Posted on Wednesday, November 5, 2014

Q & A: 7 Tips to Get Rid of Knee Pain

Q. Over the last month or so, I have had a pain in the back of my knee. My knee feels really stiff when I sit cross-legged or try to squat. What should I do? –Sam

A. Great question, Sam! The symptoms you are describing sound like the pain may be coming from your meniscus. The meniscus is the cushion found between the two major leg bones, the femur and the tibia. It is made of a cartilaginous substance. Many times, the meniscal cartilage can be torn. It would be similar to getting a hang nail near your cuticle. A tear occurs when the cartilage rises up and causes pain, a feeling of knee instability, and/or locking up of the knee. Other times, the cartilage can become frayed like an old rope. This fraying can cause pain and stiffness, particularly pain behind the knee in an area known as the popliteal space.

The good news is that most meniscal related injuries don’t require surgery. Research suggests that the proper physical therapy program can be superior to surgical intervention with long term outcomes. There are times when surgery will be indicated, but physical therapy is typically indicated as an initial course of action. (Particularly, when there are no episodes of knee locking occurring.)

The following 7 tips will help you to rehabilitate your knee. If symptoms worsen, then additional assessment and follow up is likely needed. I would anticipate an improvement of your symptoms in a few of weeks or less when initiating this program. (Depending on the severity, it could take longer for a full recovery.) If the pain continues, please seek additional assistance from a qualified physical therapist or physician.

1. Warm up prior to exercise. I recommend that you increase your normal warm up time by at least 10 minutes in order to increase blood flow to the area. This allows for better mobility and also promotes healing as movement is necessary to bring in the nutrients. Use a stationary bike or the rower machine initially to get the muscles warm and the knee joint more lubricated. Then work on moving into a deep squat position multiple times as part of the warm up. You may need to hang onto a beam or a pole to take some pressure off of your knee as you move in and out of the squat.

2. If it hurts, don’t do it! Modify the activity or discontinue it completely. If your knee is hurting when performing a squat, then initially don’t move as deep into the exercise. This would also be true for a lunge position or step up. Modify any exercise as you need to, and don’t compromise technique to complete an exercise. Poor technique will only increase your risk of injury elsewhere.

3. Work on strengthening. The primary goal of a strengthening program is to work on quadriceps and glut medius (hip abduction) strengthening. Weight lifting is an appropriate choice, but you may have to initially limit your range of motion (ROM). Most of my clients begin on a non-weight bearing program, then progress to partial weight bearing, and eventually, full weight bearing. The more severe the symptoms, the longer it will take for an individual to progress to more difficult exercises.

To initiate a physical therapy program, please refer to Meniscus Rehab Exercises. This exercise guide is designed to address the muscles that I find are weakest in most individuals. The exercises are listed from easiest to most challenging and are designed to primarily improve quadriceps and hip strengthening. Start with exercises like a straight leg raise (possibly with an ankle weight) and bridging (either one or both legs). Wall squats holding for time also works well. A Thera-Band Exercise Band can be tied around the thighs above your knees to make your hips more engaged.

Weight training exercises (with machine weights or free weights) should be geared toward general leg strengthening and may include: squats; leg press; hip abduction machine; step ups; dead lifts; and straight leg dead lifts. If further instruction is needed, search YouTube to watch the proper technique for a specific exercise.

The speed at which exercise is performed while in group exercise classes is typically too fast for an individual who is properly and safely exercising his/her knee during a rehab and recovery phase. You can still participate in group exercise classes or CrossFit WODs (Work out of the Day), but your specific knee program should be separate from any group structured activity. You need time to insure proper technique.

4. Cool down. After performing your exercises, take extra time to cool down and stretch. Use either a stationary bike (at a causal/slower pace) or the rower machine. Both are reduced weight bearing exercises that promote movement and circulation to the knee as well as increasing range of motion (ROM).

5. Improve your Range of Motion (ROM). The goal of the rehabilitation program is to regain full pain free ROM. This can be accomplished many ways. Perform heel slides by lying on your back and sliding your heel toward your buttocks. Consider using a pole to assist in performing deeps squats. Hang onto a pole or a door frame, and bring your heel toward your buttocks as you perform a quadriceps stretch. These exercises can be performed within a mild to moderate amount of discomfort in order to regain full pain free ROM. If you experience muscle tightness and soreness, I recommend using a foam roller to assist with any myofascial symptoms. To learn how to use a foam roller, please refer to Foam Rolling for Rehabilitation.

6. Drink more water. Cartilage tends to have a poor blood supply. The more water you drink, the more hydrated your body becomes. This can help the body to deliver much needed hydration and nutrients to the meniscus.

