Knee Pain! Osteoarthritis!


To my fellow Boomers out there ….. How are your knees doing?  We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof.  Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.

 WHY KNEE OSTEOARTHRITIS?

Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older.  It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking.  Ouch!  The prevalence of osteoarthritis is rapidly increasing due to two main factors.  Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years.  Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration.  One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it.  Wow!  Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.

WHAT IS IT?

Osteoarthritis is the joints response to structural damage caused by mechanical problems.  It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint.  If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.

MECHANICAL STRESS YOU SAY?

Pathological mechanical stress of the knee joint may be due to:

  1. Increased overall load through the weight bearing joint surfaces (e.g. obesity).
  2. Reduced load bearing surface area thereby increasing the pressure (same force through a smaller area) exerted through the joint (e.g. misaligned joint: bandy or bow-legged).
  3. Repetitive impulsive loading of the joint (e.g. trauma, doing moguls).

Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis.  Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively.  Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well.  Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.

HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?

Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees.  Walking results in a force through the knee equal to 3 – 4 times your body weight each step.  If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take!  Talk about happier knees!  An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.

For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.

In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors.  Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few.  Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition.  As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed.  A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life.  Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function.  Who would not like that!?

All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis.  The therapists work as part of a team comprised of you the patient, your physician and the physical therapist.  Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.

YOUR CALL TO ACTION!

  1. If you are overweight start a simple lifestyle change that entails weight loss (Call Joe Dibble, dietician at Sierra      Strength and Speed, for a consult.  He is really knowledgeable and practical.)
  2. Call Custom Physical Therapy so we can evaluate your      arthritic knees and set you up with appropriate treatment.
  3. Forward this post to someone you know who has sore      knees or you think may be interested in the information.

You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain.  You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.

Break a Leg? Literally!


I really enjoyed Laura’s blogging of her total knee replacement.  I think this is a great idea and one which can help other people who are potential knee replacement candidates get a sense of what the process looks like from a patient’s perspective.

Great job, Laura.  We all hope you are doing well.

Break a Leg? Literally!.

Total Knee Replacement Season – What does the rehab look like?


Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less.  An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.

The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA).  So what does the rehabilitation process involve?

The first thing to understand is that 50% of a successful outcome is the caliber of the surgery.  If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly.  That is the easy part of the process; after all you slept through it!

Then you wake up and realize your knee hurts.  It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work.  You have difficulty transferring from supine (lying on your back) to sitting and then to standing.  Now you have to walk with a walker, another foreign experience.   After 3-5 days, the doctor may send you home from the hospital.  Now you need to get into the car to be driven home.  This requires you to bend your new knee, another daunting thought.  Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.

HELP!

Physical therapists now become your best friends and should be for a number of weeks to months following the surgery.  You will be guided through a steady progression to return you to full function.

FIRST INPATIENT PHYSICAL THERAPY:

You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker.  You will also need to ascend and descend stairs,  You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair.  Detailed instruction should be given regarding how to control the postoperative swelling.

Avoiding DVTs:  perform the embolic isometric contraction sequence of the calf, quadriceps and gluteus musculature (in that order).  Also, do ankle pumps.

Surgical wound care:  keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently.  The knee became infected and was never the same again.  Luckily it was not a TKA and the infection, therefore, did not enter the bone.  It is worthwhile doing it right and accepting you will be a little dirtier than usual!

Walking:  The majority of TKA patients start walking with a front wheel walker, day one or two after surgery.  The large base of support gives the individual more stability.  You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently.  This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon).  As a result, you have difficulty straightening your knee and controlling it in full extension.  When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.

Negotiating stairs with your walker:  The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker.  All homes have at least one to three steps to ascend from the garage to the house or at the front door.  Just remember:  the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.

AROM:  Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!).  The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight.  They will also instruct you in heel slides to regain knee flexion.  If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game.  With 90° of flexion you can get into and out of as well as sit in the car that will take you home.

Transfers:  Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent.  You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode,  avoiding low chairs like a couch.  You walker is your friend here to and you must focus on safety in all your mobility.

Control the swelling:  This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail).  Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day.  You, the patient, must be vocal about this to get it done.  You will be glad you followed this procedure.  Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them.  Do not get the bandages wet (see paragraph above on infection!).  Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.

Now you are home.  Feel better already, albeit a little beaten up I am sure.  Out patient physical therapy now takes over.  (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).

OUT PATIENT PHYSICAL THERAPY:

The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists.  Here is where the hard work really starts and you must be dedicated.  Focus on the right things and you will get a great result.

Note: There is no need for the physical therapist to aggressively bend or straighten your knee.  This may inflame the joint and increase the likelihood of arthrofibrosis.  I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required.  I measure at the beginning of each physical therapy session to track progress.  If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.

