The Injury Episode!

With Special Guest Dr. Ben Shatto

http://marathontrainingacademy.com/injury-episode

Marathon Training Academy

May 11, 2017

In this podcast interview with Angie Spencer (RN and Certified Running Coach) and Trevor Spencer (co-host of the Marathon Training Academy Podcast), we discuss the prevalence of running injuries, the top mistakes we see runners make, and answer injury related questions from runners.

In this episode we talk injury prevention with our friend and physical therapy doctor Ben Shatto. Plus we answer injury related questions from real everyday runners like you. Glutes, calves, hamstrings, IT Band, foot and knee pain . . . we cover it all! Listen to the podcast

Disclaimer: This blog post and podcast are not meant to replace the advice of your doctor/health care provider, or speak to the condition of one particular person but rather give general advice.

Q & A: How did I get a Stress Fracture in my Foot?

Q.  I have been diagnosed with a stress fracture in my foot.  What causes a stress fracture?  Now what should I do?  The doctor wants me to avoid any weight bearing for the next four weeks.  How do I heal?  Denise

A.  Thanks for your question, Denise.  I’m sorry to hear that this has happened to you.  Stress fractures are a unique type of bone fractures as they rarely occur due to a specific trauma.  Stress fractures typically occur due to a silique of events that leads to the bone not being able to handle the stress of your activity which results in a crack in the bone.  Stress fractures are common in the foot, but they can occur almost anywhere.

Initially, you might barely even notice the pain associated with a stress fracture, but the pain tends to worsen with time.  The tenderness usually originates from a specific spot and decreases during rest.  As the injury worsens, the pain tends to spread out and become more diffused with a focal area of tenderness.  You might have swelling around the painful area.  In some cases, the entire foot may begin to swell.

footpain

Stress fractures typically occur as the bone is subjected to a new unaccustomed force without enough time for recovery.  Bone adapts gradually to increased loads through remodeling, a normal process that speeds up when the load on the bone increases.  During remodeling, bone tissue is destroyed, and then rebuilt.  This is a similar process in muscle tissue.  When the load and/or volume of activity are too much for the bone, a fracture will occur.

Risk Factors for a Stress Fracture:

  • Certain sports.  Stress fractures are more common in people who participate in sports such as track and field, basketball, tennis, dance or gymnastics.  High repetitive impact sports tend to have the most stress fractures.
  • Increased activity.  Stress fractures often result from increasing the amount or intensity of an activity too quickly.  For example, people who suddenly shift from a sedentary lifestyle to being more active (increasing training volume significantly) or those who rapidly increase the intensity, duration or frequency of training sessions.
  • Gender.  Women are more likely to develop a stress fracture, especially those who have abnormal or absent menstrual periods (known as amenorrhea).
  • Foot problems.  People who have flat feet or high, rigid arches are more likely to develop stress fractures.  Worn or poorly fitting footwear or high heels can also contribute to this issue.  For runners, transitioning too quickly from a more built up running shoe into a minimalistic style can be a factor.
  • Osteoporosis.  Osteoporosis or osteopenia causes weakening in the bones that makes it easier for stress fractures to occur.
  • Prior stress fractures.  If you have experienced one or more stress fractures, you’re at a higher risk.
  • Poor nutrition.  Lack of Vitamin D, calcium, Vitamin K, and magnesium can make bones more likely to develop stress fractures.  Generally poor eating habits are also a factor.
  • Hard surfaces.  Spending long periods of time or training on hard surfaces, such as concrete, can increase your risk.
  • Smoking.  Smoking leads to poor blood flow and affects the body’s ability to heal and recover.
  • Obesity.  The heavier you are, the more forces that ultimately go through your foot.  Depending on how you are exercising, your particular footwear and the surface which you walk on can contribute to increasing your risk factors.
  • Gait abnormalities.  Alterations to your normal mobility (from either another injury or a change in your body) that affect how you typically move.  The change in mobility, along with your activity level, can be enough to overload the bone.  Particularly, when other risk factors are present.

In most cases, it’s not one specific risk factor that leads to the stress fracture, but a combination of risks and events that lead to the injury.  Diagnosis is usually through X-ray.  However, an acute injury may not initially show, so a second X-ray may be needed after a week or so to confirm the diagnosis.  A bone scan can also be useful to determine if there is an injury to the bone.

In the case of a poorly healing bone, the use of a bone stimulating electrical device may be recommended by your physician.

Initial Treatment

Non-weight bearing or limited weight bearing for four to six weeks is a very common course of treatment.  It provides enough time to initiate the healing response while reducing the stress on the injury site.  If you continue to stress the site of injury, the fracture can worsen and require more invasive treatments (possibly even surgery).  Crutches, a walker or a Roll-A-Bout knee walker can be used while you have weight bearing restrictions.  A walking protective boot is also typically used to protect the injury site.

As with many injuries, the initial treatment for a stress fracture in the foot is PRICE (Protection, Rest, Ice, Compression, and Elevation).

  • Protection.  Wear a walking boot, and limit weight bearing on the foot.
  • Rest.  Limit any activities that cause pain.  Depending on the severity and your personal health status, this can last from two to eight weeks.  Those with diabetes usually take a significantly longer period of time to heal.
  • Ice.  Use ice as needed for pain and edema control.  The rule for icing is to apply ice no more than twenty minutes per hour.  Do not place the ice directly against the skin, especially if you are using a gel pack style.  A bag of frozen peas can be ideal.  Individuals with poor circulation or impaired sensation should take particular care when icing.
  • Compression.  If swelling is present, utilize a simple ACE wrap around the foot and ankle to help with the swelling and pain.  Start at the toes, and work up the leg.  Take care to not apply the ACE wrap too tightly as over squeezing the foot can be irritating.
  • Elevation.  Use pillows to position the foot above the level of your heart to help reduce swelling.  This would be an excellent time to apply ice, too.

In general, the application of heat, cold, or over the counter (OTC) topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help you to manage pain and stiffness.

Addressing Your Risk Factors

After you have initiated PRICE and the pain and swelling has decreased, address any risk factors (if and when possible).

Stop Smoking

If you smoke, please stop.  It not only affects your bone density, but it has negative effects on every other body system.  It also increases your risk of cancer and heart disease.

Nutritional Management

Address any nutritional deficits.  This includes having adequate levels of Vitamin D3, Vitamin K1 and K2, magnesium, and healthy fats.

Vitamin D3 is critical to the absorption of calcium, through the intestinal wall, which is important for bone health.  Although calcium is a critical component of bone health, I cannot recommend extra supplementation because of the potential cardiac risks to over supplementation.  A healthy varied diet will typically supply adequate calcium levels (assuming that adequate Vitamin D3 levels are present for absorption and that you are avoiding drinking soda).  Vitamin D3 is also a critical nutrient in maintaining a healthy immune system.

Research indicates that Vitamin K can help to reduce bone loss by helping the body regulate osteoclast function with in the bone.  An osteoclast is a type of bone cell that breaks down bone tissue.  These very important cells are integral in maintaining proper bone density and insuring an appropriate amount of calcium in the blood stream.  Without adequate calcium, many critical cell functions can be affected (including heart function).  Both Vitamin K1 and K2 have been proven to reduce the risk of fractures, including hip and vertebral.

Vitamin K, found in green leafy vegetables, has anti-coagulation benefits.  If you take blood thinning medications, your physician will need to know how much you consume on a regular basis.

Magnesium is a critical component of bone health and health in general.  Magnesium helps the body to regulate calcium levels.  This has a positive effect on bone health and also has been proven to reduce the risk of kidney stones.

I also use magnesium as a sleep and recovery aid.  I consume it at night to help me sleep.  Magnesium can also reduce muscle soreness, cramps, and/or spasms.  You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates.

Most people are deficient in the amount of magnesium they consume on a regular basis.  I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose in 100 mg intervals as needed.  I would caution you that taking too much magnesium can lead to diarrhea.  Mag Glycinate in its oral form is the most highly absorbable.  Although not quite as absorbable, Thorne Research Magnesium Citrate is also a fantastic product.