7. Add a joint supplement. CapraFlex is my preferred supplement for meniscal related injuries. I have recommended this supplement for years as my clients have had successful outcomes with use. I have taken it to help prevent injury as I entered a particularly intense period of training as I prepared for a marathon. It has also assisted in recovery from my many injuries. Essentially, it combines an organic glucosamine and chondroitin supplement with other natural herbs which are designed to reduce inflammation. CapraFlex can be taken long term or intermittently to help heal from an injury. I recommend that you try it for 30 days to see if it improves your knee pain. (If you are taking blood thinners, please consult with your physician prior to use as the herbs could interact with some medications.)

Thank you, Sam, for your question. I hope these 7 tips will help you to rehabilitate your knee and recover quickly! If the pain continues, please seek additional assistance from a qualified physical therapist or physician.

Which treatments for knee pain are the most effective for you? Please share any recommendations that you may have by leaving your comments below.

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.

Posted on Wednesday, October 8, 2014

Q & A: Can CrossFit Cause Elbow Pain?

Q. A lot of CrossFitters, including myself, seem to have tendinitis of the elbow or other achy elbow issues. Do you know why that is? What exercises are we doing to cause it? What therapy would you recommend to help the pain? I appreciate you and love this blog that you are doing! I always look forward to reading it! -Stephanie

A. Thanks, Stephanie, for the great question! I have worked with quite a few CrossFitters who have experienced elbow pain. I have treated people new to the sport and those who participate at a high level. Elbow pain can be debilitating by limiting your ability to exercise and perform daily tasks. I will address potential causes and how to alleviate elbow pain associated with exercise. (Note: You don’t have to be a CrossFitter to benefit from this information.)

Possible reasons for developing elbow pain include:

Poor grip strength.
Muscle imbalances between wrist flexion and extension strength.
Improper lifting technique (which is the primary problem for the newer participant).
The progression of training is too quick (which again tends to be an issue for the newer participant).
Mobility related issues in the wrist, shoulder, or thoracic spine. (Poor mobility can affect both those who are new to the sport as well as CrossFit veterans.)
Excessive mobility or hypermobility may also be an issue. It tends to be more common in females than in males and is usually associated with the shoulders or elbows.

Poor technique is a frequent complaint in regard to safely performing CrossFit. Many people believe that there isn’t enough emphasis placed on proper lifting technique or specific CrossFit exercise techniques (particularly with the new participant). Some complain that the emphasis is on speed, not form, during WODs (Workout of the Day). This may be true in some Boxes (gyms/clubs), and it’s a valid concern.

Please be honest with yourself when you start a new activity. This is especially important if you’re starting very high intensity activities with very specific movements which require a high degree of skill to perform such as CrossFit. Beginners to CrossFit should spend the necessary time to learn the proper technique. With any new activity, there is always a learning curve. It’s the responsibility of the coach and the client to insure proper form.

The power clean is an example of a common movement in CrossFit and Olympic Weightlifting. This exercise can cause elbow pain when performed incorrectly. One reason for elbow pain to develop during this movement is that the bar is reversed curled. It causes excessive strain on the wrist extensor muscles instead of the participant exploding the bar upward, and then dipping underneath. There shouldn’t be a reverse curl movement to this lift. I witness it fairly often as a common mistake. If you’re experiencing aches and pain in your elbow or elsewhere, please see your coach or athletic trainer to insure that your lifting technique is correct.

Poor wrist, shoulder, or thoracic mobility is also commonly related to elbow pain associated with exercise. If the wrist cannot extend properly, it not only causes wrist pain, but excessive stretching of the forearm muscles and strain on the elbows (possibly leading to pain).

Poor shoulder or thoracic spine mobility can also cause excessive strain on the elbow. Consider exercises like the overhead lift or pull ups. If the shoulder cannot fully flex or the thoracic cannot fully extend (allowing proper shoulder flexion), then the elbows will absorb more of the load. The lack of shoulder or thoracic mobility also affects proper alignment of the upper extremity during the movement. Over time and with multiple repetitions, this overloading can cause pain and injury to the elbow.

Whenever one part of the body doesn’t have adequate mobility, another part will do more to allow for the movement to take place. When an exercise is performed at a high speed, high relative weight, or high repetitions, a lack of mobility can make you more susceptible to pain and injury.

Excessive mobility can have a similar effect. For example, if you’re performing an overhead lift, but your shoulders flex past 180 degrees, then the bar is too far behind your head. This causes excessive force to be placed on the shoulders and elbows. Again, this can lead to injury and pain when performed at a high speed, high relative weight, or high repetitions.