Rehabilitation is typically broken down into phases.  Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling.  Progression is not based purely on a timeline.

Phase 1:  Post op days 1-10

Goals:

  1. Understand the goals of the rehabilitation process.
  2. Good pain control (pain less than 5/10)
  3. Good control of swelling.
  4. Can contract your quadriceps.
  5. Can do a straight leg raise (SLR) with minimal lag (minimal loss of full knee extension when you raise your leg off the table while sitting).
  6. Full passive extension (straight knee).
  7. Active knee flexion 90°.
  8. Independent gait and transfers.

Phase 2: Weeks 2 – 12 post-op

Goals:

  1. AROM 0°-130° (we routinely are attaining 140° or more)
  2. Mild joint effusion (swelling within the joint).
  3. Can keep knee straight between physical therapy sessions.
  4. Full SLR.
  5. Normal gait pattern.
  6. Independent in a suitable gym and/or home program based on specific individual needs of the patient at discharge.

So, there is a lot of work to do in recovering from a total knee replacement.  It is not rocket science but it does require focused dedication.  Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.

Your call to action:

  1. If you are planning on a total knee replacement (or any other joint replacement) and have questions of any sort, call us at Custom Physical Therapy and a physical therapist will address your questions.  Call 775-331-1199.
  2. Forward this to a friend, family member or coworker who may be having a total knee replacement.
  3. Forward this post to your physician and have them post a comment.  It would be great to have their input too.
  4. If you have had a total knee arthroplasty, please post a comment.  People having knee replacements would benefit from hearing what worked and what challenges you faced during your recovery.
  5. Do something kind for a stranger today!

 Thanks for reading this.

 André

A quick survey!


I am interested in how people decide where to go for their physical therapy. Let us know how you pick your provider and watch the results.  Should be interesting.  Knowing this information will help Custom Physical Therapy’s efforts to provide better services to our patients.  Thanks for your efforts.

Pre- Employment Screening – Limiting work injuries.


The goal of a pre-offer or post-offer pre-employment screen (PWS) is to mitigate risk in an effort to minimize workers compensation claims.  In high risk jobs, those which cost your business the most in workers compensation claims due to higher injury rates, there are essential and critical job functions which can be tested prior to placing an employee in a position which may result in an injury.

Matching the right worker to the job is not a new concept, but has grown with the advent of companies concerned with providing an “Industrial Athlete” approach to the workplace – essentially ensuring that their employees are “game ready” and able to meet all challenges ahead of them. So, how should you proceed?

The first thing to do is decide if the pre-offer or post-offer screen should be used.  The pre-offer pre-employment screen identifies the applicants who are physically able to safely complete the essential job functions of the position for which they are applying. It also will give you a baseline assessment of their physical abilities.  If they do sustain an injury at work, this is the baseline physical ability to which they will be rehabilitated too.  A post-offer pre-employment screen performs the same function but you can include a medical examination too.  The advantage of a post-offer over the pre-offer screen is that you can ascertain if the applicant you have offered the job to contingent on passing the PWS has any disability (e.g. are they under physical limitations by a physician due to a prior injury). The functional test has a significant advantage over just doing a medical screen, as an employee may not choose to report a pre-existing condition.  The functional test will uncover and thus document this unreported inability to perform tasks if their pre-existing condition is deemed a hindrance to performing the job demands.

Now your company must identify the high risk jobs within your business.  High risk jobs are those which are simply physically difficult to perform.  They are not easily modifiable to the employee nor are they easily changed to improve safety.  Hence, the employee must be fitted to the demands of the job.   These jobs historically may include heavy lifting, highly repetitive functions or aerobic activities.  Is there a manufacturing or laborer position which results in a larger proportion of your workers compensation costs?  Do you have musculoskeletal injuries occurring in a particular type of worker in a production line?  Is there a high turnover rate for a particular position at your business?  Are there employees who are physically taxed during the work day (sweating, out of breath, unusually fatigued) and hence avoid doing the more challenging aspects of their job by giving it to the newer, younger employees?  If you have a “Yes” to the above questions, your business should be performing pre/post-offer pre-employment screens on these specific high risk employees as part of the selection process.

The next step is to develop a well-constructed, objective, accurately measured job demands analysis (JDA) for each high risk job you identified.  This entails evaluating the job to ascertain the essential and nonessential tasks and objectively quantifying them.  This process involves close teamwork between the employer, the physical therapist performing the JDA and worker representatives.  Teamwork such as this produces a JDA that accurately reflects the high risk job functions and will comply with the American with Disabilities Act and the U.S. Equal Employment Opportunity Commission laws.  Not only is the JDA used for PWS design, it is also used in rehabilitating any injured workers.  The JDA should be used by the physical therapist treating your injured worker to design the rehabilitation program based on essential job functions listed in the JDA.  In addition, the physical therapist will be able to clearly ascertain if the employee is ready for a safe and most importantly a sustained return to work. This same JDA becomes the foundation for any Fit for Duty testing, Job Transfer or post injury evaluation job placement.