If you’re female (and especially if you suffer from amenorrhea, abnormal or absent menstrual periods), then consuming adequate levels of fats is pertinent.  Adequate levels of Omega-3 fatty acids and other healthy fats (primarily from plant sources such as avocados and coconut or olive oil) are critical in order to insure that your body has what it needs for proper hormonal support.  Amenorrhea can be a sign that your diet is lacking in adequate high quality fats as well as a sign of overtraining.

Avoid Soda and Distilled Water

Excessive soda intake (particularly diet soda) has been linked to poor bone density.  The exact cause isn’t entirely clear.  Many theorize that the acidic nature of the soda along with the chemicals and additives cause increased osteoclast activity in the bones.  This releases more calcium into the blood stream in order to help fight the negative effects of soda consumption.  It’s clear that too much soda is bad for your health and bones.  Similarly, distilled water is water that has been leached of all other nutrients and minerals.  Drinking too much distilled water can leach needed nutrients out of the bones. 

Weight Management

It’s important to manage your weight effectively.  Excessive body weight can cause additional stress on the body.  Whenever possible, work toward optimizing your health.  This includes maintaining a healthy body weight.  The heavier you are the more stress forces present throughout the lower extremity.

Rehabilitation

Once you’re cleared by your physician to initiate exercise and activity, it’s time to progress your rehabilitation.  For detailed descriptions and photos of potential helpful exercises, please refer to Foot Stress Fracture Rehabilitation Exercises(If you’re already working with a rehabilitation professional, such as a physical therapist, consult with him or her prior to starting my recommended rehabilitation exercises.)

  • Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles (as well as the smaller foot intrinsic muscles) can lead to excessive strain on the tissues on the bottom of the foot including the plantar fascia.  I recommend initiating a complete ankle/foot strengthening protocol.  Please refer to Ankle Resistance Exercises Using the Elastic Exercise Band.
  • Improve your balance.  Poor balance is often associated with muscle weakness in the foot and ankle as well as weakness in the knee and hip musculature.  Weakness and balance deficits can lead to poor foot mechanics, which ultimately can lead to a stress fracture or even metatarsalgia.  Improving your balance can help to reduce the risk of metatarsalgia and is an important part of the rehabilitation process.  For more ideas on how to improve your balance, please refer to Improving Balance by Using a Water Noodle.  As your pain level improves, I recommend that you perform these balance exercises without shoes on.
  • Add an orthotic.  Often times, the stress fracture occurred due to alterations in foot mechanics or an old or poorly fitting shoe or orthotic.  If you are recovering from a stress fracture, consult with a podiatrist or a physical therapist that specializes in orthotics to determine the proper orthotic or shoe for you.
  • Did you progress too quickly into a minimalistic shoe?  The standard built up shoe offers more foot support and padding than most minimalistic style shoes.  If you attempted a quick progression, this may have contributed to the injury.  Unless you are a child or teenager, expect a safe transition to take at least three months.  A slow transition will allow your body to adequately adapt to the new stresses.
  • Weight training.  Once you’re cleared by your physician, initiating or returning to a weight training program is critical to the development and maintenance of strong bones.  Weight training (particularly barbell training) loads the skeleton progressively over time, which can decrease bone loss and increase bone mineral density.  It also positively affects the hormones, such as human growth hormone (HGH) and testosterone, needed to improve bone density and muscle strength.  Barbell training is the most effective method due to the progressive load on the skeletal system, and the muscle pull being exerted on the bone, which also stimulates bone formation.  The key to maintaining and improving bone density is always progressive axial skeletal loading and the associated pull of muscles against the bone during activity (particularly, strenuous activity).  Examples of such exercises include squats, lunges, and dead lifts.

It’s critical that you to slowly progress back into high impact activities.  It’s equally important that you address any of these risk factors in order to help reduce the risk of re-occurrence.  If you have experienced one or more stress fractures, you’re already at a higher risk.  As you taper up activity, monitor for signs of swelling and pain.  If symptoms occur, taper down the intensity.  Continue to work in a pain free range in order to strengthen around the injury site.

If you don’t experience a significant relief as you progress into your rehabilitation, please consult your medical professional.  I recommend a physical therapist that specializes in feet or who works with athletes for the treatment of stress fractures.  The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  You may also consider consulting with a podiatrist.

Thanks, Denise, for the question.  I hope you find this information to be helpful as you manage your condition.

Have you experienced a stress fracture in your foot before?  Which treatments worked the best for you?  Which treatments didn’t seem to help as much?  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: A Holistic Approach to Managing Autoimmune Disorders (Myasthenia Gravis)

Q.  I have been diagnosed with Myasthenia Gravis.  It’s affecting my speech, swallowing, and general head, neck, and arm strength.  Are there certain activities that I should modify or avoid?  Which type of exercise can I perform in order to improve my function?  Owen

A.  Thanks for your question, Owen, as it presents an opportunity to discuss a very devastating autoimmune disease, Myasthenia Gravis (MG).  Your willingness and desire to maintain your strength and physical function despite the disease is an encouragement to others who may be suffering as well.

Approximately 50 million Americans (20 percent of the population or one in five people) suffer from autoimmune diseases.  Women are more likely than men to be affected.  Some estimates state that 75 percent of those affected are women.

Myasthenia Gravis (MG) is one of many different types of autoimmune diseases such as Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS, which is also known as Lou Gehrig’s Disease).

An autoimmune disorder occurs when the body’s immune system attacks and destroys different parts of the body because it has confused itself with a foreign body or invader.  The body’s own immunogenic response against itself is a challenging and difficult problem to fix.  Although there are many different and evolving treatment methods, most (if not, all) autoimmune disorders are not curable.

manwithhishandonthroat

In the case of MG, it’s considered a neurologic autoimmune disease because the immune system attacks the nerves that control certain muscles of the body.  Symptoms of MG vary wildly and sometimes can be quite severe.  Symptoms may include:

  • Muscle weakness
  • Drooping of one or both eyelids
  • Double vision
  • Altered speech
  • Difficulty swallowing
  • Problems chewing
  • Limited facial expressions
  • Weakness in your neck, arms, and legs.  (If the neck is weak, it may be hard to hold up your head.)

Proper medical management is critical in all cases of autoimmune diseases.  Those diagnosed with MG (or any other autoimmune disease) should always be medically managed by a specialist in the disease.  In most cases, management of MG will be overseen by a neurologist (preferably, with experience in treating MG and other neurologic autoimmune diseases).  

In order to best address any autoimmune disorder, a multifactorial approach to managing the disease should be implemented.  Although the condition may affect one specific aspect of your body, a healthy and balanced body will always function better and be more resilient to fight and thrive in spite of the condition.  In addition, it’s important that you and your loved ones learn as much about the disease as possible.

A Holistic Approach to Managing Autoimmune Disorders (Myasthenia Gravis):

