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Region Specific Uncategorized

Weak Ankles?

At Move Physio, we see a variety of orthopedic conditions in which we determine that the ankles and feet are at least partially responsible for. These conditions include knee, hip and even back pain. But what happens when the ankle has been injured, is weak or painful? As often as we see ankles with limited mobility, we also hear patients describe a history of “weak ankles” resulting in or from ankle sprains. Traditional rehabilitation in a typical physical therapy facility may incorporate an elastic exercise band for strengthening of the ankle musculature directly involved with the ankle. Even Consumer Reports published these exercises for preventing or fixing ankle sprains:

In terms of the big picture, I have a problem with these. These exercises do not resemble movements that we make in real life: walking, running, stair negotiation, or any functional activity that consists of our feet being on the ground. Look again at the pictures above. Do these resemble anything you do in real life? The gas and brake pedal are about the only things I can think of. Exercise band and ankle isolation exercises may be an appropriate start if weight-bearing is not allowed or is too painful. However, there is a lot more likely involved when a person describes his or her ankles as “weak.” The trunk (including the core), pelvis, hips, and the rest of the lower extremities, although far from the ankles, contribute greatly to overall function of the ankle. These regions “act on” the ankle. Greater efficiency above makes for less demand on the foot and ankles. As you’ve probably heard: “It’s all connected.”
Why is this important? It is because too many rehabilitation programs for “weak” or sprained ankles rely primarily on the exercises above. I question whether these types of exercises are doing anything at all. Minimal strengthening of the small muscles around the ankle will likely do very little the next time you run, jump, pivot or negotiate steps.
Do your ankles feel weak, roll or sprain easily? The key dysfunction may be from up above. If true weakness is found in the ankles then functional, foot-on-the-floor activities and exercises that target these muscles may be more appropriate.

Dr. John De Noyelles, PT, OCS, CSCS

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Methodology & Techniques Principles Uncategorized

All wound up?

What are you stretching?

I have written previously about short versus tight muscles, using an example of short or tight hamstrings limiting the ability to bend and touch your toes.  Think about the stretch feeling you get in the back of your thighs when attempting to bend and reach for your toes.  That stretch feeling is coming from the elongation of your hamstrings as muscle fibers are being pulled to their limits, right?  Maybe.  We don’t exactly know what structure is generating that feeling.  It may be muscle fibers, the tendons that attach the muscles to bones, or nerves under tension.     

Unlike skin, fascia, muscle, tendons and ligaments, nerves do not have elastic properties.  In other words, nerves don’t stretch well.  Nerves like to glide.  They run inside sleeve-like structures that allow them to slither and slide to accommodate movement.  The sciatic nerve and its branches, receiving connections from the brain and spinal cord, reach from your low back all the way to your feet.  This nerve moves and winds intricately through and around bones, muscles, tendons, and ligaments to allow for someone to bend.  So, what happens when a movement such as bending tugs on a nerve?  It is difficult to be precise, and symptoms are often vague, but any of the following are theoretically possible: feeling a stretch, numbness, tingling, pins and needles, burning, stiffness, or even pain.  This has been labeled ‘adverse neural tension,’ although ‘adverse neurodynamics’ has been used most recently and is more indicative of the mechanism behind the symptoms written above.1

Any of the symptoms noted above (stretch, numbness, tingling, burning, stiffness, or even pain) can be NORMAL. These symptoms do NOT mean that something is wrong.  I am confident I can put almost anyone in a position that tenses a nerve.  Tension on a nerve can be a normal limitation.  We can all feel these symptoms with specific movements and positions.  However, it is only when normal, functional, every-day movements are limited AND reproduce neural tension symptoms that suggest adverse neurodynamics may be at play.  How do we know?  It is not always clear, but physical therapists have specific tests that can help determine if adverse neurodynamics are contributing to your pain or dysfunction.  Tests involving the lower and upper extremities, including the sciatic, median, radial and ulnar nerves, are the most standard. 

In my experience, when adverse neurodynamics are involved they are only part of the picture of what brings someone to physical therapy.  There are typically other things that we need also need to work on.  As far as why a person experiences adverse neurodynamics is usually unclear.  I see it sometimes following surgeries, injuries, immobilization, and for reasons totally unknown.  It is important to differentiate certain musculoskeletal diagnoses, as adverse neurodynamic involvement may mimic common diagnoses like carpal tunnel syndrome and tennis elbow.2  A physical therapist examination can help determine this involvement and provide interventions to improve nerve excursion, symptoms and restore function.