Utilizing the JDA, the PWS is then developed by the physical therapist.  It tests the essential job functions prior to placing the employee in the high risk position.  The final PWS will involve combinations of lifting, pushing, pulling, carrying, ladder climbing, overhead arm use, cranking, kneeling, crawling and any other essential job functions specific to the job in which the employee will be placed on passing the test.  All tasks will have a critical cadence which must also be assessed to place these tasks in a physical demands category: sedentary, light, medium, heavy or very heavy.  Job specific weights will thus be lifted to job specific heights at job specific critical cadences.  Job specific weights will be pulled or pushed for job specific distances.  It is important that all tasks tested in the PWS are absolutely specific to the job. All tests in the protocol have to have a solid foundation of evidence supported by peer-reviewed and published papers to validate a proper extrapolation to a full eight hour workday.

Is this a cost-effective program for your business?

Consider the following savings reported by companies who utilize this approach:

  1. Lear Seating performed 104 PWS in a year.  Thirty percent of applicants failed the test indicating they were unfit to complete the demands of the high risk job.  Total Savings: $2,073,000.
  2. A frozen foods company reduced their musculoskeletal injury rate by 41.7%.  Total Savings: $5,153,500. Return on investment:  3:1.

Considering the average cost of industrial injuries ($13 to $15 billion annually for musculoskeletal disorders), setting up a program to limit injury rates and hence workers compensation premiums is a good idea for any company which has high risk jobs.

By matching physically suitable employees to the appropriate high risk jobs you are mitigating risk, reducing lost time and thereby improving productivity and yielding a better bottom line through a healthier workforce.

André Meintjes, M.P.T., C.F.E.,Ph.D. is a physical therapist and owner of Custom Physical Therapy in Sparks and Reno, Nevada.  Contact him at 775-331-1199 or ameintjes@usphclinic.com

Further information can be viewed at www.custom-pt.com or www.fit2wrk.com

Shoulder Instability – Part 2 of Shoulder Series.


We see many patients with shoulder instability thanks to either genetics giving them ligamentous laxity (you can’t pick your parents) or due to trauma causing a subluxation or dislocation (You have to live life!).

 
What is shoulder instability?


Recall the last post in which I described the bony structure of the shoulder as a basketball on a tea cup saucer – built for mobility. In an effort to keep the basketball centered in the tea cup saucer you have the rotator cuff muscles (“SITS” – Supraspinatus, Infraspinatus, Teres Minor, Subscapularis) functioning to control the biomechanics of the glenohumeral joint. The long head of the biceps muscle runs over the top of the humeral head (the ball) and attaches at the 12 o’clock position on the glenoid fossa (the socket). In addition, there are very strong ligaments within the joint capsule. This joint capsule surrounds the ball and socket like a rubber boot that encases the springs of a car – the entire joint is within the capsule. The ligaments within the capsule are the superior, middle and inferior glenohumeral ligaments. Then we have the labrum, a triangular shaped ring of cartilage around the glenoid fossa (the socket). It deepens the socket.

Such an incredible structure must have specific functions. Broadly categorized they are:

1. Create static stability – this is done by the ligaments, the capsule, the bony/labral structure.

2. Create dynamic stability – done by the rotator cuff and the long head of the biceps muscle.

Shoulder instability occurs when either static or dynamic stability is constrained. Let us look at two broad categories of shoulder instability:

 
1. Atraumatic Instability – failure of the static and dynamic stabilizing forces due to genetic ligamentous laxity and/or rotator cuff malfunction (weakness, poor proprioception). You may be aware of someone who does that age-old party trick of subluxating (partially dislocating and relocating) his/her humeral head inferiorly (downward) under his/her own muscle power. This creates a sulcus sign – a divot beneath the acromion (recall from the previous post?) as the humeral head drops downward. Why? The above listed static restraints are looser than normal and hence there is more movement in the joint.

 
2. Traumatic Instability – need I say this one really hurts!? If there is a blow to the proximal humerus (upper arm) forcing the arm into combined extension (backwards), abduction (away from the body) and external rotation (hand rotated outwards) there may be an anterior dislocation. The humeral head pops out of the glenoid fossa to the front. If there is axial loading of the humerus (a force directed upward from the elbow to the shoulder like falling forwards onto your outstretched hand with elbows locked or falling onto your elbows) while the humerus is adducted (across your body) and internally rotated (hand turned inwards), the shoulder will dislocate posteriorly (backwards). Very rarely is there an inferior dislocation and even less so a superior one – we will not cover these in this post.

