Physical Therapy for ACL Injuries

By Morgan Diver, PT, DPT

ACL is an abbreviation for the Anterior Crutiate Ligament. It is one of two ligaments that cross in the middle of the knee, connecting the femur (thighbone) to the tibia (shinbone).¹ Its role is to help stabilize the knee joint. An ACL injury refers to tearing of part or all of the ligament fibers.

Cause:

This injury most commonly occurs during sport or fitness activities that involve a sudden stop or change in direction¹ such as football, soccer, basketball, or skiing. Other causes include:

• pivoting with your foot firmly planted
• landing awkwardly from a jump
• a fall
• twisting or overextending the knee
• a car accident

How to know you might have torn your ACL:

• you hear or feel a “pop” in your knee when you are doing one of the above activities
• a large amount of swelling and/or bruising in the knee joint
• a feeling of instability or “giving way” in the knee
• limited knee movement
• pain in your knee when you place weight on your leg

Risk factors:

Women are at a greater risk then men due to:

• strength imbalance of the hamstrings (muscles in the back of the thigh) and quadriceps (muscles in the front of the thigh)
• structural body differences
• joint laxity / looseness
• hormonal influences
• smaller ACL size then men

Tests for diagnosis may include one or more of the following:

• X-ray – to rule out a possible fracture
• Magnetic resonance imaging (MRI) – to show the extent of injury
• Ultrasound – to check for injuries in the ligaments, tendons and muscles of the knee.

Treatment:

• rest, ice, compression, elevation (RICE) initially
• medication to decrease pain and swelling
• physical therapy to improve range of motion and strength along with decreasing pain
• surgical repair / replacement of the torn ligament
• bracing to improve stability of the knee

Prevention includes a proper training program:

• improve your overall conditioning
• strengthen your hamstrings (muscles in the back of the thigh)
• use proper technique for jumping/landing, cutting and change of direction

Sources:

1. http://www.mayoclinic.com/health/acl-injury/DS00898
2. http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-injuries-topic-overview

3. Dutton M. Orthopedic Examination, Evaluation, and Intervention.

2^nd ed. New York, NY: The McGraw-Hill Companies, Inc.; 2008:1012-13.

Exercise Guidelines during Pregnancy            

By Jessica Wyen

If you have been following a regular exercise program before pregnancy there is no reason why you shouldn’t be able to continue throughout your pregnancy.  Check with your health care provider before beginning a program or continuing.  Your health care provider can give you exercise guidelines based on your past medical history.  (Photo from www.bestpregnancytips.com.)

The American College of Obstetrics and Gynecology recommends greater than or equal to 30 min exercise per day most days of the week. ¹

General guidelines include:

• Avoiding holding your breath during activity
• Avoid fall risk activities such as: horseback riding or skiing
• Avoid contact sports such as: football, and basketball
• Avoid activities such as: jumping, hopping, skipping – though if you were a runner before, you can continue on a modified routine
• Avoid deep knee bends
• Avoid exercises in positions that make you uncomfortable such as laying on your back
• Avoid exercises in hot, humid weather
• Avoid allowing you heart rate to raise >140 beats per min
• Wear comfortable clothes and footwear while exercising
• Take multiple breaks
• Drink plenty of fluids
• Weight training is advisable to improve tone but avoid using weights that may strain your lower back
• Eat a healthy diet
• Never exercise to the point of exhaustion

Warning signs to stop exercising include:

• Chest pain
• Abdominal or pelvic pain
• Headaches
• Feeling fait or dizzy
• Vaginal bleeding
• Irregular or rapid heart rate
• Increased swelling in your legs
• Shortness of Breath

References:

1. http://women.webmd.com/exercise-during-pregnancy
2. http://www.americanpregnancy.org/pregnancyhealth/exerciseguidelines.html
3. http://www.acog.org/publications/patient_education/bp119.cfm

By – Dan Pasiak

Hip bursitis (also known as Greater Trochanteric Bursitis) is by definition an inflammation of a bursa at the side of the hip.  A bursa is a small jelly-like sac that usually contains a small amount of fluid. The bursa acts as a cushion between bones and overlying soft tissues, helping to decrease friction between the bone and soft tissues gliding over top of it.

When irritated, the bursa swells and causes pain that may be sharp and intense at first and then gradually become achy and spread out. It may be worse lying on the side of the injury, or with running, walking, or stair climbing.  Pushing on the boney point of the hip will typically increase pain.

Hip bursitis is most often a symptom of another underlying problem in the muscles surrounding the hip or the joints near the symptoms including the hip joint itself as well as the sacroiliac joints or low back.  Consequently, people who are diagnosed with hip bursitis may have other symptoms not caused by the bursa itself including back pain or sciatic pain due to the body attempting to compensate for an imbalance.  One of the most frequent causes of hip bursitis is due to an imbalance between two hip muscles, the tensor fascia lata (TFL) and the gluteus medius.