  • Medical/Physician Management.  Depending on the condition and triggering events, this may include pharmacological management or surgical intervention.  In the case of MG, the trigger may be a tumor in the thymus gland.  Your physician may order a CT Scan of your chest to screen for a tumor.
  • Speech TherapyOften with MG or other autoimmune disorders, you may develop difficulties with swallowing.  I highly recommend that you work with a Speech Therapist (ST).  Speech therapists are highly trained medical professionals that specialize in treating disorders that affect swallowing, speech, and cognition.  They can use very specific treatment modalities from exercise to diet modification.  Neuromuscular electrical stimulation (NMES) can be utilized to help the muscles responsible for swallowing improve in strength and coordination.
  • Nutritional Management.  Consume foods that promote a low inflammatory diet, including a diet high in Omega-3 fatty acids and other natural herbs (like garlic and turmeric) which can naturally lower inflammation.  Consuming food that helps to support the immune system is important because the nervous system is affected by MG and other autoimmune diseases.  This includes a diet high in Omega-3 fatty acids and having adequate Vitamin D3 levels.  Include foods that support the nerves and are typically high in good fats such as avocados, coconut oil, and healthier fish (such as sardines and wild caught salmon).  If you’re experiencing difficulty with swallowing, be sure that your food is prepared in such a way that you can safely eat and that it’s in accordance to advice from your speech therapist.
  • Weight Management.  It’s important to manage your weight effectively.  Excessive body weight can cause additional stress on the body.  Whenever possible, work toward optimizing your health.  This includes maintaining a healthy body weight.  Depending on the autoimmune disease and your body in particular, this may also mean maintaining enough body weight.
  • Activity Modification.  As the disease progresses, it’s important to understand how your body is functioning, and then learn how to adapt to manage the disease.  Unfortunately, certain activities and how you perform them will need to be modified or avoided.  Learn to pace yourself and take more frequent rest breaks.  Adequate night time sleep is also critical.  If any of your joints are affected, learning to limit the use and strain on them will be important.  Utilize adaptive devices (such as a cane) in order to limit the strain placed on your body during activities.  An assistive device will allow you to be mobile and will reduce your risk of falling.
  • ModalitiesThis is a broad category, but there are many ancillary treatments that can be utilized to help you feel more comfortable.  The good news is that they rarely have associated side effects.  In general, the application of heat, cold, or over the counter (OTC) topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help you to manage pain and stiffness.  Gentle massage and TENS (Transcutaneous Electrical Nerve Stimulation, a form of electrical stimulation performed by a physical therapist) may also be beneficial for pain relief.  TENS is different than the neuromuscular electrical stimulation (NMES) used by speech therapy.  TENS is used for pain control only.
  • Limit StressOften in cases of autoimmune disorders and in particular, MG, poor stress management will lead to worsening symptoms.  The ability to effectively manage stress will be critical in managing your symptoms.  There are many different methods to help you manage stress more effectively.  Common methods include:  meditation; journaling; deep breathing; Tai Chi; and yoga.  You may also need to reconsider certain friendships and relationships in your life.  The key to effectively managing stress is to find an enjoyable activity, and then stick with it.  This is a process–a journey (not a destination).
  • Exercise.  Implementing exercise in order to promote general health will not only help you to feel better, but it will optimize your well-being during this very difficult time.
    • Strength TrainingStrength training is encouraged, and the exercise program should be established by a professional who is familiar with managing MG.  All exercises should be performed in a slow and controlled environment within the available range of motion (ROM).  Maintaining muscle mass through strength training is critical and should be performed only one to two times per week to minimize any risk of over fatigue.
    • Endurance Training.  Endurance training is critical for general health and should be included as part of a comprehensive exercise program for individuals with MG.  Focus on less impact activities such as bicycling, rowing, and water aerobics.  Avoid excessive fatigue.
    • Flexibility TrainingFlexibility training is important for everyone as part of a healthy lifestyle.  Take every joint through a full ROM at least once a day.  I highly encourage a regular two to three times a week flexibility program in addition to a daily ROM program.  Tai Chi and yoga both also address aspects of strength and balance and are wonderful for managing stress.  Other options include:  Pilates; water aerobics; and a stretching routine.
    • Aquatic Therapy.  Water can also be very useful in pain control and help with relaxation.  Many find that performing a regular exercise program in an aquatic environment can satisfy most exercise needs, including flexibility and strength.

Managing an autoimmune disorder, such as MG, is difficult and everyone’s journey will be different.  Your specific treatment protocol should be individualized based on your specific condition, how the symptoms are affecting you (which will vary over time), and your current health status.

Thanks, Owen, for the question.  I hope you find this information to be helpful as you manage your condition.

What has your experience with managing autoimmune disorders been like?  Are there any treatments that have or have not worked well for you?  Additional discussion can help others to manage these difficult diseases as well.  Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: What Causes Headaches?

Q.  Several members of my family frequently get headaches.  Thankfully, I rarely get them, but what causes headaches?  Why do some people get them and others do not?  Thanks, Ben!  -Brad

A.  Thanks for your question, Brad!  Headaches are a very complicated subject.  I will do my best to answer your question from a physical therapist’s perspective.

Headaches can range from mild to severe with symptoms varying wildly.  Approximately 15-20% of the population will suffer from headaches at any given time.  It’s one of the top medical ailments for which people seek treatment.  Headache suffers are also one of the most heavily marketed to group.  There are no shortage of scammers and snake oil salespeople trying to sell you the next great remedy to cure your headaches.

Although there are many potential sub categories of classifications a person could use (particularly, within the tension class), I tend to classify headaches in one of five categories:  tension; cervicogenic; sinus; migraine; and cluster.

Business people with stress and worries in office

Classifications of Headaches:

Tension

These are the most common type of headache.  These headaches are often related to tension in the muscles of the head, neck and jaw and are frequently stress related.  The actual physical cause is still not fully understood, but it’s likely linked to how the brain and nervous system perceives muscular pain and stress.

Tension headaches are categorized as either episodic (meaning that you experience less than 15 headaches per month) or chronic (meaning that you experience more than 15 per month).  Women tend to experience them more often than men.  Many food or environmental factors can trigger tension or migraine headaches.  Food and environment triggers for headaches could easily be a classification of their own.

Please refer to Prevention and Treatment Strategies for Tension Headaches.

Cervicogenic

Not everyone would say this is a separate class of headache, but I tend to classify cervicogenic headaches separately.  Cervicogenic headaches are often associated with tension type headaches.  There can be a lot of overlap with tension headaches, but in this class the underlying cause of the headache is from the cervical spine.  There are many pain generating structures in the cervical spine.  A few potential causes could be nerve related, trigger points, facet joint or cervical mal-alignment related, or cervical disc related.  I find that postural dysfunction tends to go hand in hand with this type of headache as well as in tension headaches.

Cervicogenic headaches tend to be found more often found in women.  This seems to be primarily due to the anatomical differences of men versus women.  Men tend to have more muscular necks while women tend to have more long and slender necks with less muscle to provide support to the head (meaning that there is less muscle strength for support).

Please refer to Cervicogenic Headaches: A Real Pain in the Neck (and Head).

Sinus

Your sinuses are located on your forehead, behind the bridge of the nose and under your cheek bones.  In cases of infection or allergy, the mucosal lining will become inflamed and causes pressure and pain.  This results in headache type symptoms.  Pain is often worse when bending over or straining.

Other than headache type pain, you may also be suffering from other symptoms of illness including a stuffy or running nose, earache or fever.  Sinus headaches are often a trigger to other types of headaches such as tension and migraines.

For more information, please refer to 9 Treatment Tips for a Sinus Headache.

Migraine

Migraine pain is the second most common type of headache (with tension/cervicogenic type headaches being the most common).  Up to 16-17% of the population complains of migraines.  These headaches can be far more debilitating than the typical tension/cervicogenic type headache.  Migraine pain is often in combination with tension headache pain.  Migraines can also be caused by menstruation or hormonal imbalances.

Frequently, people will classify any type of severe headache pain as a migraine although it may or may not actually be the case.  The severity of pain is not what leads to a migraine classification, but which symptoms are present.

Symptoms of a migraine will differ for everyone.  Initial symptoms and patterns may occur one to two days prior to the actual migraine.

Typical symptoms may include:

  • Throbbing pain on one side of the head (but pain can be present on both sides)
  • Pain behind the eyes
  • Difficulty performing typical activities which worsen with activity or heat
  • Nausea
  • Vomiting
  • Sensitivity to light, noise, and smell

Less common symptoms may also include:  difficult with speaking; tingling in the face, arms, and hands; and short term upper body weakness.

Migraines are more commonly found in women.  Like tension headaches, migraines are often associated with known varying triggers like food, smells, excessive heat, fatigue, and dehydration.

Please refer to How to Prevent and Treat Migraine Headaches.

Cluster

This type of headache tends to appear in cycles (clusters) which last hours to days.  By most accounts, these are the most painful type of headache.  Typically, cluster headaches present with a sudden onset and usually subside as quickly as they start.

These headaches are the least common and only affect approximately 1% of those who suffer from headaches.  The first onset for this type of headache is usually between 20-30 years old.