Dr. John De Noyelles, PT, DPT, OCS, CSCS

References:

1 Ellis RF, Hing WA. Neural Mobilization: A systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008: 16(1):8-22.

2 Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008; 13:213-221.

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Principles Uncategorized

“If it’s not their ass it’s their elbow.”

A client of mine said this. I can’t take credit for it and please don’t hold me responsible for the foul language. She took an old saying and modified it to convey how her clients describe their current aches and pains. My client, although not in a healthcare profession, provides more competent healthcare advice than Google (and probably many licensed healthcare providers). She’s also been handing out my business card left and right because she has been on the receiving end of competent manual therapy.

Pain comes in many forms and is ALWAYS a different experience for each and every person. It is an individual experience. Every working day, my client has a conversation with someone describing what ails them. “It’s always something… if it’s not their ass it’s their elbow,” she says. I understand what she’s saying: people are in pain and either can’t find relief or accept it for what it is. Let me be clear: pain is not normal. Here are a few client populations I see who carry this common sentiment and the reason, I believe, that sentiment is inaccurate:

  • “I’m old (or getting old)”: Someone should not be in pain simply because they are aging. Seek conservative treatment (physical therapy) and make yourself more functional. Don’t use pain, stiffness, etc. as an excuse for not doing the things you love. The active approach involves a call to us.
  • “I’m an athlete, things are supposed to hurt”: Although constant, year-round athletics with no rest may be a burden on our bodies, it doesn’t mean we have to suffer through it. Pain is a warning signal that something is not right. A movement pattern may be dysfunctional and treatment can be the key to unlocking your full potential.
  • “I have a job with heavy physical requirements”: Sure, repetitive, laborious work will likely lead to aches and pains, whether you’re sitting at a computer 40 hours a week or slinging tires across a local tire garage all day, every day. I’ve seen both extremes. Don’t deal with what you may think is normal pain because of what you do on a daily basis. Again, pain is not normal. Take the active approach with conservative therapy. Let us find your dysfunction and address it so that your daily activities are performed in a more efficient and less stressful manner.
  • “But I have arthritis”: For more on this please read THIS.

If it’s not your ass but your elbow, and especially “if you don’t know your ass from your elbow,” then take the active approach and seek conservative treatment. A thorough physical therapy examination is needed and a physician (MD) prescription is not typically necessary. Give us a call and we will help you get on the road to recovery.

Dr. John De Noyelles, PT, DPT, OCS, CSCS

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Condition-Specific Uncategorized

“But I have Arthritis!”

Arthritis is an unfortunate term. Due to our association with the diagnosis, we picture an evil presence inside our body and a “disease” that spreads and wreaks havoc on our joints to cause pain and stiffness. We didn’t see it coming and we don’t know how it got there. We are the innocent prey, and the arthritis is the sly hunter that lurks and finally attacks when we pick something up, negotiate stairs, or reach overhead. The Internet is filled with pictures of people holding their Photoshop-enhanced red joints, perpetuating the pain, dysfunction, and anxiety one experiences. Just looking at these pictures tweaks my own joints.

Osteoarthritis is joint specific and not an overall, body-wide condition. Rheumatoid arthritis is a separate entity and should not be confused with osteoarthritis.  A true diagnosis of Rheumatoid arthritis is only made by a medical doctor following a series of specific tests. For our purposes here, only osteoarthritis will be discussed.

Technically, arthritis is inflammation of a joint. Pain and stiffness are possible symptoms.

Just because you have arthritis in one body part does not mean you have it elsewhere. More importantly, arthritis as diagnosed on a radiograph (x-ray) does not mean it’s causing pain, and the worse it looks on a radiograph does not equate to more pain.1

Instead of taking a passive approach to a diagnosis of arthritis, take the active approach. Non-painful exercise and continuing to be active are both paramount. Further assessment, such as provided by a physical therapist, may yield movement dysfunctions and musculoskeletal findings such as decreased range of motion and strength from nearby body parts that are contributing to undue stress on that arthritic, painful joint. Surgery is not the answer except in extreme degenerative or painful cases. Surgery also comes with more risk than a conservative approach that includes exercise and physical therapy. Allow us to identify your movement dysfunction so you can remain active. Together, we can keep the imaginary Photoshop red out of your joints.

Dr. John DeNoyelles, PT, OCS, CSCS

Reference:

1 Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskeletal Disorders. 2008; 9:116.