 
What does physical therapy do for a patient with either an atraumatic or a traumatic dislocation?

 
1. Atraumatic dislocation: The primary goal in physical therapy is to maximize the rotator cuff function so that the dynamic stabilizers can compensate for the failed static stabilizers. Yes, this means improving the rotator cuff strength. This is, however, not enough. The rotator cuff muscles must work in concert with each other and with the primary (larger and stronger) muscles which move the shoulder e.g. deltoid, pectoralis major. Rhythmic stabilization exercises are done to train the rotator cuff to keep the humeral head centered in the glenoid fossa while performing a variety of both static and dynamic tasks in the clinic. The rotator cuff muscles must contract together to compress the humeral head into the glenoid fossa thus creating a secure scapulohumeral connection (recall last post?). They must also be able to contract selectively to resist the forces created by the primary movers of the shoulder so that the humeral head does not move off center too much. If it does move off center the shoulder could subluxate, dislocate or simply impinge tendons on the acromion thus causing pain and dysfunction.

 
2. Traumatic dislocation: The primary goal after a traumatic dislocation is to avoid surgical stabilization. However, this mechanism of injury frequently requires surgery due to damage to stabilizing structures. However, a well constructed rehabilitation program can prove beneficial in avoiding surgery or, at least, can maximize the range of motion and rotator cuff strength preoperatively which, in my experience, results in a significantly better outcome following surgery. The physical therapist will help the patient regain normal range of motion and strength while protecting any traumatized (torn?)(unstable!) structures. Techniques used by the therapist will be joint and soft tissue mobilization to improve the accessory motions of the humeral head within the glenoid fossa, appropriate stretching to regain full range of motion while protecting traumatized structures and then progressive strengthening of the rotator cuff musculature in a selective manner – for example, anterior dislocations need stability anteriorly so more focus will be placed on tightening up and strengthening anterior structures.

 
In summary:
1. If you need to choose between atraumatic or traumatic shoulder instability I would suggest the atraumatic variety! This typically responds well to an expertly designed shoulder stabilization program (which you do for the rest of your life!).
2. Traumatic dislocations of the shoulder frequently require surgical intervention.
3. Shoulder joint function is dependent on static and dynamic stability mechanisms functioning in concert.
4. When you go to physical therapy for shoulder instability you should be prepared to work really hard both in the clinic WITH the physical therapist AND at home doing a comprehensive home exercise program specifically designed for your shoulder and your needs.

 
YOUR CALL TO ACTION!
1. Please forward this on to your friends, family members and co-workers.
2. Call us with any questions you may have regarding this post or stop by one of our clinics to get your questions answered.
3. POST something on this blog. Custom Physical therapy would love to hear from you.

NEXT POST: SHOULDER IMPINGEMENT

Shoulder Pain – Part 1


Shoulder pain can be due to tendinitis, tears of the rotator cuff, a labral tear, an unstable joint, referred pain from the neck, an acromioclavicular joint separation, a dislocation, or buritis, to name a few musculoskeletal causes. This post is the begining of a series addressing shoulder pain, a fairly common problem.  In 2003, the Center for Disease Control (CDC) estimated shoulder pain affected 13.7 million people in the United States.

A brief description of the anatomy will help with understanding the reason for the different causes of shoulder pain.

Consider the bony construction of the joint:  There is very little bony stability in the design of the shoulder.  It is designed for mobility.  The head of the humerus (the ball) sits in the glenoid fossa (the socket) like a basket ball sits on a tea cup saucer.  Yes, thats the geometry, a really big ball on a small shallow socket.  Clearly this is built for mobility and not stability.  Contrast this anatomy with the hip joint which is build for stability.  Here the head of the femur (the ball) sits deep in the acetabulum (the socket) which almost surrounds the ball (it is deeper than the glenoid fossa) giving far greater structural support to the joint from the bony anatomy.  This contrast in design between the hip and the shoulder fits perfectly with the function of the joints:  the hip is a weight bearing joint for walking while the shoulder is a non-weight bearing joint which serves to place our hand anywhere in space so we can use the fine motor skills of our hand e.g. scratch your back, tie your shoes, put on a shirt, push open a door, pull a rope, play tennis, throw a ball, shoot hoops!