Please refer to Cluster Headaches, the “Suicide Headache” for more information.

When to Seek Emergency Care:

Although most headaches do not require emergency medical attention, the following signs and symptoms indicate when to seek emergency care.

If you have any of these signs or symptoms, please seek emergency care:

  • Abrupt, severe headache
  • Severe unrelenting pain
  • Headache with a fever; stiff neck; mental confusion; seizures; double vision; weakness, numbness; and speaking difficulties
  • Headache after a head injury (especially, if the headache gets worse)
  • Muscle weakness/paralysis and/or face drooping (signs of a CVA)

How to Determine the Cause and Design an Effective Course of Treatment:

The symptoms of headache pain are nearly as diverse as the causes of headache pain.  Regardless of the onset whether sudden (such as from an injury, from a fall or motor vehicle accident) or more subtle and chronic, there are few aspects of care that are important for all headache suffers to consider.

  • Start a headache log or diary.  I always recommend beginning the process by keeping a diary in order to determine the most likely culprits prior to working on less common scenarios.  There are many obvious and common potential causes to address first.  Sometimes, it takes some serious detective work to rout out the cause and design an effective course of treatment.  The patterns noted in the diary will be clues to guide you down the right treatment path.  Don’t perseverate over every little detail of your headaches, but you need an accurate account of frequency and triggers.
  • Look for patterns.  Try to establish patterns to the headaches.  When do they occur?  Do certain foods trigger the headache?  Which activities will cause a headache?  What makes the symptoms better or worse?  Are they associated with certain movement patterns, activities or even certain times of the day or month?
  •  Which treatments work for you?  Everyone has his/her preferred cure, but what really works for you?  Don’t feel bad if someone else’s cure doesn’t work for you as we are all different.
  •  Leave no stone unturned.  When looking for patterns, consider all aspects including: food, medications, and supplements.  Also, consider your living environment.  Could there be mold in the home?  Other unknown allergens?  How is your micronutrient status?  Dental issues?

Don’t give up hope!  Headache pain is difficult to manage, but with proper care most headache pain can be cured or effectively managed.  The most frequent mistake I see people make is to not stick with a thorough plan.  Jumping around from one treatment to another rarely works.

With severe and/or chronic headache pain, a very thorough and specific plan of addressing all aspects of your health and wellbeing will need to be addressed for long term success.  This process can be slower than desired, but when executed properly, it will almost always leads to significant success.

Thanks, Brad, for the question!  I hope you and your family members find this information helpful and that they are able to experience some relief from headache pain!  Stay tuned as I will profile typical self-treatment strategies for each type of headache in upcoming posts.

Do you or a loved one suffer from headaches?  Which treatments have worked the best for you?  Please share your experience.  Together we can all grow and learn how to best manage this condition. 

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: Spinous Process Fracture

Q.  My son was recently injured in a weight room accident that resulted in a C7 spinous process fracture. The neurosurgeon says not to worry about it and that he can return to sport in six weeks.  He is a very talented athlete, and he’s trying to get a college football scholarship.  I’m concerned for his safety and scholarship prospects.  Do you have any advice? -Jennifer

A.  I am so sorry to hear about your son’s injury, Jennifer. Weight lifting is such a critical component to any training program as well as for those who are trying to maintain muscle mass and general health. Sadly, accidents happen and can be very serious. However, weight training will be an ongoing critical training component if your son is to compete in football at a collegiate level.

Thank you for letting me share his imaging pictures. Viewing the imaging allows for a better discussion, but please note that I have not evaluated your son.  The following advice is only for the purpose of general discussion.

Spine_Collage

(Left: X-ray of C7 fracture. Right: CT Scan of C7 fracture.)

As you can notice on the imaging provided, only the spinous process was injured. Although close to the lamina of the vertebra (which has a primary role of protecting the spinal cord), it was not injured.  This was confirmed by the physician’s physical exam, X-rays, and CT Scan. I’m glad that the injury was taken seriously with appropriate medical follow up.  One should never take unwarranted risks when evaluating spinal injuries.

This particular fracture is also known as a Clay Shoveler’s Fracture. This occurs when the end of the spinous process is either broken off by a physical impact (as in the case of Jennifer’s son when the barbell hit his neck) OR as a result of the muscle pulling so hard that it breaks the bone and literally tears off part of the spinous process.  The role of the spinous process, particularly in the cervical region, is to help limit cervical hyper extension.  More importantly, the spinous processes are there as an attachment point for muscles and ligaments.

C7 is the largest cervical vertebrae in the neck. The C7 vertebra is right in the middle of transition from the cervical spine to the thoracic spine and is home to many fascial attachments and muscular attachments from the neck and shoulder girdle.  Many of the deeper neck extensors and rotators such as the splenius capitus and splenius cervicis as well as the trapezius, rhomboids and serratus posterior muscles have C7 attachment points.

Typical Symptoms

In most cases, there is pain immediately after the injury which is often described as a burning or “knife-like” stabbing pain.  Other symptoms include muscle tightness and sharp pain that increases with repeated activity and movement of the neck or shoulder girdle. The pain is often described as feeling similar to a severe muscle strain in the upper back.  The area of fracture as well as the nearby spinous processes is typically very tender as are the nearby muscles.

If only the spinous process is injured, you should not see any neurologic symptoms. You will likely see loss of cervical motion and possibly shoulder motion as those motions will cause muscles to pull directly on the site of injury which limits one’s desire to move.  Symptoms are typically worse with the head down or when the arms are active in front of the body (such as driving or working at the computer).

Treatment Considerations

Bone healing is a complex process and will differ significantly among individuals. Factors affecting bone healing include:  the type of fracture and the patient’s age; underlying medical conditions; and nutritional status.  For a person with good health status, the bone will take on average six to eight weeks to heal to a significant degree.  In general, children’s bones heal faster than those of adults.

However, with a spinous process fracture that is separated to this degree, the bone will most likely never heal. The bone will not re-attach itself back to vertebrae.  When this occurs, it’s known as a non-union.  Scar tissue and fascia will surround the injury site and in most cases, form a solid fibrous pseudo-union between the two pieces of bone.  In most cases, there will be no deleterious effects from the injury and healing process.  Like bone healing, this process typically takes six to eight weeks for most individuals.

Acutely there is likely to be pain, but long-term pain typically subsides. However, as with all injuries, there is the risk of chronic pain or long-term irritation to the area associated with the muscle and tendon that insert/attach onto the spinous process involved in the injury.

Pain Management

Initially, I don’t recommend treating with NSAIDS (non-steroidal anti-inflammatory medication) as there is research that indicates that the healing response could be delayed. Instead and whenever possible, I would recommend other alternatives for pain management like applying heat or ice. Typically no more than 20 minutes per hour would be recommended, and don’t apply heat or ice directly to the skin (use a towel as a barrier).

Pain medication, such as acetaminophen, is always an option if recommended by your physician. You may also want to consider utilizing topical agents, which can help to decrease pain and muscle spasms. The method of action varies greatly according to the product used.  You may find that one product works better than another.  Some of my favorite products in my medicine cabinet include:  Biofreeze Pain Relieving Gel; Arnica Rub (Arnica Montana, an herbal rub); and topical magnesium.

Another option is oral magnesium. You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates. Taking additional magnesium (particularly at night) can help to reduce muscle cramps and spasming.  It is also very helpful in reducing overall muscle soreness and aiding in a better night’s rest.  Most people are deficient in the amount of magnesium they consume on a regular basis.  I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose as needed.  I would caution you that taking too much magnesium can lead to diarrhea.  Mag Glycinate in its oral form is the most highly absorbable.  Although not as absorbable, Thorne Research Magnesium Citrate and magnesium oxide can also be beneficial.

Soft tissue massage of the adjacent muscles as well as electrical stimulation can both be used to reduce pain.  If pain persists, please discuss the options with your physician.

Activity Modification and Exercise Considerations

Activity involving the head, neck, and shoulders should be limited initially. In some cases, the physician may ask that a cervical collar be worn for several weeks.  Opinions on this vary greatly and will be dependent on the exact location of the fracture.

