Most of us have tweaked our ankle at some point or another. Typically we’re told it’s best to either stay off of it or brace it for a few weeks and it will heal. However, all too often there is an underlying process lurking deep down in the tissues that isn’t going to allow your ligament to heal fully, and leave you predisposed to chronic sprains.
Ankle sprains affect people young and old, in any population, and whether athletic or not. It may happen while playing – or cutting – during a sporting event; when walking on uneven ground or into a small hole in the yard; or you might miss-step off of a sidewalk. Sprains generally affect the outside of the ankle when the ankle rolls, making the anterior talofibular ligament (ATFL) the most commonly injured tendon – which attaches from your outside ankle bone to a bone in your foot.
Once an ankle sprain occurs, there is tissue damage. This can range from a few fibers tearing – causing minor discomfort for a day or two – to a full-blown tear. Unfortunately, with status quo treatments re-sprains are far too common.
We have sensors in all of the muscles, tendons, ligaments – and even in the joint capsules surrounding the joints. Sensors provide our brain with important information about stretch, muscle activation, and joint position. This information allows the brain to form an internal picture of how the joint is doing at that moment. When the initial injury occurs, these sensors get disrupted and stop working properly. When this happens, the brain is unable to create an accurate picture of how the joint is functioning. This altered picture causes the ankle to be less responsive to demands put onto it, preventing your brain to effectively stabilize the ankle. As a result, something simple you may have done thousands of times – like jumping and landing on a volleyball court – may be the cause re-injury. Minor re-sprains can also happen without you knowing. These small injuries usually occur with simple activities like walking in grass. Unfortunately, these minor injuries will continue the cycle of chronic ankle sprains and may delay healing.
So, bracing and rest may not always be the best treatment for ankle sprains.
Of course they have their place with more severe sprains. However, in the case of minor to moderate sprains, braces can actually decrease proprioception and strength, making the ankle more prone to even more sprains! Physical therapy – to build up strength – is often the best treatment for a patient with this condition.
Physical therapy in ankle sprains will help guide you through progressive exercises that will improve ankle muscle strength as well as retrain the joint sensors to perform their job properly. Treatments generally consist of balance and proprioceptive drills on a variety of surfaces and with targeted strengthening exercises. Treatments should be tuned to specific tasks that will be encountered often whether in sports (cutting) or in daily life (walking on uneven surfaces). This is the best route to train the ankle to react to different challenges and prevent chronic sprains.
Bryan Esherick PT, DPT
The official start to Spring is just days away and with it comes spring training. For some of us that means races and triathlons and for others it means golf, baseball, softball and tennis. Whatever your sport or activity, enjoying the warm Spring air and getting your body moving after the long, cold winter may be what you’re looking forward to the most.
Increased activity can bring injury – and while there is no such thing as injury “prevention”, there are measures you can take to reduce your risk of injury. Reducing risk is mostly about planning and timing. You want to give your body ample time to adapt. Your risk of injury goes up when you make sudden large changes in activity or load over a short period of time.
Check out these tips to help you enjoy and injury-free season:
- Don’t increase more than 10% a week. Don’t increase overall work capacity more than 10% whether you are training distance, or weight increase in strength training.
- 4-6 runs a week is optimal, more frequent runs are better than less frequent longer runs.
- Your shorter runs through the week should total more miles than your longest run
- If you have pain during activity, stop and reset, then try again. If you have pain again, you should finish for the day.
- If you have pain after your workout or the next day, don’t increase your miles/weight/repetitions until you are performing that day’s workout WITHOUT symptoms.
- Get enough sleep! If you aren’t getting enough sleep, your risk of injury increases significantly. You should be getting at least 8 hours.
- If you are taking anti-inflammatory medication to avoid/reduce muscle soreness your risk of injury is actually going UP. Inflammation is very necessary for healing and NSAIDs interrupt that process so you sacrifice long term gains as well as increase your risk of a muscle strain or tendinopathy. The soreness you felt is your body’s way of limiting you so it has time to adapt to the forces you are asking it to handle. Listen to your body!
- Your body systems adapt at different rates. Your cardiovascular system may adapt more quickly than your bones, muscles, joints and ligaments. Be willing to change your program to give your body more time to adapt.