Top 7 Recommendations to alleviate Elbow Pain associated with Exercise:

Work on your Grip Strength. Practice bar hangs for time. Carry barbell plates (one in each hand) to challenge the grip strength. Don’t just work on wrist flexion or gripping exercises, but also work on wrist extension to improve grip strength and decrease your risk of lateral elbow pain. Use an exercise band (as shown below) to perform 2-3 sets of 20 repetitions. Extend the wrist up, and then slowly back down toward the floor. Be sure to move very slowly during the eccentric/muscle lengthening position (when your hand returns to the floor).
Identify the Offending Movement. If you’re experiencing elbow pain, try to identify which specific movement aggravates the elbow. Once you identify the movement, work with your coach or athletic trainer to insure proper lifting technique.
Work on your Mobility. CrossFit is not just about metabolic conditioning or strength training. You need to develop all aspects of your fitness, and this includes your flexibility. Work on upper body mobility by focusing on shoulder and thoracic mobility as well as lower body and spinal mobility. A free resource for shoulder and thoracic mobility is My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain which you can automatically download when you subscribe to my e-mail list. You will receive each week’s blog post sent directly to your e-mail making it even easier and more convenient!
Warm Up. Prior to activity, be sure to perform a cardiovascular warm up to insure that the muscles are ready to stretch and perform high level activities. Perform a dynamic warm up by taking the associated muscle (or muscles) needed for the workout through the anticipated and needed range of motion (ROM) in a quick and brisk manner. A foam roller can also be utilized as part of your warm up. For more instruction, please refer to Foam Rolling for Rehabilitation and Does Foam Rolling Help or Hurt Performance?
Static Stretch and Self-Mobilization Post Work Out. Continue to work on the immobile areas through static stretching and/or self-mobilization. Again, a foam roller can also assist. If you prefer a very comprehensive guide for improving mobility, I recommend Kelly Starrett’s Becoming a Supple Leopard.
Be Proactive. Once you start to feel pain, be aggressive with your management and self-treatment. I like to use either a tennis ball or roll PVC pipe over the forearm area, which can be an effective treatment for lateral epicondylitis (“tennis elbow”). For more ideas on how to self-mobilize, please refer to My Top 3 Household Items for Self Mobilization.
Contact your Physical Therapist. If the pain persists, seek additional help. Don’t let the pain linger. The longer it’s left untreated, the more potential for harm and damage which potentially could lead to a longer recovery. The American Physical Therapy Association (APTA) is an excellent resource for learning more about physical therapy as well as locating a physical therapist in your area.

Elbow pain can be debilitating by limiting your ability to exercise and perform daily tasks. Be proactive in your care and management. Most importantly, don’t let the pain linger. You can find more tips and strategies on managing pain and injury by simply using the search function (located on the upper right-hand sidebar).

What specifically causes your elbow pain? Which treatments have you found to be the most effective? Additional discussion can help others to manage his/her pain. Please leave your comments below.

Posted on Wednesday, September 10, 2014

Q & A: Exercises Beneficial in Managing Rheumatoid Arthritis

Q. I have rheumatoid arthritis in my hands, wrists, and elbows. What type of exercise can I do to keep my upper body strength? –Gloria

A. Thanks for your question, Gloria, as it presents an opportunity to discuss a very devastating disease, Rheumatoid Arthritis (RA). Your willingness and desire to maintain your upper body strength despite the disease is an encouragement to others who may be suffering as well.

Rheumatoid Arthritis (RA) is one of 171 different types of arthritis. RA is most commonly diagnosed in women, with nearly three out of four cases involving women. Over 46 million people in the United States alone suffer from one form of arthritis or another, and this number is climbing rapidly. The most commonly recognized forms of arthritis are osteoarthritis and RA. Osteoarthritis is most commonly associated with “wear and tear” syndromes (degeneration of the joint from excessive use or injury). RA (known as an inflammatory arthritis) is an autoimmune disease in which the immune system works against normal body cells by attacking the joint surfaces and eventually, even the body organs. As the condition progresses, joint surfaces become severely damaged–leading to deformities and dysfunction.

A person with RA should always be medically managed by a specialist in the disease. Symptoms are typically quite severe and not only cause pain and deformities, but also excessive fatigue and loss of appetite. RA can be found in only one joint or area, but it’s usually associated with many areas in combination, typically in a symmetrical pattern. Eventually, it can affect the entire body including the internal organs.