The basic idea is to avoid heavy use of the muscles that would specifically pull on the injury site. This would include muscles that flex, extend, rotate or side bend the head as well any arm movements that move the shoulder.  This would obviously include any type of heavy lifting or placing anything on top of the injury site like a barbell.

Although this seems very limiting, you can still move the neck and shoulders. Gently perform range of motion (ROM) of the neck and shoulders to maintain full mobility. This will also help to limit pain and muscle spasms of the surrounding tissues.  The idea is to limit extreme movement, limit the movement under load, and limit the speed of movement.

I would specifically limit most activity for at least six to eight weeks to insure an adequate amount of scarring has occurred. In addition to the above noted limitations, I also wouldn’t perform any activities that would be jarring to the body (such as jogging).  If you want to maintain your cardiovascular endurance, you could peddle on a stationary bike while keeping your upper body mostly relaxed.

At around the four to six week mark, I would slowly start working on the cervical extensor and shoulder girdle muscle exercises (as demonstrated below).  You will want to engage the muscles symmetrically as to not cause asymmetrical pulling over the injury site.  These exercises will help to engage the muscles (the cervical extensors and scapular muscles, including the rhomboids and trapezius muscle) specifically used to stabilize the injury site.

ITYExerciseCollage

Begin by performing these I’s, T’s, and Y’s exercises on a Thera-Band Exercise Ball. Start slowly without resistance.  Keep your chin tucked and head aligned with the body.  Move your arms slowly up and down in each position of I, T, and Y.  Start with 10 repetitions for 3 second holds, and then progress the number of repetitions as long as there is no pain.

Once you can easily and pain free perform 20 repetitions with 3 second holds, add a 1-2 pound weight in each hand and start the progression initially at 10 repetitions.  Be sure to always let pain guide the progression.  The exercise should remain pain free.

After the six to eight week mark, initiate a slow, but steady return to exercise. Start with lower extremity exercises such as the leg press, body weight lunges, squats or step ups.  During this time, progress with targeted exercises designed to strengthen the muscles of the mid trapezius, rhomboids, and neck extensors.

Let pain guide your progression. If you perform an activity that causes pain near the injury site, then that activity should continue to be avoided in the short-term.  Continue to perform exercises bilaterally to be sure that the force/pull over the injury site is symmetrical.  For example, when you start on rowing, then it should be a two-handed row and not a one-handed version.

Progression of exercise of the associated muscles should be slow and again, pain should be carefully monitored. Any pain provoking movements early in the rehabilitation phase should be avoided.  When returning back to weight training, start with a weight approximately 50% of your prior max.  Work within that weight for a week or two, and then slowly progress back to the prior weight used (depending on your symptoms).

You may also return to light jogging. If there is no increase in your pain level, then slowly progress back into full running and sprinting.

Exercises to avoid for at least twelve weeks include: barbell squats; overhead press; power cleans; squat cleans; and snatches.  Avoid anything that would put direct pressure over the injury site or exercises that include a speed and power component under load (such as the power clean).

Rehabilitation Recap

Due to the amount of information presented, I want to re-iterate the important parts of the rehabilitation process. Be sure that you have your physician’s clearance prior to resuming activity.

0-4 weeks: This is the time for pain management and activity modification. You want the area to scar down.  Exercise and activity should be limited although you should maintain full range of motion (ROM) of the neck and shoulder girdle if possible.

4-6 weeks: Initiate a cervical stabilization program and scapulothoracic exercises starting without any resistance.  Perform the I’s, T’s, and Y’s exercises on an exercise ball (as demonstrated above).  Progress with these exercises and continue with cardiovascular exercise such as riding a stationary bike.  You may also start bench pressing, but begin light and monitor your pain level.

6-8 weeks: Progress with shoulder and upper back exercises. Be sure to use two-handed movements.  Depending on your pain level and strength, lower body exercises can be initiated.  Begin with body weight exercises, and then progress to resistive exercises.  Continue to limit direct pressure over the injury site or asymmetric forces.  Lower body exercises, such as the leg press and dead lift, may be started.  Exercise should be mostly pain free.  If you experience pain during an exercise or movement, discontinue for now and then retry it in a week or two.

8-12 weeks: During this phase, slowly start tapering up on all activity.  During this time, you can progress your jogging to eventually sprinting as well as road bicycling.  You can progress back into lower extremity exercises as tolerated as long as there isn’t any significant associated pain at the injury site.  Focus on neck and upper extremities exercises with two-hands/arms bilateral exercises.  Focus on exercises that develop strength in the muscles surrounding the injury site without causing increased pain or asymmetrical force.  The preference is for two-arm movements for now.  This is also the time to start working on thoracic mobility to insure the entire vertebral chain can move freely.  Be sure to have full shoulder and cervical mobility.  Continue to avoid any specific pressure on the injury site.  If you haven’t already, you could start the following:  dead lifting; front squat; and lunges with load.

12+ weeks: Return to full activity. However, let pain and common sense continue to be your primary guide.  At this stage, you can return to light squatting.  I recommend a low-bar position as this typically lines up just below the spine of the scapula and should be below the C7 injury site.  Start single arm movements, such as a one-armed row, as well as power movements, such as the clean and snatch.  You can also initiate overhead lifting.  The key is to progress slowly and see how your body responds.  Begin with 50% of the load used prior to your injury.

If you don’t already own a copy, I would highly recommend that you purchase Starting Strength: Basic Barbell Training by Mark Rippetoe. This text should be regarded as the authority on strength training and should be used as a guide for beginners to advanced weight training enthusiasts.

Once a full return to weight training activities has been accomplished, a full return to sport should also be possible. Any sports that involve high impact, such as football or mixed martial arts, should have your physician’s approval in order to insure that the fracture is stable.  In most cases, the level of pain present will be a great indication of how stable the injury site is.

If you are unsure about how to properly progress in your training and rehabilitation, I recommend that you work with a highly qualified trainer or sports medicine professional to insure that you are performing your particular exercise and sport in a manner that will keep you safe and the fracture stable. The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area.  In most states, you can seek physical therapy advice without a medical doctor’s referral (although it’s a good idea to hear your physician’s opinion as well).

Good luck to your son and you, Jennifer! I hope you find this information helpful.  Thankfully, this type of injury usually results in a full return to function without many long-term deleterious effects.  The key is to allow adequate healing time, and then slowly and strategically progress back into full activity.

Have you ever suffered from a spinal fracture or avulsion fracture? Have you experienced an accident while weight training?  Please share your story below.

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com. For additional health and lifestyle information, join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: Running Injuries, Part 2

MTA_RunningInjuries_Part2

http://marathontrainingacademy.com/running-injuries2

Marathon Training Academy

February 14, 2016

Do you have a nagging stubborn injury? Recovery and injury prevention are critical and should be performed regularly so you don’t miss valuable training time.  In Part 2 of this podcast interview with Marathon Training Academy, I discuss injury prevention and treatment for the most common running injuries.  For detailed written answers and web links for more in-depth prevention and self-treatment strategies, please refer to Q & A Running Injuries Show Notes.

Fit man gripping his injured calf muscle on a sunny dayRunning injuries that crop up during marathon training are a real bummer! Here’s part two of our Q and A with physical therapy doctor Ben Shatto.

In this episode, you will hear about injury recurrence, plantar fasciitis, knee pain, ITBS, and more. My favorite quote from this episode is, “Injury is never normal.” Listen to the podcast

Disclaimer: This blog post and podcast are not meant to replace the advice of your doctor/health care provider, or speak to the condition of one particular person but rather give general advice.

Q & A: Running Injuries

MTA_RunningInjuries

http://marathontrainingacademy.com/running-injuries

Marathon Training Academy

February 11, 2016

Do you want to meet your fitness goals? Avoiding injury is critical! In this podcast interview with Marathon Training Academy, I discuss common running injuries and self-treatment strategies.

RunningInjuryOnCalfRunning injuries! In this episode we invite Dr. Ben Shatto on the podcast and fire away with injury related questions sent in by Academy members.