The glenoid fossa is part of the scapular (shoulder blade) which is attached to the rest of the skeleton via the clavicle.  The acromioclavicular joint (A-C joint) is the joint between the part of the scapular called the acromion and the distal (away from the midline of the body) end of the clavicle.  This is where shoulder pain may be felt from an A-C joint separation (more in later posts).  The sternoclavicular joint (S-C joint) is the joint between the proximal (midline) end of the clavicle and the sternum (“breast bone”) and is the only bony attachment of the shoulder to the rest of the skeleton!  Yes, the scapula floats freely on the back of the rib cage and is held in place by numerous muscles which orchestrate its movement when you use your arm.  A floating scapula and a huge ball in a shallow, small socket … now that is a joint made for movement!

Why is this important to physical therapy?

Look at the moving parts that have to function together for optimal use of your arm!  The scapula has to rotate to angle the glenoid fossa correctly with various arm movements e.g. reaching to a cupboard above shoulder height.  This is not possible if the A-C joint and the S-C joint are not moving correctly.  So these joints have a combined function – if one is not moving well then the arm may not move correctly and you may have shoulder pain.   The muscles controlling scapular motion also need to be contracting at the right time with the right force to ensure correct positioning of the glenoid.  Physical therapists evaluate and treat all these aspects of shoulder function in patients with shoulder pain.

Consider the soft tissue construction of the joint:  What is the rotator cuff?

The rotator cuff is a set of 4 muscles which originate on the scapula and insert strategically around the humeral head.  Working together, these muscles control the biomechanics of the glenohumeral joint keeping the ball centered in the socket.  You can visualize the rotator cuff as the seal balancing a ball (the humeral head) on its nose (the glenoid fossa or socket).  They are frequently referred to by the acronym SITS muscles:

  1. Supraspinatus
  2. Infraspinatus
  3. Teres minor
  4. Subscapularis

The supraspinatus muscle is the most commonly involved muscle in shoulder pain as it passes through the small space between the top of the humeral head and beneath the acromion of the scapula.  It can thus be compressed between these 2 bones (referred to as impingement).  If the biomechanics of the joint is abnormal (various reasons) there can be repeated tendon irritation against the acromion thus creating shoulder pain.  Alternately, the shoulder pain can be a consequence of the supraspinatus tendon being forcefully compressed between the humeral head and the acromion e.g. jamming the shoulder joint by falling forward onto your hand with your elbow straight, or pinching the tendon if you fall onto an outstretched hand forcing your arm all the way above your head.  The resultant inflammation of the supraspinatus tendon is referred to as rotator cuff tendinits.  Repetitive overhead tasks (e.g. electrician working overhead, pitching in baseball, lifting packages to shelves above shoulder height) may also inflame this tendon as the rotator cuff, as a whole, may fatigue and hence alter the biomechanics of the shoulder resulting in impingement and hence shoulder pain.

The other 3 rotator cuff muscles (infraspinatus, teres minor and subscapularis) serve as shoulder depressors.  That is, they pull the head of the humerus (the ball) downwards as the arm is elevated.  This reduces the compression of the supraspinatus tendon as described above.  So, if you are lifting a heavy object overhead to a shelf and the shoulder depressors are over powered by the muscles doing the lifting,  the humeral head will ride high in the glenoid (the socket) and result in impringement as described above.

In summary, the shoulder is a very complex joint.  It’s function is dependent on synchronous functioning of the muscles which move the scapula as well as the rotator cuff which keep the ball of the joint centered in the socket.  These muscles must have suitable strength, balanced (front and back of shoulder) flexibility as well as sufficient endurance.

A well trained physical therapist will evaluate all these aspects of shoulder function and determine what deficits are causing the shoulder pain.  He/she will then design a rehabilitation program to address the cause of the shoulder pain, correcting the deficiencies thereby abolishing the pain and regaining full function.

YOUR CALL TO ACTION:

  1. Post a question (or topic) you would like to see addressed.
  2. Forward this to a friend, family member or co-worker.
  3. Call us with any questions you might have.
  4. Await the next post on shoulder pain: Glenohumeral instability. 

Tendinitis


Tendinitis is the inflammation of a tendon and of tendon-muscle attachments i.e. where the tendon attaches to the bone (insertional tendinitis).  It is an overuse phenomenon, can be excrutiatingly painful and functionally debilitating.  Treatment should focus on addressing the cause of the tendinitis, reducing the inflammation and the pain, and remodelling the tendon through a controlled exercise progression.

Most frequently seen diagnoses in our physical therapy clinic are rotator cuff tendinitis (supraspinatus tendinitis), posterior tibial and peroneal tendinitis (pain in the foot and ankle), tennis elbow (lateral epidondylitis), achilles tendinitis, patella tendinitis and iliotibial band syndrome. Interestingly, we have recently been seeing an increase in tendinitis of the guteus medius (hip abductor muscle).  We see golfer’s elbow (medial epicondylitis) less frequently than tennis elbow.