In addition, it is important that you and your loved ones learn as much about the disease as possible. There must be a multifactorial approach to managing the disease. Consider the following:

Medical/Physician Management – This may include pharmacological management or surgical intervention, including total joint replacement.
Nutritional Management – Eat foods which 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.
Weight Management – It is important to manage your weight effectively. Excessive body weight can cause additional “wear and tear” (particularly on the lower extremities joints) and can worsen any damage caused by RA. Also, excessive weight can worsen RA symptoms or even cause osteoarthritis. If possible, you don’t want more than one form of arthritis if it can be avoided.
Activity Modification – As the disease progresses, it is 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. Depending on the joints affected, learning to limit the use and strain on the joint is important. For example, if your knee is affected, then repeatedly going up and down stairs could cause a strain. You may choose to eliminate or minimize the frequency of that particular activity. Repetitive joint motion and in particular, repetitive joint loading and hyper loading, should be avoided and/or minimized. Learning to use adaptive devices to limit the strain placed on the body during activities will also be helpful.
Modalities – This is a broad category, but in general the application of heat, cold, or over-the-counter topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help manage pain and stiffness. Gentle massage and TENS (Transcutaneous Electrical Nerve Stimulation, a form of electrical stimulation) may also be beneficial.
Splints – Many times, custom or over-the-counter splints (particularly for the upper extremities) can be utilized to provide support and comfort to joints which are in pain and/or suffering from deformity.

Now that you have a clear understanding of RA and options available to manage the disease, I will specifically address Gloria’s question regarding exercise for the upper extremity and exercise in general. Although the research for exercise for individuals with RA is far from complete, it indicates that a regular exercise and range-of-motion (ROM) program is a critical component to proper management of the disease. (Make sure you are adequately rested before performing any exercise program.) General guidelines for exercise include:

Strength Training – Strength training is encouraged, and the exercise program should be established by a professional who is familiar with managing RA. Excessive shearing forces and rotational forces and/or exercises should be avoided. Joints with severe involvement should be exercised with caution and an emphasis should be placed on ROM versus actual loading of the joint. All exercises should be performed in a slow and controlled environment within the available 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 stressing the joint.
Endurance Training – Endurance training is critical for general health and should be included as part of a comprehensive exercise program for individuals with RA. Avoid cardiovascular exercise (running, jogging, skipping, jump roping, etc.) which produces high impact forces. Instead, focus on less impact activities such as bicycling, rowing, or water aerobics.
Flexibility Training – Flexibility training is important for everyone as part of a healthy lifestyle, but it’s critical for those with RA. A person should 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. Appropriate options include: yoga, Pilates, Tai Chi, water aerobics, or a self-stretching routine. The program should be performed in a slow and very controlled manner by taking care to never overstretch a joint or to move too quickly.
Aquatic Therapy – Many find that performing a regular exercise program in an aquatic environment can satisfy most exercise needs, including flexibility and strength. Water can also be very useful in pain control and help with relaxation. Exercising in a reduced gravity environment like the pool limits the compression forces on the bones. Additional weight training or body weight exercise should still be performed to insure adequate bone density as one ages.

To specifically answer Gloria’s question on the upper extremities, I would encourage her to daily perform an upper extremity stretching routine which takes all of the upper extremity joints through at least one full ROM. Be sure to take several rest breaks during the day to perform stretching and ROM exercises. Strengthening exercises for the shoulders, elbows, wrists, and fingers would also be beneficial. Be sure to work the finger extensors (opening the hand) and not just the flexors (squeezing). Finger Putty is a great product which enables you to perform a variety of hand and finger exercises. I would also encourage an emphasis on posture and upper back stretching as demonstrated in My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain. Gloria, I hope you find this information to be helpful as you manage your RA. Please let me know if you have additional questions.

I would love to hear from more of you! What are your experiences dealing with rheumatoid arthritis? Have you or a loved one been dealing with this condition? What has worked or not worked for you? Additional discussion can help others to manage a very difficult disease. 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!

Posted on Wednesday, September 3, 2014

My Top 3 Household Items For Self-Mobilization

Many household items can be used to perform self-myofascial release. Why is self-mobilization and fascial release so important? Mobilization has effects on the musculoskeletal system, the vascular system, and the fascial system. Having good mobility (free of adhesions) can positively improve performance or recovery, and it’s important in maintaining a healthy body. With common household items, you can manage muscle spasms and cramping as well as those painful areas due to training (or more commonly, poor posture and sitting).

Muscle spasms and cramps can be terribly painful. They tend to occur at the most inopportune time and place. In a pinch, many household items can be used to assist in eliminating muscle spasms, cramps, tightness, and pain. When available, my first choice is almost always the foam roller. It is versatile and can be used to mobilize tissue as well as boney articulations. The foam roller also works great to increase spinal extension mobility. For more information on foam rolling, please refer to Foam Rolling for Rehabilitation and 5 Ways to Improve Range-of-Motion (ROM).

