Posts Tagged ‘Health’

This is a case presentation that I knew I had to share with my readers as i’m sure you will be as shocked with the ‘results’ as I was.

A 23 year old girl presents to me with an acute onset of left groin/hip pain after sitting down in a car 3 days prior. She came to me after getting a massage from an RMT at my clinic and was in even worse pain. She reported that after the pain started she went to the ER where the attending physician diagnosed it as a hip flexor strain/spasm. There was no imaging done.

Her complaint was that of an anterior/medial groin pain that was worse with hip flexion but was in little to no pain at rest. Her flexion/adduction/internal rotation test was positive for re-producing her complaint. She also mentioned that she has a history of hip discomfort from time to time while skiing and biking. My mind immediately went into differential diagnosis mode…could it be femoroacetabular impingement, labral tear, hip flexor strain, ingunial nerve irritation, pelvic alignment issue…the list goes on.

I continued to assess her using palpation, movemnet screens and length tension tests for the adductors, hip flexors, glutes, and quads. I also noted a mild anterior innominate on that side (yes, I know the studies proving we can’t really tell blah blah blah). After reviewing in my head her MOI and her complaint of pain with hip flexion and how a massage made no changes in her pain, I gave her a preliminary diagnosis of FAI. I treated her with gentle mobilizations of the posterior hip capsule, thomas test hip flexor stretching  and soft tissue work to the adductors. She reported “feeling better” after the initial session.  Fast forward two weeks later…

She comes back to me two weeks later stating that she felt amazing for one week after my treatment, which obviously made me happy. BUT she had xrays in her hand that she wanted to show me. She went on to tell me that while at the gym doing squats one week later the same pain returned but even worse then before. She stated that she could barley move her leg without pain. She went back to the ER and this time they decided to do xrays….and you won’t believe what they found:

Sewing needle in her leg!!

Do you see the red circle? Well, that is a sewing needle that got logged into her adductor muscles right behind her pubic bone on the left side….SERIOUSLY?!?!

She told me that when she sat down in that car (when the pain first started) she felt an immediate bout of pain but had no idea why. She was moving apartments and apparently a needle was sticking up from the car seat and BAM…right in the leg. How there was no blood or sign of the needle for almost 3 weeks (from time of injury to time of xray) is astounding to me.  I also have no idea how my treatment abolished her pain for almost a full week…yes, she literally resumed her life pain free until squatting at the gym made her sore again.

Anatomically, let’s think of how lucky she was…aside from all the muscles she must had hit with that needle, she also has one more major anatomical structure she avoided…can you guess what it is?

The needle could have easily hit her femoral artery causing a whole host of other issues! Yikes!

Femoral artery anyone?

Although this is a freakish case, it does make me think about something quite important.  My mind was all about biomechanics, and finding the route cause of her pain and not simply treating  her symptoms.  This can possibly get us in trouble at times because if we are so caught up at finding what we believe is the “cause” of the problem, we might actually miss the real cause, which might be staring right in front of us. Now, I admit that I am VERY lucky my treatment didn’t make anything worse, but there was no way that from her history I would think she was impaled by a metal object! This case made me realize that anything can walk into our doors as physiotherapists and we have a duty to our patient to make sure their pain is actually within our scope of practice to treat instead of assuming it’s due to faulty movement patterns, motor controls issues or any other catch phrase term that is popular now.

Hope you found this as interesting as I did!

Oh yeah, the doctors took out the needle using local anesthetic and she was pain free 2 hours after the surgery…go figure!

Have you ever had someone tell you that before? I get asked questions like this all the time in my practice. People who crack their hands, spine, knees, feet etc ask me if they are causing damage to themselves by cracking their joints. I always ask them if there is any pain/numbness/tingling associated with the crack. If they say no, I tell them not to worry about it as there is no evidence that says cracking is bad for you or will give you arthritis. (Authors note: The studies I am referring to were only conducted on the hands and I don’t know of any literature that addresses this question for any other part of the body).

In short, there are a few reasons why joints “crack”. It could be because of a tendon snapping over a bone (snapping hip syndrome). Or it could be a bone moving over another bone (snapping scapula syndrome). A true joint crack occurs when joint surfaces of an encapsulated joint (say a facet joint in the spine) are separated. This in turn creates a reduction in pressure within the joint cavity. In this low-pressure environment, some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave the solution, making a bubble,,which rapidly collapses upon itself, resulting in a “clicking” sound. This process is known as a cavitation and is the same sound you hear when a physiotherapist, chiropractor etc manipulates your spine.