Despite tendinitis occuring in tendons all over the body, the approach to treating the condition remains the same for each structure involved.  You treat the tendonitis by following a specific intervention progression.  The exercises are different for the different tendons but the principle remains the same:

 

Treat the cause of tendinitis.

It does not matter what tendon is involved, the cause is most frequently overuse.  Overuse means the stress the tendon has had to endure, as a result of the force it is being asked to apply (both intensity and frequency), results in microtrauma to the tendon structure and hence inflammation.  If the tendon is not given rest, it does not have the opportunity to recover.  Examples of activities which can result in tendinitis include typing, repeated gripping on a production line, fly fishing, overhead lifting or repeated jumping.  Ankle sprains may cause tendinitis in the posterior tibialis and peroneal tendons of the foot.

So, the first line of attack is to decipher what the causative activities are and modify them.  For most rapid resolution, these should be stopped completely to avoid the continuous trauma to the tendon.  Sometimes this is not possible and a program of relative rest must be designed by the physical therapist:patient team.

 

Treat the inflammation.

Part of controlling the inflammation is reducing the stress on the tendon.  The physical therapist will address this with you in detail.  As mentioned above, rest gives the tendon the opportunity to recover from the microtrauma (as noted above).  Non-steroidal anti-inflammatories or even streroids may be prescribed by your physician at the same time.  Physical therapy interventions to control inflammation include ice in the form of an ice pack or even ice massage and, iontophoresis – the administration of an anti-inflammatory, dexamethazone, to the tendon utilizing electrical currenct to faciltiate the passage of the medication through the skin (Yes!  No needles!).

 

Treat the pain.

By following the above suggestions, pain should subside over time as the inflammation is controlled.  If the pain is severe enough your physician may subscribe analgesics (pain killers).

 

Remodel the tendon.

Here is where the work is!  Your physical therapist will teach you how to stretch the involved tendon as well as progress you through a specific exercise regimen which involves both concentric and eccentric exercises which will stress the tendon.  A concentric exercise is one in which the muscle contracts and shortens at the same time e.g. the bicep contracts to bend the elbow bringing the coffee cup to your mouth.  An eccentric contraction is one in which the contracting muscle is lengthening while it contracts e.g. the bicep contracts and lengthens as it controls the extending elbow to put the coffee cup back down on the table.  An eccentric contraction places more tension on the tendon than a concentric contraction and can thus promote tendon remodelling.  Eccentric exercises are more aggressive than the concentric type.

The goal of the stretching and strengthening progression is to stimulate tendon remodelling.  This improves the flexibility and tensile strength of the tendon.  This, in turn, improves the tendons ability to tolerate the original activity which caused the tendinitis.

 

Soft tissue mobilization?  Deep transverse friction?

What about soft tissue mobilization and deep transverse friction?  Soft tissue mobilization of the involved muscle belly and, indeed, of the surrounding musculature can be helpful in alleviating discomfort.  It is less aggressive than deep transverse friction and is definitely more comfortable.

Deep transverse friction is used to stimulate blood flow in the involved tendon and break up any adhesions which may have developed as a consequence of the microtrauma of the tendinitis.  It is done by applying significant pressure (up to 7/10 pain) over the tendon with the thumb or index finger and rubbing in a direction transverse to the direction of the tendon fibers.  Sound like fun!?  It is done in conjunction with the tendon remodelling exercises detailed above.

 

YOU CALL TO ACTION:

  1. Make sure you visit us early on in the process because it is much easier to treat than if you have had tendinits for more than a few weeks.  EARLY INTERVENTION!
  2. Make sure you specifically ask to be sent to physical therapy the very first visit you have with your doctor so you can be shown the specific exercises and enjoy the hands-on treatment from the physical therapist.
  3. Pass this on to someone you know who has tendinitis.
  4. Call us with any questions you may have: 775-331-1199.

Pain? What is it really?


The International Association for the Study of Pain defines pain as follows:

“Pain is an unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage.”

So what does that mean anyway?

  1. Pain doesn’t feel good.
  2. Pain is influenced by our emotional status.
  3. There may or may not be any trauma to the body.

Put differently, per Dr. Lorimer Moseley, Ph.D., a world-renowned pain researcher and clinician at the Prince of Wales Medical Research Institute in Sydney, Australia:

“Pain is the conscious correlate of the implicit perception of threat to body tissue.”

Huh?!