People often have a weak or underused gluteus medius, causing an overuse of the TFL muscle which rides over the hip bursa.  The increased force over the bursa increases the friction on the bursa and causes swelling.  Other causes of increased force at the bursa may be a sacral iliac dysfunction, foot overpronation, a leg length difference, or tight muscles at the front, side or back of the hip.

At Probility Physical Therapy, we typically treat hip bursitis through a multi-faceted approach.  We start with trying to determine why the bursa is having increased stress placed on it in the first place and then treat that dysfunction.  This is often done through mobilizing (helping to move) any joints that are “stuck”, by decreasing muscles spasms / tightness, by using arch supports / orthotics in the feet and by using a heel lift if there is a true leg length difference.  Each of these treatments can help to decrease the pain and swelling in the hip.

Achilles Tendonitis

Author – Sarah Reese

Achilles tendonitis or tendinopathy is one of the most common overuse injuries among recreational athletes, accounting for up to 9% nine percent of injuries in elite and recreational runners, and more frequent in older runners.⁴

The Achilles Tendon attaches the calf muscles (the gastrocnemius and the soleus) to the heel bone and is what allows you to push off when walking or running.  Tendonitis is the inflammation, swelling, and irritation of a tendon.³

Symptoms:

• Sharp pain or mild ache in the back of your leg above the heel usually felt after running or other sports activity
• Decreased pain but stiffness at rest³
• Bump in Achilles tendon
• Cracking or creaking of Achilles tendon with palpation¹

Causes:

• Repetitive use or overuse of the tendon

• Low arches in feet without supportive shoes
• Tight calf muscles or decreased ankle mobility
• Change in training regime – new terrain, more pavement, increased hills, jumping activities
• Less recovery time after exercising
• Weakness in calf muscles
• Exercising without warming up¹

Treatments:

• Rest or less strenuous activities for a few days/weeks
• Increase length of calf

• • Stretch calf (both soleus and gastroc)  (see picture below)
  • Roll out calf with a foam roll  (see picture below)

• Buy shoes that properly fit your feet
• Properly warm up and cool down when exercising
• Calf strengthening – eccentric and concentric exercises
• Friction massage of the Achilles Tendon
• Icing

• • Ice cup

Get immediate care if the pain is severe – this is not a symptom of Achilles Tendonitis¹

**If it does not improve after using these suggestions, considering talking to your family physician or a physical therapist. **

What to expect when you are treated for Achilles Tendonitis at Probility:

On the first day at your initial evaluation, we will spend the majority of the session determining the cause of your Achilles Tendonitis.  It is our goal to go beyond giving you temporary relief so that we can prevent future injuries and allow you to go back to your favorite daily activities.  We will assess how your legs, pelvis and back are functioning because they all can alter how your feet hit the ground when you are walking or running, which can cause overuse and pain.

We use a manual therapy, or hands-on, method to improve foot, ankle and calf mobility.  We may also do myofascial release, or a type of massage if it is necessary to help restore normal movement of your muscles.

Following the hands-on portion of your treatment session, we move into exercises which are mostly focused on stretching and eccentric strengthening.  Other treatment modalities may be used to help control pain, swelling and muscle spasms.

If our suggestions for self-treatment don’t fix your pain, consider physical therapy so we can help you get back to your normal activities as soon as possible!!

1. http://www.mayoclinic.com/health/achilles-tendinitis/DS00737/DSECTION=symptoms

2. http://www.sportsinjuryclinic.net/cybertherapist/back/achilles/tendinitis.htm

3. http://physicaltherapy.about.com/od/orthopedicsandpt/ss/Tendonitis.htm

4. http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=14&hid=8&sid=d0bd61c6-0854-4357-a1d7-a642a3764b3c%40sessionmgr12 Satyendra  Effectiveness of physical therapy for Achilles tendinopathy: An evidence based review of eccentric exercises

5. http://www.google.com/imgres?imgurl=http://www.empowher.com/files/ebsco/images/si55551225.jpg&imgrefurl=http://www.empowher.com/media/reference/achilles-tendonitis&usg=__7_MZXyQ1QtNaMHFCpzYAejYGkiI=&h=255&w=391&sz=21&hl=en&start=0&zoom=1&tbnid=yfFEf_vnYyoUQM:&tbnh=119&tbnw=183&prev=/images%3Fq%3Dpictures%2Bof%2Bachilles%2Btendonitis%26um%3D1%26hl%3Den%26sa%3DN%26biw%3D1440%26bih%3D708%26tbs%3Disch:1&um=1&itbs=1&iact=hc&vpx=1121&vpy=378&dur=459&hovh=181&hovw=278&tx=229&ty=98&ei=uJOjTLXTDNGUnQfLjYGJBA&oei=uJOjTLXTDNGUnQfLjYGJBA&esq=1&page=1&ndsp=31&ved=1t:429,r:22,s:0