The common advice that “cracking your knuckles gives you arthritis is not supported by any evidence to date. A 2011 study from the Journal of the American Board of family Physicians examined the hand X-rays of 215 people (aged 50 to 89) and compared the joints of those who regularly cracked their knuckles to those who did not. The study concluded that knuckle-cracking did not cause hand osteoarthritis, no matter how many years or how often a person cracked their knuckles. “The prevalence of OA in any joint was similar among those who crack knuckles and those who do not”

In 2009 a doctor by the name of Donald Unger won a Nobel Prize for a study of one participant…HIMSELF! He cracked the knuckles of his left hand every day for more than sixty years (that’s dedication), but he did not crack the knuckles of his right hand. In the end, no arthritis or other ailments formed in either hand after 60 years of cracking his left hand.

So all in all, cracking the hands is not a problem, and there is nothing that would lead me to say stop doing it. However (and it’s a big one)…If you have ANY pain or limitation with joint cracking, it is best to seek consultation with a health care professional. You may have a joint instability or hypermobility which may cause you problems down the road if not properly addressed.

Have a great week!

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

DeWeber, Kevin, and Rebecca Ortolano. “The Journal of the American Board of Family Medicine.” Knuckle Cracking and Hand Osteoarthritis (2011): n. pag. Knuckle Cracking and Hand Osteoarthritis. Web. 22 July 2012. <http://www.jabfm.org/content/24/2/169&gt;.

 

 

This article is not going to be about manual therapy, exercise prescription or reviewing recent literature. Today I want to share with you some of the key concepts I have learned over my first 2 or so years as a Physiotherapist. This article was inspired by a bright young physio student (soon to be physio) named Dave Leyland… read his latest article for some motivation in case you feel like you might be lagging behind. In essence, this article will just be me talking about what I have changed and what I want to change as a physio since graduating almost 2 years ago.

I started practicing September 8th, 2010. I remember my very first patient like it was yesterday (to those who have been in practice 20 or 30 years, I bet 2 years ago does actually feel like yesterday!). Her name was Nancy and she had an MCL and medial meniscus tear. She was a great first patient to have started my career with…friendly, nice, open to having a newbie work on her…she was a pleasure. I treated her with “the best” care I knew how to provide at the time. She got better and I felt like a super star…. Until my 2nd patient! My 2nd patient (ever) was the son of a relatively famous former NHL hockey player. He had a full AC joint separation after being hit in the boards during hockey. I remember going home at night a researching “the best” rehab protocols for such an injury. UnlikeNancy, this young man had been to other, more experienced therapists and actually knew a thing or two about therapy. He questioned me insensately and his surgeon called me to inquire about exactly what I was doing, why I was doing what I was doing, and what were my objective outcome measure after each session…these are all valid questions, but as a new grad I was forced to be very on the ball… it was rough…it was then I realized that knowing what I knew was just not going to be enough…and the more I learned, the more I realized that what I knew was just not going to cut it in this field…not by a long shot.

Over the past 2 years I have made huge gains in my skill set. I am more confident as a therapist. I am better able to recognize clinical patterns, and I know I can help most anything that walks into my door. Here is a list of the most important concepts I have learned over the pat 2 years in practice.

Looks a bit like me after work some days

1) I learned nothing in physio school! Well alright, maybe that’s a bit dramatic… but in reality, coming out of physio school I knew just enough not to hurt anyone. I thought I knew a lot, but when what I was doing as a physio wasn’t providing consistent and positive results I realized I needed to step up my game. The second I embraced the fact that the learning only really starts after you get the degree was the second I became better at what I did.
 

 

2) “The foot bone is connected to the leg bone… the leg bone is connected to the hip bone”. Remember that song from back in the day? Well who would have thought it would form the basis for my philosophy as a therapist. I learned only after school just how interconnected our bodies truly are. The “joint by joint approach” or regional interdependence model of care is now a corner stone of my practice. Simply put, most times pain in one area has contributing factors from other areas as well. This sounds simplistic, but it has and will continue to take me years to figure out all the reasons why people develop pain.