This suggests that pain does not originate in the tissue due to injury or a degenerative process.  Instead, it is a very complex interaction between the peripheral tissues (e.g. torn muscle, knee arthritis, lumbar disc herniation, whiplash injury, broken bone) and the brain. The brain processes information as follows:

  1. From your experiences in life – how did your family deal with pain when you were growing up?
  2. Cultural factors – Italian men have been shown to be stimulated by a blue placebo pill and sedated by a red one while men of other cultures in the study experienced the opposite.
  3. Social and work environments – if you enjoy your job and like your boss then less pain may be experienced than if you don’t.
  4. Your expectations as to what might happen as a consequence of the pain – if you do not have an adequate understanding of a particular injury you have sustained you might be concerned as to how you will return to work or your hobby/sport and thus experience more pain.

So pain is an output from the brain after the brain has processed all the above information as well as the nerve impulses coming from the injured area, called sensory input.  Once it has synthesized the need for an output you will then “be told by your brain” if something is painful or not. Think about the person I spoke to a few years ago who had a motor cycle accident and felt minimal pain when she stopped skidding along the highway and noticed her leg 20 feet away from her!  Why no pain then? The brain had compiled an appropriate response at that time that suggested she had more important survival needs and thus did not feel pain. When she was loaded into the ambulance and the emergency personnel took over (they were in charge of survival now) she began to feel pain.

So what kind of output from the brain results once it has decided there needs to be a response to the “painful situation?”

  1. Pain is produced which makes us do something to address the “dangerous”  position we are in.
  2. The sympathetic nervous system causes the fight or flight reflex.  Increases in heart rate occur.  Energy systems are stimulated.  We sweat. We are ready to take evasive action!
  3. Muscles are reactive and are set to fight or run away as well as protect the damaged area. If you have torn a hamstring muscle you know you cannot move due to spasms – a physiological brace per se!
  4. The endocrine system is mobilized and in so doing hormones circulate in the blood stream to help mobilize energy for use by the muscles and reduce other nonessential body functions such as intestinal motility.

The most recent research into pain has changed the viewpoint from one of a noxious stimulus causing pain (i.e. a peripheral origin of pain) to one of the brain being the decision maker as to what is painful and what is not (i.e. a central origin of pain). How complicated is that! It is not as simple as treating the injured tissue to relieve the pain. Pain needs to be treated from multiple angles with a multi-disciplinary approach.

YOU CALL TO ACTION!

  1. Check out Dr. Lorimer Moseley’s blog at : http://bodyinmind.org/resources/journal-articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/
  2. What do you think of this new concept of how pain is generated? Post your ideas on this blog for others to read.
  3. Invite a friend who is struggling with pain to read this.
  4. Call us at any of our three clinics if you have any questions:

Sparks location: 775-331-1199

South Reno location: 775-853-9966

Northwest location: 775-746-9222

Swelling, Edema, Effusion, Echymosis, Bruising: What’s the difference?


If you sprain your ankle severely you may hear your doctor and physical therapist mention the words swelling, edema, effusion or bruising. If you have surgery on your knee for a meniscus tear or a ligament reconstruction you will hear similar terms (and see them too!). What is that bruising and swollen area in the muscles in front of your shin (tibia) when you ding your lower leg on the corner of a coffee table?

The Definitions (Dorland’s Medical Dictionary):

Swelling is defined as “a transient abnormal enlargement or increase in volume of a body part or area not caused by proliferation of cells.” The good thing is that it is transient so, as we have all experienced, swelling subsides over time (see below for hints on treatment).  It is due to some form of trauma to the body such as an ankle sprain (the ankle looks bigger) or a muscle tear (larger girth of your thigh with a hamstring tear) or a surgery (which is really a trauma to the tissue). Fluid accumulates – the enlargement is not a consequence of cell division (proliferation) such as may occur with an enlargement due to cancer in a tissue or the enlargement seen in a bone from a healed fracture.
Edema is “the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body.”  Here fluid accumulates between the cells (intercellular). This may be a consequence of tissue trauma, poor circulation resulting in lower leg edema, heart failure, blood clots, lymph node resection as happens with breast cancer, renal failure,  pregnancy and cirrhosis to mention a few causes.  In outpatient musculoskeletal physical therapy we mostly see patients who have edema due to surgeries (e.g. knee replacements) or an injury causing tissue trauma.  We may treat someone who has a comorbidity (co-existing condition) which has resulted in edema but if caused by a particular medical condition your doctor will be treating it, not us.
An effusion is “the escape of fluid into a part or tissue, as an exudation or a transudation.”  An exudation is “the escape of fluid, cells, or cellular debris, from the blood vessels and their deposition in or on the tissues, usually due to inflammation.”  Inflammation may occur due to trauma or surgery.  Blood vessel walls become more permeable or may be compromised. Fluid and cells can thus escape from the artery or vein into the surrounding area. Transudation refers to the passage of fluid across a membrane or tissue surface (e.g. the synovial lining of the knee joint), which may or may not be due to inflammation. In physical therapy, we commonly see a joint effusion where fluid has accumulated in the joint.  This may follow a knee or shoulder surgery or an ankle sprain, for example.
Ecchymosis refers to “a small hemorrhagic spot in skin or mucous membrane, forming a nonelevated, rounded or irregular, blue or purplish patch.” This is a medical term for  bruising which is defined as “a superficial injury produced by impact without laceration.” Both describe blood leaking into the surrounding tissue. You know this one!  Remember biting your cheek when you were chewing gum?  Your mucous membrane inside your mouth went blue.  Next time you do it tell who you are with that you have just created some ecchymosis in the mucous membrane of your cheek!