- Remember, the point of exercise is to be fun and to keep you out of the doctor’s office, not put you into it!
If you liked this, please feel free to share it. If you’ve got any questions about your spring training plan, feel free to ask questions: [email protected]
Samuel S. Spillman, DC
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
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:
- MENTAL HEALTH:
- improves mood
- fights depression
- relieves anxiety
- improves cognitive function
- stimulates nerve creation
- boost self esteem
- builds social relationships
- PHYSICAL HEALTH:
- 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
If you’ve ever noticed an ache around the outside of your elbow that just doesn’t seem to go away, you might be experiencing a condition commonly known as tennis elbow. Once it starts, this type of injury can affect your strength and function in your arm. So, if you’re feeling that ache and haven’t done anything about it, now might be the time.
Despite its name, this condition rarely affects tennis players.
It’s most common in sports and occupations that require repetitive movements – think computer work, climbing, heavy labor jobs, etc. Tennis elbow is a form of a tendinopathy – affecting the tendons of the forearm muscles – classically called tendonitis. The tendons undergo a degenerative process as a result of highly repetitive stresses. This process causes: increased blood to flow to the area; collagen creating cells; and ground substance. This cascade of changes can lead to pain and discomfort in the area – as well as poorly formed tendon structure which is then vulnerable to further injury.
Due to the nature of the injury, and the general inability to stop activities that aggravate the condition, it can take from a few months to up to two years for the tendon to fully recover and for pain to subside. It is possible for the condition to subside on its own, but there are steps you can take to decrease the duration of the symptoms.
Treatments for this condition vary greatly from surgery at the most extreme end, and to wait-and-see on the other, with everything in between. At Balanced we focus on rehabilitating the tendon through gradual loading of the tissue to reorganize collagen; and soft tissue work to relax overactive muscles; and education to empower our patients to heal quicker. We generally recommend avoiding bracing, cortisone shots, and surgery. By optimizing the environment for the tissue to heal, our patients often obtain quicker results and are able to return to normal activity and reach their goals within a more predictable time frame.
Bryan Esherick PT,DPT
A good recipe can help you cook your way to one’s heart. Someone also once told me that the key to a happy life, is a happy wife. So, for this Valentine’s Day, I decided to put the two together and share this idea for your special holiday planning this week. h/t to Mark Bittman of the NYT for this inspired meal.
Black miso cod, miso soup, salad, rice, and chocolate ganache covered strawberries for the ever-coveted dessert.
This is a great recipe for someone who is not an experienced hand in the kitchen. It’s amazing, and tastes like the most complicated and delicate dish ever prepared. But, as it turns out, is really easy!
- Combine 1 cup of miso paste with 1/2 cup of sugar and 1/2 cup of sake and simmer in a small sauce pain. You can bring it to a boil but then let it cool.
- Lay out your Chilean Sea Bass or Black Cod (they are very similar) in 6-8oz pieces.
- Fire up your broiler. Place the rack 4-6 inches from the top.
- Generously coat the fish in the miso sauce.
- Broil until done, typically about 5 minutes per 1/2″ of thickness.
- Remove from the oven, plate and enjoy!
Pair it with some miso soup (also easy to make):
- Bring 4 cups of water to a boil with 1 tablespoon of dashi.
- Add 1/3 cup of red or white miso paste and stir.
- Add 6-8 oz of shiitake mushrooms and you’ve got a simple and flavorful miso soup in about 10 minutes.
I’d consider a simple tossed salad with Japanese style ginger dressing.
Lastly no Japanese meal is complete without a bowl of steamed rice! Any Japanese short grain will do, I usually choose Calrose.
Finish it off with chocolate covered strawberries, with fresh ganache:
- Destem and wash large, fresh strawberries
- Melt 8 oz of dark chocolate chips in a small pan inside of a larger one filled with water
- Slowly and steadily stir in ½ cup of heavy cream until fully mixed.
- Dip the strawberries and leave them to cool on some wax paper in the refrigerator.
*If you don’t mind a little corn syrup you could add a splash to the chocolate mixture (just a splash) and it will give the ganache a nice shine. But this is optional. Make as many as you’ll think you’ll eat.
Voila – simple to make, decadent and romantic Valentine’s dinner!
– 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)