You will learn when to self-treat an injury versus visiting a physical therapist, how to pick a PT, and great questions and answers about glutes, hamstrings, and muscle imbalances. Lots to love!  Listen to the podcast

Disclaimer: This blog post and podcast are not meant to replace the advice of your doctor/health care provider, or speak to the condition of one particular person but rather give general advice.

Q & A: How to Manage Spondylolisthesis Pain

Q What are some tips on how to decrease pain caused by spondylolisthesis? -Lisa

A.  Excellent question, Lisa! A spondylolisthesis (spondy) is a certain kind of back injury that is associated with a pars interarticularis defect which is part of the vertebrae. It’s often called the “scotty dog” fracture because of its shape. This condition can be congenital (from birth) or happen from trauma. It’s diagnosed slightly more in males (5% of the male population versus 3% in the female population).

It is important to note if the fracture is stable or not. If the spondylolisthesis is unstable during active motion, such as bending forward or backward, the vertebrae can actually slip and move forward or backward.

Spondylolisthesis injuries are graded I, II, III, IV, and V.

  • A Grade I defect occurs when 25% of the vertebral body has slipped forward.
  • Grade II occurs when 50% of the vertebral body slips forward.
  • Grade III occurs when 75% of the vertebral body slips forward.
  • Grade IV occurs when 100% of the vertebral body slips forward.
  • Grade V occurs when the vertebral body completely falls off which causes a spondyloptosis.

In many cases, you will never know if you have this particular condition unless an X-ray is taken. For most people, this condition is completely benign and painless (particularly, in Grade I defects).

Spondylolisthesis_XRay

If you have a Grade I or II spondylolisthesis and are experiencing pain, conservative treatment (including formal physical therapy) is usually the first form of treatment. Surgical intervention may be performed as needed in the case of a Grade II spondylolisthesis. Surgical intervention is almost always necessary in cases of Grade III or higher.

Exercise and Treatment Considerations

In case of a stable Grade I and some Grade II spondylolisthesis, exercise is an important part of the treatment strategy. There are a few items of consideration. First, obtain clearance from your medical physician. Often, a series of X-rays will be taken while you are standing and standing bending either forward or backward. This can determine if the area is stable. If so, then conservative treatment can be initiated.

When determining which motions to guide your treatment, always let pain and directional preference guide your movements. A directional preference is simply a method to identifying a pattern to the pain.  Does the pain get worse when you bend over or does it improve?  What happens when you repeat this movement?  Determine how your pain responds.  If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction.  Stop that particular movement.  If the pain improves then continue with exercises in that direction.  Never do anything that worsens your pain or symptoms.

On average, I tend to have my clients be less aggressive with lumbar range of motion, especially press-ups and backward bending. Although it’s not prohibited completely in the case of a stable injury, it’s merely a precaution as some research indicates that it may have the potential to cause more pain and worsen the pars defect.

It’s also entirely possible that the cause of pain has nothing to do with the spondylolisthesis. A thorough physical therapy evaluation should help to determine the actual cause of the pain (although, sometimes it is never truly known). The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

The focus of the treatment and exercise is on the strengthening of the inner and outer core muscles and lumbar extensors. With the only caveat being that you may need to avoid excessive loading with the spine extended. In this instance, I recommend that you work with a highly qualified trainer or sports medicine professional to insure that you are performing your particular exercise and sport in a manner that will keep you safe and the fracture stable.

It is also important to insure proper hip and pelvic mobility so that the spine is not over worked. In cases of spondylolisthesis, insuring a normal amount of hip extension in addition to proper hamstring length and hip rotation is important. If the hip cannot fully extend during walking and running, it will cause excessive lumbar extension. You may even want to focus on having less of a lumbar curve (a posterior pelvic tilt) if your tendency is to hyper extend with an anterior pelvic tilt. Be sure to work on thoracic mobility to insure the entire vertebral chain can move freely.

Exercise is the critical component to the management of this condition. I would highly advise that you consult with a local physical therapist that has a Lumbar MedX exercise machine.  This particular machine can isolate the lumbar multifidus during exercise better than any other exercise that I am aware of.

Other exercises can be utilized to activate the multifidus. These Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Generally improving your core strength is a critical component to the overall treatment. My only caution is to once again avoid excessive loading in hyper extension and to take your strength progression more slowly while monitoring your symptoms.  If you perform an activity that causes worsening pain, then you will need to modify or eliminate that particular activity until it can be performed pain free.

In some cases, more flexion biased stretches would be indicated. This would be determined by the directional preference.  If extension biased exercises worsened the pain and flexion biased exercises improved the pain, then initially you would proceed with flexion biased exercises to help control pain while you progress into your core and lumbar stabilization program.  Examples of flexion biased stretches would be a single knee to chest (below left) or a double knee to chest exercise (below right).  Hold these for 20-30 seconds at a time and perform 4-5 repetitions each.

Spondylolisthesis_Collage_1200pxx450px

Good luck, Lisa! I hope you find this information to be helpful and provide some relief from the pain you’re experiencing.  For more information on treatment strategies for low back pain, please refer to How to Safely Self-Treat Low Back Pain.

Do you suffer from spondylolisthesis? Please share your best tips for pain management.

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com. For additional health and lifestyle information, join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: What to Expect after Breaking a Collarbone

Q.  I fell snowboarding last weekend, and I broke my collarbone. My doctor says that I don’t need surgery and that I will be fine in a couple of months.  I want to be more proactive than that.  What should I do? -Shawn

A.  Thanks for the question, Shawn. I’m sorry to hear about your snowboarding accident.  Fractures of the collarbone (clavicle) are actually fairly common and typically result from falling on the shoulder, the collarbone or an outstretched hand.  Collarbone injuries are also very common in toddlers, typically due to a fall out of bed or tripping when running.

The collarbone attaches the sternum to the scapula (shoulder blade). Many important structures, such as nerves and blood vessels, lie just below the clavicle. However, these vital structures are rarely injured when the clavicle breaks.  Diagnosing a clavicle fracture is typically performed via X-ray. In certain circumstances, a CT Scan may be performed for a more thorough image of the injury.

RightClavicleFracture

Symptoms of a Collarbone Fracture include:

  • Pain in the shoulder or over the collarbone.
  • Difficulty raising your arm due to pain.
  • Slumping or sagging of the shoulder, typically downward and forward.
  • A grinding sensation in the collarbone area when attempting to raise the arm.
  • A “bump” forms over the collarbone. In severe cases, the bump will be similar to a piano key sticking up and will be mobile.
  • Bruising and swelling over the collarbone area.

Surgical Intervention

Depending on the severity of the injury, surgery may or may not be indicated. In most cases, a simple fracture (where the bones are still aligned) will not require surgery.  Even in cases of minor malalignment, most people will not undergo surgery.

Surgical fixation is most common when there is a significant displacement or malalignment present. The purpose of surgical fixation is to hold the bones in place while they heal.  The physician will either utilize a metal plate and screws or small pins to hold the bones in place.  Although the surgical hardware can be removed once the bones have sufficiently healed, often it will remain throughout a person’s lifetime.

Rehabilitation post-surgery is fairly straight forward and is similar to the following nonsurgical treatment recommendations. Please follow your physician’s recommendations after surgery as each procedure can be different.  Variations in recovery and rehabilitation can occur and are dependent on: the area that was fixed; the severity of the fracture; and the stability of the bone and fixation.  These factors will determine how quickly you can progress through the rehabilitation.

Nonsurgical Treatment Recommendations

Most collarbone fractures do not require surgery (particularly, if the fractured area retains its alignment). Your physician will assess the severity of the fracture.  This will determine how quickly you can progress through the stages of treatment.

A general time frame for healing (with an initial return to function) is on average 6 weeks for adults and about 4 weeks for children. Complete bone healing, remodeling, and a full return to all activities will take longer.  This will depend on your age, health status, and the severity of the injury.