My Top 3 Household Items for Self-Mobilization:

1. PVC Pipe – This works great for sore forearms (including “tennis elbow”) as well as tight hamstrings or shin splints. You can use one hand or both to press or rub the PVC pipe over sore or tender areas. The amount of pressure shouldn’t be painful. Avoid pressing on especially boney areas.

2. Tennis Ball* – This is perfect to pinpoint those hard to reach places on the back or in the buttock region. Hold pressure over the sore area or spasming muscle until the spasm releases. This could take a couple of minutes depending on the severity of the spasm. (*A tennis ball may be substituted with another firmer and smaller rubber ball as shown below.)

3. Racquetball – This is perfect for self-foot mobilization or if you need to provide more pressure using a firmer ball. If you suffer from plantar fasciitis or poor mobility in your feet, I highly recommend performing this daily for a couple of minutes on each foot. Be sure to work the entire foot, not just the arch.

Muscle spasms, cramps, tightness, and muscle soreness are often quite painful! These three common household items can be used to help mobilize, minimize, and/or eliminate muscle pain. For more helpful ideas, please refer to Muscle Cramping & Spasms – Treatment Options, in which I discuss specific treatment options for managing pain including: massage, self-mobilization tools, topical agents, and supplements.

What are your top household items for dealing with muscle cramping and spasms? Please post your comments below as we could all use a few more tricks to eliminate pain!

Posted on Monday, August 25, 2014

Muscle Cramping & Spasms – Treatment Options

The list of potential reasons for developing a muscle cramp or spasm is quite long and somewhat arduous. Once the cramp or spasms begin, it’s often quite painful! Therefore, we’re highly motivated to act quickly to eliminate the spasm. What can you do to prevent muscle cramps and spasms? More importantly, how can you recover from experiencing one? I will provide simple treatment options to quickly help aid in your recovery.

For discussion purposes, I will address a spasm which isn’t caused by a serious medical condition such as a fracture, muscle tear and/or injury, or other medical conditions which would require the immediate attention of a healthcare practitioner. If you believe that the spasm is from a serious medical condition, please do not attempt to self-treat the condition–immediately seek competent medical advice.

Over training or overexertion is a common issue experienced by many of the clients who I work with. It remains a very sensitive topic as no one wants to admit that he/she was physically unprepared for an event or activity in which he/she participated in. Don’t worry! The point of participating in competition and other difficult activities is to test your body and to have fun! During a race or sporting event, you will likely overreach from your training plan. The hope is that your body is physically prepared to handle this overreaching without injury. If you experience muscle cramps or spasms before or during an event, modify your training routine for the next event.

Top Tips for Treating Muscle Cramping & Spasms:

Massage – Contact a masseuse, physical therapist, athletic trainer, or friend who is skillful in body work and massage to relieve the area in spasm. The specific massage technique to use will vary according to your preference. Massage techniques range from a light relaxing massage to a deep tissue massage or utilization of acupressure points.
Foam Roller – The foam roller allows you to perform self-massage and tissue mobilization. The foam roller is a wonderful tool to prevent muscle cramping and spasms. Please refer to the following posts for more information: Foam Rolling For Rehabilitation and 5 Ways to Improve Range-Of-Motion. I highly recommend a High Density Foam Roller to help aid in your recovery.
Other Self-Mobilization Tools – Many times, a friend or masseuse isn’t available to assist when you need the help the most. A foam roller cannot effective reach places in the upper back or arms, so other self-mobilization tools may be necessary. You can get creative and use a tennis ball or golf ball, but I like a specific tool called a Thera Cane Massager. This tool allows you to apply direct pressure to a spasming muscle. When held for a long enough period of time, the Thera Cane Massager will usually cause the muscle spasms to release and provide much needed pain relief! I am also a big fan of the Thera-Band Standard Roller Massager. I particularly like that its firmness allows for a deep amount of pressure. If you prefer something similar (but more flexible, for the boney regions of the thigh or lower leg), I recommend The Stick Self Roller Massager.
Topical Agents – Many topical agents can help decrease and eliminate 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.
Magnesium Bath – The combination of warm water with magnesium is very soothing and relaxing. Options include: Epsoak Epson Salt or Ancient Minerals Magnesium Bath Flakes. I find that the magnesium flakes work better, but they are significantly more expensive than Epson salt.
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. 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.
Increase your Electrolyte Intake – You may need to increase your potassium, sodium, or calcium intake to your diet or consider supplementation. Sherpa Pink Gourmet Himalayan Salt contains the electrolytes you would expect as well as a host of other trace minerals. I have found this to be highly effective for cramps and muscle soreness. It also helps me to sleep more soundly. I highly recommend it to anyone who is suffering from chronic cramping or after participating in an athletic event. Drink a small glass of warm water, mixing in a teaspoon full of pink Himalayan sea salt, before bedtime.
Fix Your Posture – Poor posture is one of the most common causes of muscle cramping and spasming as well as pain. This is particularly true if you spend a good portion of your day sitting. Sign up to receive my weekly blog posts via e-mail, and I will share with you My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain. These simple exercises, with complete instructions and photos, will help you to improve poor posture and can be performed at home.
Move More – Not only has research proven that sitting for more than two hours at a time decreases your expected life span, but extended sitting also leads to increased muscle tension, cramping, and pain. If you sit most of the day, get up and walk. If you stand most of the day, frequently change your standing posture. To optimize health and joint function, you should take each joint in your body through a least one full range-of-motion (ROM) every day.
Stretch – Stretching is a wonderful way to help eliminate a muscle spasm. We instinctively stretch when we feel a spasm begin. Try gently stretching (lengthening) the muscle which is in spasm. I recommend beginning with a short 30-60 seconds stretch, then repeating as needed. If the spasm or cramp is severe, you will likely need to continue stretching several times in a row, multiple times throughout the day. Stretching should always be part of a general fitness and lifestyle program. As we age, muscle and tendons tend to lose elasticity so stretching becomes even more important. I highly recommend a daily stretching routine or participation in a group class, such as yoga, which incorporates full body stretching.
Acupuncture – I am personally a big fan of acupuncture. It is very useful in treating all kinds of medical conditions. It can be particularly effective in treating muscle cramps and spasms as it addresses the issues on multiple layers. Acupuncture directly stimulates the muscle by affecting the nervous system response to the muscle while producing a general sense of well-being and relaxation.
Speak with your Physical Therapist (PT) or Physician (MD) – If the above techniques are not helping or if the muscle cramps and spasms continue to come back regularly, speak to your medical provider to determine if other causes are contributing to the problem. 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).