Categories
Methodology & Techniques Principles Uncategorized

The ‘Magic Wand’ of Therapy

Those in pain want an easy fix. Who can blame them? But relying only on pills or magical passive techniques typically won’t do if longstanding pain relief is the goal. To a fault, many healthcare practitioners tend to over-rely on passive techniques. Physical therapists are no exception. A passive treatment is one that is done to you with little to no participation on your part. Massage, manipulation, and therapeutic ultrasound are a few examples. Active treatments are those that you participate in such as exercise and certain types of manual therapy. Many passive treatments are effective in relieving pain. However, this relief is typically short-term when not followed by an active approach.

We happen to use a good amount of manual therapy at Move Physio primarily because we see positive outcomes from its use. However, we ALWAYS follow-up with active treatments to complement the manual therapy. For instance, manual therapy may help to reduce pain, increase range of motion, or improve functional movements. The next step is key. Once the threat of pain is decreased, reinforcement with movement and exercise will help maintain the improvement. Simply, the brain says to itself, “Hey… this isn’t so bad. I can do this and not have to report pain.” If mobility is gained through manual therapy, it is crucial to safely move in that new range so that the body adapts and learns how to control within its new expanded boundaries.

Physical therapy should not ONLY consist of ultrasound, heat, and stim. Unfortunately, this still occurs within the industry. Therapeutic ultrasound (the “magic wand”) is fortunately on the decline but some practitioners still use it. Most do it for 8 minutes for billing purposes. Nonetheless, research for therapeutic ultrasound demonstrates little to no effectiveness even with longer durations of 20-25 minutes of application.

It’s important that you evaluate the true effectiveness if you’re a patient of a clinic that performs purely passive treatments. You have every right to be an active participant in your healthcare. Need more information? Contact us and we will be happy to help.

John De Noyelles, PT, DPT, OCS, CSCS

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Region Specific Uncategorized

Knee Pain? Treat the hip.

Your knee hurts.  It’s been annoying you for a few weeks or months now, but you’ve been too busy to get it checked out.  Finally, you schedule an appointment with an orthopedist who gives you a knee-related diagnosis and writes you a prescription for physical therapy.  Or, you were aware that you could skip this step and you venture directly into an orthopaedic Physical Therapy clinic.  You tell your PT that something is wrong with your knee including when it started and what you were doing when it started.  After a thorough examination, the PT tells you that your hip muscles are weak and your hip and ankle mobility are limited.  Apparently, the PT did not understand that it’s your knee that hurts.  Time for a second opinion?  Probably not.

We often experience pain in a location that’s actually not the problem, while the true problem spot hides its devious self.  In the physical therapy world this is called Regional Interdependence, where one dysfunctional region is responsible for pain in another region.  The knee and hip relationship is no exception to this and provides a great example.

The knee is a joint that works in three planes of motion and is not limited to simply bending and straightening.  In fact, it rotates when you bend and straighten your leg and when you pivot.  This rotation is not a lot, but it’s significant enough so that you don’t walk around like a robot.  The hip on the other hand is a ball and socket joint that specializes in rotation.  But what happens if the hip, for one reason or another, loses some rotational mobility?  Well, if you were to pivot, squat, or perform an activity that requires rotation of the hip it’s not going to be there.  Something else, such as the knee, has to pick up the slack.  So now the knee is responsible for more rotation than it’s used to and it begins to let you know.  Again, that pain is like your car’s check engine light and you need to bring your car into the shop (or more appropriately, a physical therapy clinic) before things get worse.  You may have heard this: “It’s all connected.”  Truly, the knee and hip are connected.  The femur (thigh bone) is the same bone that makes up the hip and knee joints.  That means that hip muscles function for the knee, helping to promote and control our movements including rotation. 

Please recognize that this is only an example before you Google to find hip exercises, stretches, and mobility techniques for your knee pain.  The problem spot may be beyond your hips and involve your foot, ankle, pelvis, spine, and possibly more.  The problem may also be right at your knee, requiring treatment to where it actually hurts.  Only a thorough examination will tell. 

Dr. John De Noyelles, PT, OCS, CSCS

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Principles Uncategorized

Sleep series: Pillows

“If you’re not sleeping, you’re not healing”

I say this a lot.  When we sleep our bodies switch over from ‘go’ to ‘recovery’.  That is — if you let it.  This short article is a part of a series where I will be discussing some of the most important components of sleep.  Today, that topic is Pillows.