PRICE (Protect, Rest, Ice, Compression, and Elevation)

  • Protect. In many cases, you will be advised to wear a sling (particularly, during your daily activities). This will help to protect the area from too much motion and activity while allowing the bone to heal in its proper place. It will also indicate to others that you have an injury, so that they may avoid knocking into you.
  • Rest. Allow the arm and shoulder time to rest and recover. Do not utilize the arm for activities that cause pain. Avoid excessive motions and use. As the pain subsides, you can slowly taper up the use of the arm by starting with simple daily activities.
  • Ice. Apply ice to the painful area–typically the sooner, the better. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
  • Compression. It’s not easy to apply compression in this area. In most cases, it’s not necessary. In some cases, a simple ACE wrap can be used around the shoulder and collarbone area to help reduce the pain. The wrap is typically applied to help hold the shoulder in a backward and slightly downward direction.
  • Elevation. Elevation is typically not necessary unless you are experiencing excessive swelling in the affected arm and hand. You can position the arm in a slightly elevated position by using pillows while lying on your back or on the non-affected side. This would be an excellent time to apply ice, too.

Sleeping

When sleeping, try not to lie on the affected side. Hug a small pillow for comfort.  This also promotes optimal blood flow to the shoulder area.

Pain Management

Initially begin with PRICE (Protect, Rest, Ice, Compression, and Elevation).  Pain medication, such as acetaminophen, is always an option if recommended by your physician.  You may also want to consider utilizing topical agents, which can help to decrease pain and muscle spasms. The method of action varies greatly according to the product used. You may find that one product works better than another. Some of my favorite products in my medicine cabinet include: Biofreeze Pain Relieving Gel; Arnica Rub (Arnica Montana, an herbal rub); and topical magnesium.

Another option is oral magnesium. You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates. Taking additional magnesium (particularly at night) can help to reduce muscle cramps and spasming. It is also very helpful in reducing overall muscle soreness and aiding in a better night’s rest. Most people are deficient in the amount of magnesium they consume on a regular basis. I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose as needed. I would caution you that taking too much magnesium can lead to diarrhea. Mag Glycinate in its oral form is the most highly absorbable. Although not as absorbable, Thorne Research Magnesium Citrate and magnesium oxide can also be beneficial.

Supplements

Mt. Capra, an organic goat farm in eastern Washington State, offers superior quality products primarily utilizing goat based products. CapraFlex by Mt. Capra is the best bone and joint supplement I have found. It is a blend of natural herbs and spices along with glucosamine and chondroitin.  The herbal and spice formulation is designed to naturally decrease inflammation and support healing.  I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level.  I personally use it, and in my practice, it has helped clients recover faster and prevent injury.  It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.

Vitamin D3, such as Viva Labs Vitamin D3, is critical to the absorption of calcium through the intestinal wall which is important for bone health.  Although calcium is a critical component of bone health, I cannot recommend extra supplementation because of the potential cardiac risks to over supplementation.  A healthy varied diet will typically supply adequate calcium levels (assuming that adequate Vitamin D3 levels are present for absorption and that you are avoiding drinking soda).  Vitamin D3 is also a critical nutrient in maintaining a healthy immune system.

Be sure to maintain a generally healthy diet. Give your body the needed nutrients to heal and recover quickly.

Range of Motion

Depending on the severity of the fracture, you will likely have to limit the range of motion (ROM) of the shoulder to less than 70-80 degrees of flexion (forward) and abduction (sideways) motion. You will also have to limit reaching behind your back. A person may typically wear a sling for 2-4 weeks while limiting the motion.

The initial treatment to maintain ROM is to perform the pendulum exercise (as demonstrated in the picture on the left down below). Bend forward at the waist, and let your injured arm hang down toward the ground. Make small circles with your hand, and let the momentum move your arm around effortlessly.  Try to make both clockwise and counterclockwise circles. For more instruction, please watch How to Properly Perform Pendulum Exercises.

PendulumExercise_ShoulderPulleyExercise

Around the 2-4 weeks mark, you can begin to work on regaining full forward flexion by using an over-the-door shoulder pulley (as demonstrated in the picture on the above right). Work slowly on motion for 5-10 minutes at a time. You may push though minor discomfort, but you should never experience significant pain during this process. For more instruction, please watch How to Use Shoulder Pulleys to Regain Shoulder Motion.

As flexion improves (typically after the 4 weeks mark), then you can begin to work on all other motions of the shoulder. This includes motion out to your side (abduction) and behind your back (internal rotation). The shoulder pulley can be utilized to regain these motions as well. Otherwise, you could walk your fingers up the wall when facing forward to regain flexion and sideways to regain abduction. You could use a towel to regain the motion behind your back.

Strengthening

Initially avoid lifting anything over 5 pounds. Typically around the 4-6 weeks mark (depending on severity of injury), you can begin a gentle rotator cuff strengthening program. These exercises should always be performed pain free and initially, the resistance will be very light. For specific exercises, please refer to Rotator Cuff Exercises.

The rotator cuff is a critical component to shoulder mobility. It is made up of four different muscles whose job is to make sure that the ball of the humerus (arm bone) rotates and slides properly in the socket, which is made up of the scapula. The rotator cuff allows the other major muscles of the arm, such as the deltoid and Latissimus dorsi (lats), to properly move the arm.

When there is weakness or dysfunction, it will cause rubbing of the muscle tendon on the bone. This can lead to impingement or eventually fraying and tearing. Insuring proper strength in the rotator cuff after a collarbone injury is an important component in avoiding shoulder impingement syndrome.

Return to Full Activity

Around the 8-12 weeks mark, you will likely consult with your physician to have another X-ray taken.  Once you’re cleared by your physician, you can slowly taper back into more strenuous exercises and a return to full activity.

If your injury was severe or required surgery, it may be closer to the 16 weeks mark before you can return to full activity and be cleared to lift heavier weights.  I recommend that you slowly taper back into your prior activities.  If you are experiencing pain, then back off that particular activity and try it again at a later date.

Help from a Physical Therapist (PT)

Every injury is different. If you’re experiencing pain or difficulty regaining your strength and shoulder range of motion, please consult with a physical therapist that is an orthopaedic certified specialist (OCS). The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

Good luck, Shawn! I hope you find this information to be helpful and provide some relief from the pain you’re experiencing.

Have you broken your collarbone? What was your experience like?  Please share your best tips for recovery.

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com. For additional health and lifestyle information, join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

Q & A: How to Manage COPD

Q.  Hi, Dr. Ben. I was recently diagnosed with moderate COPD.  I “knew” I have had it for a few years, but I didn’t want to admit it.  What exercises do you recommend that I perform to keep my lungs functioning at their best capacity?  I know I need to keep active, keep a healthy lifestyle, and keep going!  I gave up smoking last week when I was diagnosed.  I am not on oxygen at this time.  Inhalers are being used to manage my COPD at this time.  I hope this will help others from being stubborn, choose to give up the smokes, and “get real” because this can happen to any of us!  Thanks, Ben!  -Linda

A.  Thanks for your question, Linda! I am sorry to hear about your recent diagnosis of COPD.  It sounds like you are already making some appropriate and much needed lifestyle changes to help to manage the disease.

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease (meaning it worsens over time).  COPD is currently the third leading cause of death in the United States.  It is typically diagnosed in middle aged or older adults.  Cigarette smoking is the leading cause of COPD.  Most cases of COPD are associated with those that have smoked, used to smoke or who were around heavy amounts of smoke.  Other potential causes include: exposure to chemicals that irritate the lungs (such as air pollution, chemical fumes from paint or other industrial causes); exposure to high levels of dust and dirt; and genetic factors.

Chronic Obstructive Pulmonary Disease

Symptoms of COPD:

  • Coughing (typically producing large amounts of mucus).
  • Wheezing.
  • Shortness of breath (SOB).
  • Tightness in the chest.

With COPD, there is less air flow in and out of the lungs.  This can occur for one or several of the following reasons:

  • The airways and air sacs (alveoli) lose their elasticity.
  • Walls between the air sacs are damaged and/or destroyed.
  • Ways of the air sacks become thick and/or inflamed.
  • There is excessive mucus production in the air sacks causing them to clog.