What are your top tips for dealing with muscle cramping and spasms? Please post your comments below as we could all use a few more tricks to eliminate pain!

Posted on Wednesday, August 13, 2014

Ankle Sprains – Rehabilitation (Part III of III)

As a physical therapist, I find that the most exciting part of a person’s rehabilitation is the full return to function, activity, or sport. Countless variations of exercises and activities are performed while working toward restoring the full functional use of the ankle. Concluding the three part series, the final stage in rehabilitation is centered on improving ankle and foot strength, stability, as well as addressing any balance deficits.

How rehabilitation progresses will vary greatly for each individual. Therefore, no treatment plan will be alike. For discussion purposes, I will address a generic treatment plan, which should be modified for your personal needs and activity level. In this final stage of rehabilitation, you will progress to normal daily activities, including any athletic endeavors. This is also when you work toward limiting any future re-occurrence of the sprain.

At this stage in recovering from a lateral ankle sprain, you should be walking relatively normally and mostly pain-free. Running and more active side-to-side movements likely still cause pain. Although not contra-indicated, these types of activities should be limited (unless you’re wearing a good lace up brace or are being regularly taped by a professional).

The initial portion of the rehabilitation is centered on improving ankle and foot strength, stability, as well as addressing any balance deficits. This process begins with statically based exercises and activities. Ultimately, it progresses into dynamic strength, balance, and mobility activities. How rapidly a person progresses in this phase is wildly variable. The key is to progress at your own pace. If you start experiencing increasing pain, feelings of ankle instability, and sensations that it may “roll” or sprain again, then you need to taper down your activity level. After the pain subsides, continue to focus on the activities that that didn’t cause pain or discomfort previously.

The following treatment plan includes exercises for strength and balance as well as mobility drills and full athletic simulation drills. Each category is listed in an easiest to most challenging format. You shouldn’t progress to the next exercise until the first one is mastered.

Strength

Continue with the Ankle Resistance Exercises, but progress to a stiffer Thera-Band Exercise Band (http://amzn.to/USkOeo).
Heel/Toe Raises – A person should be able to perform 25 heel raises in a row with only minimal fingertip assistance on a counter top. A normal amount of calf strength would be considered once you can perform 25 heel raises.

One Leg Squat – Perform a one leg squat without using your hands for balance to increase the difficulty level. The one leg squat on your tip toes is a harder variation which involves more calf muscle activation. Start with two sets of 10 repetitions, then progress to three sets of 10 repetitions.

Clock Exercise – Stand on your affected (injured) foot and attempt to touch your tip toe of the non-affected side as far out as you can reach. Bring your foot back to the center or starting point according to the hands on a clock. For example, 1 o’clock to 6 o’clock (clock-wise) or 12 ‘o clock to 6 o’ clock (counter clock-wise) depending on which foot is affected. Perform the routine between three to five times slowly.