In summary, based on the above definitions, you can safely say that swelling refers to the enlargement of the body part involved and the swelling is due to fluid accumulation (edema, effusion) or blood accumulation (ecchymosis, bruising).

How do we treat swelling, edema, effusion, ecchymosis and/or bruising?

  1. Rest, Ice, Compression, Elevation:  “RICE” is what we know it as.  Rest refers to the need to limit activity so as not to create further trauma.  However, rest is relative.  That means you should move the affected area or tissue gently to keep it mobile and prevent stiffness during this phase but not so much that you increase the pain and swelling associated there with. There are times when movement is contraindicated … think broken bones! Ice for the first 48 to 72 hours after an injury with resultant swelling. The goal is to limit fluid accumulation in the injured area by reducing blood flow to the area. Cold temperatures result in blood vessel vasoconstriction reducing blood flow to the area which decreases the inflammatory exudate (see ‘exudation” described above) or bleeding into the involved tissue or joint. Remember this: ICE IS NICE! Compression refers to the use of an elastic wrap to compress the injured area and thereby limit swelling. The amount of compression should not be so much that blood supply is cut off or pain is increased. Elevation serves to decrease the hydrostatic pressure in the affected body part by raising it above heart level. The reduced pressure decreases the exudate and increases fluid removal from the area.  Add in gentle motion and you have a complete package.
  2. Heat: Use heat after 72 hours with the purpose of increasing blood flow to the injured area to flush out the accumulated fluid and inflammatory by-products. Heat also improves tissue flexibility thus making movement easier which is another method employed to reduce fluid accumulation in a joint or tissue.
  3. Movement? Yes, you should keep the injured area moving gently unless you have been told not to by your doctor or physical therapist. Movement of the injured joint (e.g. ankle sprain) or tissue (contracting the injured muscle) promotes pumping of the blood from the site as well as limits stiffness.  As mentioned above, movement may be contraindicated … think broken bones!
  4. Limit aggravating activities. After the initial shock of the injury due to pain, swelling and the limited function often associated with it, you may feel ready to increase your activity level. This is fine but must be closely monitored so as not to increase the already present fluid accumulation and pain. Limiting aggravating activities but still moving as normally as possible promotes healing of the injured tissue. For example, if you sprain your ankle and it is swollen and bruised but you can tolerate walking on it without limping for 10 minutes on level surfaces without increasing your pain and fluid accumulation then do so but stop before your symptoms are aggravated. Or, if you strain your hamstrings you may be able to walk with a normal gait pattern on level ground but not negotiate stairs without increasing the pain and worsening the gait pattern. Therefore, limit the use of stairs. Recall, we want normal movement early on following the injury to promote tissue healing.
  5. Lymphatic drainage. This is a manual technique used by physical therapists who have additional training specifically in lymphedema management. It involves very gentle massage techniques in specific areas of the body in a particular order to stimulate lymph drainage.  It is particularly effective for edema control. In addition to the massage techniques used, you are taught how to wrap the affected limb to promote drainage between massage sessions. You may also be taught how to massage yourself as a home program. If you need this type of treatment, make sure you ask the clinician you schedule with if they have specific training in this area. You can also look for a physical therapist who has this training via the National Lymphedema Network at http://lymphnet.org/.

In summary, swelling may encompass the terms of edema, effusion, ecchymosis and bruising as long as there is an increase in volume (size) of a body part or tissue due to fluid accumulation. RICE is the treatment of choice immediately after an injury/surgery but heat and controlled movement should not be avoided. If you have lymphedema you should consult with a physical therapist with specialty training in lymphedema management.

YOU CALL TO ACTION!

  1. What have you found most helpful in addressing the above symptoms?  Post your ideas on this blog for others to read.
  2. Invite a friend who has recently had an injury or surgery to read this and post their experiences.
  3. Call us at any of our three clinics if you have any questions regarding the specific application techniques to avoid ice or heat burns:

Sparks location: 775-331-1199

South Reno location: 775-853-9966

Northwest location: 775-746-9222