COPD is most commonly associated with two conditions, either emphysema or chronic bronchitis.  In the case of emphysema, the walls of the air sacs are damaged and/or destroyed which leads to less air sacks (alveoli) to assist in gas exchange during breathing.  In the case of chronic bronchitis, the lining of the airways is chronically irritated and inflamed.  This leads to a thickening and excessive mucus production, which blocks the airways and causes difficulty with breathing.  Generally individuals with COPD tend to have both emphysema and chronic bronchitis.

Those with COPD are especially prone to other illnesses, such as colds, flu, and pneumonia, and they are in a high risk category.  Although controversial in western medicine, I am convinced that proper supplementation of key nutrients can assist your immune system in fighting many common illnesses.

Strategies for managing COPD:

Medication.

Your physician will likely prescribe medications to help you to manage COPD.  These will typically include anti-inflammatory medications and bronchial dilator medications.  Be sure to always follow your physician’s advice when utilizing prescription medication.

Stop smoking.

This may sound obvious, but smoking cessation is critical to managing COPD.  Smoking was likely a major contributing factor to developing COPD.  It will be very difficult to manage the disease long term if you do not stop smoking.  If a person continues to smoke, lung function and prognosis for disease management will decline at a much faster rate than average.  Many programs are available that can help you to quit smoking.  Please speak with your physician to learn more about resources in your area.

Daily activity.

Daily activity is important for everyone, but especially for those with COPD.  A sedentary lifestyle will only worsen your symptoms.  Depending on the severity of your COPD, your ability to perform certain activities will vary.  For more information, please refer to How to Jumpstart a Sedentary Lifestyle and Why You Should Walk, Not Run.

As your disease progresses, it will become increasingly difficult to remain active. Activity modification will be part of your management strategy, but continue to do what you can. It is critical to keep regular activity as part of your disease management strategy.

Exercise.

It is critically important that you engage in specific, purposeful exercise.  A thorough exercise program should include components of each of the following:

  1. Weight Training
  2. Cardiovascular Exercise
  3. High Intensity Training

Each exercise program should be specifically designed for the individual.  These three forms of exercise have significant research in improving physical function (including muscular, cardiovascular, and pulmonary function).  It is extremely important that your exercise program is properly dosed and prescribed just for you.  As your disease progresses, your dosing and exercise prescription will also change.  To adequately mange the condition, you must implement a thorough exercise program.

You will likely need assistance in designing a program specifically for your needs.  First, please speak with your physician.  Then seek a qualified physical therapist that specializes in cardiovascular disorders.  The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to seek your physician’s opinion as well). Another option is to seek a local cardiac and pulmonary rehabilitation program in your area. These are usually associated with your local hospital.

As your disease progresses, it will become increasingly difficult to exercise, but continue to do what you can. The intensity and duration may change and you will need additional rest. It is critical to maintain some form of exercise as part of your disease management strategy. This is an exercise is medicine approach.

Rib and thoracic mobility.

Addressing rib and thoracic mobility is one way to make quick improvements in a person’s ability to breathe and generally improve endurance and lung function. Unfortunately, this is underutilized in most COPD sufferers.

Since COPD affects the lungs, restrictions in the musculature and the skeletal system that encase the lungs will only worsen a person’s breathing difficulties. The key is to help your body move as efficiently as possible. In order to achieve this, the ribs and thoracic spine along with the associated musculature must be free to move. Any restrictions in this area will only make it more difficult to breathe.

When you sign up to receive my blog posts via e-mail, you will automatically gain access to my FREE resource, My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain. These exercises address the most common rib and thoracic restrictions, so that you can maximize your rib and thoracic mobility in order to breathe easier. Detailed photos and exercise instructions will help you to get started.  I recommend that you combine these with a daily deep breathing program.

Deep breathing.

Learning a variety of breathing techniques will also be a critical component in managing COPD. Deep breathing allows the body to uptake more oxygen. It also helps to reduce stress and anxiety. The mechanical act of breathing more deeply helps your ribs and thoracic spine to remain mobile. It also helps to train all of the muscles associated with breathing–from the diaphragm and intercostal muscles to the lesser known accessory breathing muscles (sternocleidomastoid, the scalenes, serratus anterior, pectoralis major and minor, trapezius, latissimus dorsi, erector spinae, iliocostalis lumborum, quadratus lumborum, serratus posterior superior and inferior, levatores costarum, transversus thoracis, and the subclavius).

Incentive Spirometer

When performed properly, deep breathing can help you to maintain your lung capacity. An incentive spirometer should be used regularly as part of maintaining proper lung capacity and function. It can also decrease your risk of pneumonia, which is always a concern for those with COPD.

Learning multiple methods of breathing will be important as you progress in your disease management. Each method is used for a different situation. Along with deep breathing exercises, diaphragmatic and pursed lip breathing techniques will also be beneficial.

Adequate sleep.

Poor sleep is linked to the following cardiovascular risk factors:  high blood pressure; atherosclerosis; heart failure; heart attack; stroke; diabetes; and obesity.  These all have negative effects on COPD management.

Be sure to get as much sleep as you need (typically 7-9 hours at night).  Short naps are also an excellent way to get more sleep.  I recommend that you read Michael Hyatt’s 6 Strategies to Sleep Soundly, Wake Rested, and Accomplish More.

Acupuncture is also a proven method to help people sleep better and more soundly.  It can be used to treat insomnia as well.

Reduce your stress.

Stress is a normal part of life.  Poorly managed stress or excessive stress can lead to emotional, psychological, and physical problems, such as cardiovascular disease and high blood pressure.  High stress leads to more anxiety which can affect breathing patterns.  Individuals with COPD will already struggle at times with breathing, which will worsen as the disease progresses.  High stress will only make this worse.  Regular exercise, massage, yoga, acupuncture, and Tai Chi have all been proven to reduce stress.

Maintain a healthy weight.

Additional weight makes it more difficult to move around. It also creates additional pressure in the rib cage–making breathing more difficult. The heavier you are, the more difficult it will be to exercise which is a critical component of COPD management. Obesity is associated with diabetes, high blood pressure, and coronary artery disease.  These all increase your risk of developing heart disease and have a negative effect on health and COPD management.  Studies have shown that excess body weight (not including all of the other associated medical conditions) can also lead to heart failure.  Even if you are healthy otherwise, being overweight still places you at a greater risk of developing cardiovascular and pulmonary related diseases.

Stay hydrated.

Drink more water.  The older you are, the easier it is to become dehydrated.  Proper hydration is critical to keeping lung tissue healthy. The human body is primarily made of water, which is critical for all body functions. Dehydrated tissues are prone to injury as they struggle to gain needed nutrients to heal and repair. Dehydrated tissues are less flexible and tend to accumulate waste products. Water intake supports proper brain, lung, muscle, and hormone function as well as lubrication of the joints and skin appearance.

Stay hydrated by drinking water. Try to avoid beverages that contain artificial sweeteners or chemicals with names that you can’t spell or pronounce. Drinking more water not only prevents dehydration, but it also aids in preventing urinary tract infections (UTI).

Living with and managing COPD will be a different journey for everyone.  When managed correctly, individuals with COPD can live a long time.  Although there isn’t presently a cure for COPD, treatment options continue to improve every year.  The important part is to start addressing the disease early through medication management and lifestyle changes including:  smoking cessation; healthy eating and proper hydration; stress management; breathing techniques; and optimizing your exercise and activity levels in order to maintain proper rib and thoracic mobility.

Thanks for your question, Linda!  For additional information on the topic of COPD, please visit the following:  http://www.nhlbi.nih.gov/health/health-topics/topics/copd/ and http://copd.about.com/od/copdbasics/a/copdlifeexpectancy.htm.

Do you or a loved one suffer from COPD?  Please share your experience with us.  Together we can all grow and learn how to best manage this disease.

If you have a question that you would like featured in an upcoming blog post, please comment below or submit your question to contact@thePhysicalTherapyAdvisor.com.  Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice.  No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.