Balance

Stand on one foot – A 30 second hold with eyes open during the first time, then closed during the second time, is considered normal.
Stand on one foot on a pillow – A 30 second hold for two to three repetitions. As you progress, stand on the pillow and perform the Clock Exercise as described above.
Stand on one foot on a water noodle – This exercise challenges your balance due to the softer surface and narrow water noodle. It also challenges the side-to-side stability of the ankle, which is the weakest area, yet the most critical, with a lateral ankle sprain. A 30 second hold for two to three repetitions.

Stand on one foot and bounce a ball against a wall.
Stand on a Wobble Board, Bosu Balance Trainer, or other unstable surface.

Mobility Drills

Initially, start with forward and backward movements and progress from a walk, to a jog, to a sprint.
Jump Rope
Side Stepping – Progress the speed as pain allows and if you’re not experiencing the feeling of instability.
Karaoke or Grapevine – Walk or run sideways while alternating the placement of the foot either in front or behind the other.
Sprint Ladder – A number of agility drills can be performed with the sprint ladder. Search YouTube and pick your favorite video which closely mimics the footwork desired for your particular sport or activity.
Short side-to-side Wind Sprints – While sprinting, touch your hand to the ground at each change of direction.

Full Athletic Simulation Drills

Depending on your sport of choice, return to your sport specific training drills. You may still require additional support. I recommend wearing a good lace up brace or being taped by a professional for support. Additional support should only be used temporarily and with the intention of progressing from using them as your ankle can tolerate.

Depending on your time table for recovery and the severity of your injury, the information provided in this three part series on ankle sprains will likely be very helpful in your recovery. For some, it won’t fully meet your needs for a full and speedy recovery. Each person and injury is different. If you continue to experience pain and swelling, and/or require an accelerated time table for recovery (or return to competition), then I recommend the services of a sports medicine physical therapist or athletic trainer. Many modalities, such as electrical stimulation, manual techniques and taping methods can assist in recovery when properly utilized. To find a qualified physical therapist in your area, search at American Physical Therapy Association (APTA).

If you have additional questions or comments regarding this series, 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!

Posted on Wednesday, August 6, 2014

Ankle Sprains – Intermediate Phase (Part II of III)

Ankle sprains are one of the most common and prevalent musculoskeletal injuries. Although more likely to occur in children, ankle sprains can happen to anyone anytime. In my last post, Ankle Sprains – Acute Phase (Part I of III), I addressed how to handle the initial acute phase of an ankle sprain. I will continue to guide you through the treatment plan on how to rehabilitate your ankle in this three part series by addressing the progression from the acute phase into the intermediate phase.

Sprains are categorized as Grade I, II, or III. A Grade I sprain is the most common. It’s typically associated with only mild damage to the ligament, and instability doesn’t affect the joint. A Grade II sprain is a partial tear to the ligament and is usually associated with some laxity (hypermobility). If this occurs, it’s best to wear a brace for several weeks. Ideally, scar tissue will form and compensate for the lax ligament, so the joint doesn’t become hypermobile. Good muscle strength and proprioception of the lower foot is important to limit future sprains. In Grade III sprains, a full tear of the ligament occurred. One typically consults with an orthopaedic surgeon for possible repair. After surgery, a guided physical therapy program is recommended.

For discussion purposes, I will only address a Grade I sprain. Initially, one may wear an air splint, ACE wrap, or some other lace-up or slip-on style brace to help with stability, inflammation, and pain control of the ankle. In most cases, a person will want to transition from wearing the brace as soon as the initial pain subsides. (If one had a Grade II sprain, he/she would wear a splint for several weeks so that the ankle would initially stiffen.)

At this point in your recovery, you are likely three to seven days since the initial injury. This phase of rehabilitation can last from seven days to several weeks before progressing into the final phase of rehabilitation (and ultimately, back to full function). Progression out of the intermediate phase is always symptom dependent. You should be able to stand with equal weight on your feet and not experience an increase in ankle pain. The ankle is likely stiff at this time, but it is time to start walking, progress range of motion (ROM), and start gentle resistive exercises.

