
Above EVERYTHING else, sports should be fun. This obviously goes for adults as well as kids, but it needs to be said that your child is not a small adult – they do not have the mental capacity to go to work at the same job day in and day out the way we do as adults. Think of their sport like a job; it is not hard to see how playing soccer 365 days a year can eventually come to feel like a job. Kids are meant to spend most of their time playing, exploring and having fun, and movement is one of the best ways to do that. There is no reason for any child under the age of 18 to be experiencing burnout or injury; let’s not take their childhood from them too early. I promise, it will have no detrimental effects on their ability to be a high-performing adult. Quite the opposite in fact.
If you are curious about how to optimize your child’s athletic development, reach out to our sports specialist Dr. Wason. She can answer any questions you may have, provide athletic development training sessions for healthy athletes ages 10-18, and physical therapy services for young athletes with overuse injuries. [email protected]
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:
- The obvious, moving from 4x’s a week to 5-6x’s a week and increasing mileage
- Moving from a treadmill which absorbs some shock to pavement
- Flat to hilly terrain
- Even to slightly tilted or cracked sidewalks
- Going from a consistent speed or cadence to one that is likely more varied
- Change in temperature
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.
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
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]
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!
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.
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
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
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]
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.
Femoroacetabular 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!