6. http://www.google.com/imgres?imgurl=http://www.joint-pain-solutions.com/images/ice-massage-cup-ready.jpg&imgrefurl=http://www.joint-pain-solutions.com/achilles-tendonitis-treatment.html&usg=__cRE1NJU6-mZe_f0yNXpGTgHWzLI=&h=181&w=200&sz=12&hl=en&start=0&zoom=0&tbnid=7DjQ0q80zjJc7M:&tbnh=94&tbnw=104&prev=/images%3Fq%3Dice%2Bcup%2Bfor%2Bachilles%2Btendon%26um%3D1%26hl%3Den%26biw%3D1440%26bih%3D708%26tbs%3Disch:1&um=1&itbs=1&iact=hc&vpx=179&vpy=248&dur=270&hovh=94&hovw=104&tx=64&ty=13&ei=xpWjTObsApOLnAeZ54iJBA&oei=xpWjTObsApOLnAeZ54iJBA&esq=1&page=1&ndsp=21&ved=1t:429,r:0,s:0

http://sportsmedicine.about.com/od/flexibilityandstretching/ss/FoamRoller_6.htm

http://www.google.com/imgres?imgurl=http://www.systonfootcare.co.uk/images/calfstretch.jpg&imgrefurl=http://www.systonfootcare.co.uk/footexercises.php&usg=__ziad-JspxRCys6fJQ1EtmXMnh84=&h=160&w=481&sz=13&hl=en&start=105&zoom=1&tbnid=N0uPoy86DK2afM:&tbnh=57&tbnw=170&prev=/images%3Fq%3Dcalf%2Bstretch%26um%3D1%26hl%3Den%26sa%3DN%26biw%3D1440%26bih%3D708%26tbs%3Disch:10%2C1653&um=1&itbs=1&iact=hc&vpx=916&vpy=401&dur=207&hovh=128&hovw=384&tx=204&ty=84&ei=lpajTILcLMP58AbkqfGvCg&oei=ZJajTPHNKsmLnAfGtfGIBA&esq=4&page=4&ndsp=33&ved=1t:429,r:13,s:105&biw=1440&bih=708

There is a fairly common form of headaches called “cervicogenic headaches”, which means that the headache is actually originating from a problem in the neck.  This can be from a joint in the neck not moving correctly and causing referral up to the head but it is most commonly from one or more muscles in your neck having a “knot”, or hypertonic area, in them and the knot referring symptoms up to your head.

What is significant about this kind of headache is that a person does not have to have neck pain at the same time of the head pain (but they also can).  This type of headache is significant to me because it happens to be something that I personally have 1-2 times per month.

I am going to focus on the muscular cause of headaches and typical pain patterns you see as well as why you might get them in the first place.

Common referral patterns and the muscles involved:

1.  Suboccipital Headaches – the suboccipital muscles are located at the base of your neck, where your neck and the back of your head meet.  These muscles tend to cause headaches that radiate from the back of your head, around the side or over the top and onto your forehead.  They can also skip any portion and just cause pain at the back of your head, side of your head or in your forehead only.

2.  Sternocleidomastoid Headaches – These are large muscles in your neck that run from the bone behind the base of your ear down to your sternum and collarbone, on each side.  They will tend to cause headaches that are located at your temple and wrap around your eye.

3.  Upper Trapezius Headaches – This muscle runs from the back side of your head down onto the top of your shoulder, on each side.  These muscles cause headaches that wrap around your ear, from the back, around the top and to the front, like a large fish-hook.

4.  Temporalis Headaches - This muscle sits right at the temple area of your head, which is just to the lateral side of your eye, on both sides.  Headaches from this muscle will stay right at the side of the head, where the muscle is located.

5.  Occipitofrontalis Headaches -the occipitofrontalis muscles are located at the back of your head, near the base.  These muscles tend to cause headaches that radiate from the back of your head, over the top and onto your forehead.  They can also skip any portion and just cause pain at the back of your head, top of your head or in your forehead only.

This is not a complete list of every muscle that can create a headache but what I see most commonly in my practice – Probility Physical Therapy.  If you ever have a headache in the areas described above, try massaging the muscles around the “X” points indicated for each one.  If you find a very tender spot which reproduces your pain, you’ve got a Trigger Point which is causing a cervicogenic headache!  Gentle massage to that spot will often relieve the headache, at least somewhat.  Good luck!