Walking – If you have been using a crutch to unweight the foot, then start the progression to weight bearing during walking. If you have been walking, then increase the amount of weight you have been putting on the ankle and foot. At this time, the focus will be to normalize your walking pattern. This means having a good heel strike, rolling onto the foot into full weight bearing on the leg, and then propelling forward with a good toe off. You will continue to use the crutch as long as needed until you can walk nearly normal without limping. Until then, utilize the crutch to unweight the leg and foot as much as necessary to perform a nearly normal walk or gait sequence.
Range of Motion (ROM) – Start to increase the range of motion of the ankle. Initially, work to progress the plantarflexion and dorsiflexion movement (the forward and backward movement of the ankle). As pain subsides, progress the side to side motion as well as all other motions.
Recommended Exercises:
- Ankle Pumps – A very easy exercise. Just pump your ankle forward and backward into plantarflexion and dorsiflexion movement. Perform 10-15 repetitions several times a day on both feet

Ankle Alphabet – Move the foot and ankle only by pretending your big toe is a pen, and draw the alphabet using capital letters. Perform 1-2 times a day.
Calf Stretching – Hold each stretch for at least 30 seconds, three times on each leg, 2-3 times a day. This stretch shouldn’t cause more than a mild increase in pain or discomfort.

Gentle Resistive Exercises:
- Perform plantarflexion and dorsiflexion movement by initially using an exercise band. I recommend using a Thera-Band Exercise Band (http://amzn.to/USkOeo). As your pain improves, you can progress to standing heel and toe raises as long as you don’t experience more than a mild increase in pain levels.
- As pain and range of motion improve, progress to inversion and eversion with the exercise band. Stop if you experience more than a mild increase in pain levels.
- For further instruction and photos, please refer to Ankle Resistance Exercises.
Initial Balance and Proprioception Exercises. For a complete discussion on the specifics of balance, please refer to How Do I Improve Balance? (Part I) and How Do I Improve Balance? Part II.
- Standing on one foot. Initially, you may need to use your hand (or a finger) on a counter top for added support. As the pain subsides and your balance improves, you may need to increase the difficulty level. As you progress, balance will become of greater importance (to be addressed in Part III).

Toward the end of the intermediate phase, you should be walking fairly normally. There will likely be some swelling. It is typical for some amount of swelling to come and go. It will be directly related to how long you are on your feet and your general lower extremity circulation. I highly recommend you continue to wear compression stockings during this time. You may also continue to experience soreness and pain–particularly after a long day or a lot of upright activity. Continue to utilize a regular icing protocol as needed for pain and swelling. Also, continue to supplement with Capra Flex by Mt. Capra (http://amzn.to/1pF936I).

It’s time to progress into the final stage of rehabilitation once you have returned to near normal walking, your pain levels are relatively low, and you are able to complete the basic exercises listed above. The final stage of rehabilitation includes a full return to daily activities and eventually, all sport or athletic activities. I will address the specifics of the final stage of rehabilitation in Part III.

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Posted on Wednesday, July 23, 2014

Foam Rolling for Rehabilitation

The foam roller is a wonderful tool which allows me as a practitioner or you as an independent user to manipulate the body’s soft tissues which has a potential positive effect on the fascial system, the musculotendinous system, and the circulatory system. Research on foam rolling for rehabilitation and its use in clinical rehabilitation is at present minimal (although increasing all of the time). Clinically, I have used the foam roller in my practice extensively, and I highly recommend using one. I use the foam roller during treatment and extensively as a home exercise tool.

Possible reasons to utilize the foam roller include:

A different way to perform myofascial release.
It can be used as a mobilization tool for soft tissues as well as boney articulations.
It is an excellent tool for home exercise programs.
It can be easily adapted for use on multiple areas of the body.
An effective tool which one can easily travel with.
If a client is adverse to close quarters or physical touch, touching the foam roller provides a safety barrier in his/her mind, but allows the physical therapist to provide the needed mobilization to aide in recovery.

How should I use the foam roller?

I typically recommend one to three minutes of body weight rolling (if it is tolerated) per extremity, and the same for the thoracic, low back, and buttock area.
A good rule of thumb is to roll out an area that is tender and sore, or recently worked, until it no longer feels tight and sore.
Again approximately one to three minutes per area although this may vary based on your size. Increased time will be needed the more developed your muscles are.
Use the foam roll on tight or restricted areas prior to performance without risk of deleterious effects unlike static stretching.
Use the foam roll after exercise or competition to speed up recovery times and decrease the risk of muscle soreness or restriction.
The foam roller can also be used as an aide to increase the intensity of a stretch during static stretching activities.

Foam rollers come in many different lengths and sizes. Each size has a slightly different purpose and use. For most individuals, the three foot long by six inch diameter size will be the most versatile. You can purchase a quality foam roller for a good price online on Amazon.

For more information on the use of a foam roller, please refer to Does Foam Rolling Help or Hurt Performance? What has been your experience with using the foam roller? Is it worth the effort? Please share your comments or questions!

*Individuals taking blood thinning medications or with blood clotting disorders should consult his/her physician prior to using a foam roller for mobilization.