What to buy:

I’ll try to keep this short and sweet.  The type of pillow you need to be directly under your head is white down (not feathers).  I said down. Not down alternative, not ‘orthopedic,’ not foam, and definitely not filled with water or goo or anything else.  This does not change if you are a side, stomach or back sleeper, although the way you use it may change.  I’ll explain in a minute.  First, lets answer the most common response: “I have allergies.”  Thats OK!  You still want down…just zip it up in an allergen cover.  The pillow that I have found to be the greatest value can be found at Bed Bath & Beyond in-store.

Why Down?:

White down provides the best, most adaptable support without pushing back.  To understand what ‘pushing back’ means, push your finger into your foam pillow, then relax your finger.  See how it pushes back?  This means that the muscles in your neck are fighting that push-back all night, which does not allow for full relaxation.  Relaxation = recovery and repair.  Down alternative has inconsistent properties at best.  I won’t get into the water or goo.

When to use foam pillows:

If you are ONLY a back or stomach sleeper you can skip this section —your head only needs down.  Side sleepers: listen up.  Depending on how broad your shoulders are and how heavy your noggin is, down may not be enough and you may need more underneath.  If you’re a giant and a back sleeper, you may need this also.  To find out how thick that underneath layer needs to be, start by using a thin foam pillow and add a bath towel underneath.  Add layers until your head and neck can be supported in a straight, neutral position.

Switching positions, mattresses or pillows can take time to adjust.  Keep this in mind and experiment with variations. Next up in this series is POSITION HACKS.

 

Dr. Justin Sullivan, PT, DPT, OCS, CSCS, SFB, SFG

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Region Specific Uncategorized

Nagging Shoulder Pain?

If you have undergone previous therapy for shoulder pain then this exercise may look familiar:

If it looks familiar and you still have a painful shoulder, then maybe this exercise was not the most effective or appropriate. This exercise is one of several cookie-cutter activities for the rotator cuff. It is a standard go-to in the majority of orthopaedic and sports physical therapy clinics and proclaimed “cure” when searching for self-help for shoulder pain on the Internet.

More often than not, I find that these exercises do not help and may even increase pain. For most, the rotator cuff is already on fire and overworked. Trying to strengthen muscles that are working over-time is not the best method. Instead, addressing other limitations (such shoulder or spine mobility, for example) is a great first step.

Rotator cuff exercises are not necessarily “bad.” They may be appropriate with decreased pain AND strength. If I use them (which is rare), I like to customize and have my patients perform them in more functional patterns that mimic daily activities required of that patient.

The bottom line: there is so much more that can be done, with either exercise or manual therapy, which may better address your shoulder pain.

Dr. John De Noyelles, PT, OCS, CSCS

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Region Specific Uncategorized

The Gluteal Muscles: More than Seat Cushions

As a society we do a LOT of sitting. We sit during our morning and afternoon commutes, while at work, during meals, and while watching TV or using our mobile devices. This adds up to 12-16 hours per day. Our poor gluteal muscles take most of the brunt, as we shut them down and rely on their padding properties. If an alien race wanted to determine the role of our gluteal musculature, they would likely conclude that the primary function of the gluteus maximus is cushioning. Fortunately, these muscles are capable of so much more.

I often find untapped potential in my patient’s gluteal muscles. I will do a simple strength test and find weakness. After facilitating activation of these muscles through a variety of possible techniques, I then retest strength. Abracadabra! The patient then tests and feels stronger. How does this happen? It’s not because the muscles increased in size during one session. That takes weeks to months to occur. Instead, it’s more likely that the brain was reminded about these muscles. Basically, the brain says, “Hey, I remember you guys!”

If you have back, knee, ankle, or foot pain, or daily functional movements or your athletic performance are less than desired, a lack of punch from the gluteal muscles may be playing a role.

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Principles Uncategorized

Tug of War

Discover Your Potential

We all have the potential to perform better. We just have to know and learn how to use all that we have.

The night before my son had a tug of war competition between his class and the other kindergarten classes, I told him, “During tug of war, your power should come from your leg and butt muscles. Don’t only use your arms to pull. Instead, get low and dig your feet in.”

As you can see, he took my advice and put forth a maximum effort. Did he have an advantage because his father is a physical therapist? Possibly. Although I wasn’t there to pull the rope, perhaps I enabled his approach in order to tap into his full potential.

I didn’t coach the other kids and it didn’t seem to matter as his class won the competition. I like to think that the little guy pictured above, perfect form and all, made the difference.

Discover your potential at Move Physio.