3) Patients do not care about the letters after your name. They only care about results. I used to think that having “MSc.PT” after my name made me credible in the eyes of my patients. I now know that they couldn’t care less. They care about how much you know to get them feeling better. They want to feel taken care of and that their problems are meaningful to me as a therapist. I am currently in the manual therapy stream of courses held by the orthopaedic division of the CPA. Once I complete the entire syllabus system I will get the designation “FCAMPT”…and will a single patient care? Probably not. I do these things for my knowledge and skill set…if you do them to impress patients you will be surely disappointed.

4) Confidence is king. This relates to my 3rd point, but clients need to know that their therapists knows exactly what is going on and how they will “fix” them. They need a game plan to follow and someone to coach them along the way. This is hard to do as there are some times clients that walk in my door that have very odd conditions. And I for one will not lie to a client and make something up just to give them an answer. That would be the easier route, but I rather tell them I don’t know but will figure it out. Does that always work? I’m not sure, but at least I can go to bed knowing I’m 100% honest with all my clients. The #1 way I have learned how to gain confidence is to LEARN! Always read, ask questions and then read some more. So much info is out there…you just have to wade through the B.S to find it.

5) The over arching theme I have learned over the last 2 years is that I will never be comfortable knowing what I know and leaving it at that. The second you become stagnant is the second you become obsolete as a therapist. Having an internal drive to know more is a gift I guess. I force myself to stay up to date and read as much as time always. Blogs, books, webinars, articles…I always wind up getting something from everything I invest time into. What you get out what you put in is never truer than with my career as a physiotherapist.

6) This will be my “rant” point off the list. I have come to realize that treating clients who are unmotivated is both physically and emotionally draining! I want to cure the world and make everyone 100% better, but I have learned that just isn’t always possible. The greatest exercise means nothing if the client doesn’t care enough to do it. This is an epidemic these days with some clients. I could write an entire blog on how everyone wants the quick fix, but that’s not the point of this article. Essentially I have come to realize that if I care more about my patients’ well being then they do, I will burn out quick! So I make a point of telling each new client I see that they have to be committed to therapy for optimal results to be achieved…it’s a two way street. Passive care is great, but it can’t all be that.

Can’t be all about the money

7) Money will come. I used to think I wanted lots of money right away and many of my decisions were based on how much money I could make. I’m lucky to have realized very quickly that money will come when I deserve it. Being the absolute best therapist in my client’s eyes is what creates value. This is something that takes time to achieve…you know, the whole “always learning stuff” I keep talking about… that’s what makes money. When people deem you to be so essential that they will spend their hard earned dollar to have you work on their body…that’s when money will come (more money that is).
 

 

8) I am a puppet on a stage EVERY single day I go into work. My patients don’t care how tired I am or how bad my night was. They have their own problems to deal with and are paying me to worry about their issues…not mine! Each day I go into work I have to put aside any and all problems in my life and become 100% sympathetic to my clients needs. There are no off days for me. I can’t afford to be indifferent with even one client because you never know who that client knows and how they might help your career one day. This was a hard pill to swallow because lets face it…as much as I love my job there are definitely days where I MUCH rather be elsewhere. Learning how to “act the part” day in and day out was tough…but that’s just the way it is!

 

9) Customer service customer service customer service!  Writing down the names of my patients kids, their birthdays, when and where they went on vacation, what their favourite sports teams are…these are the little “tricks” that really help solidify relationships with my patients.  Think about it…wouldn’t you love it if the next time you walked into your doctors office and he or she asked you how your trip to ‘insert destination here’ was? That little extra care really goes along way. I make a habbit of emailing clients videos of exercises to make sure they fully get them. I call clients back ASAP if they have any questions. I always tell clients to call or email me when and if they need me for anything physio related. That kind of selflessness is what drives customer service. If you do just this I think you are ahead of the game.

Overall, I am happy to say that I love my job and I feel honoured to be able to do what I get to do each day. It can be a hard job, but it can also be immensely rewarding! I can’t wait to see what I learn in the next 2, 4, 10, 20 years!

What have you learned since becoming a therapist? What tips do you have for newer grads like me to ensure success in a demanding industry such as ours?

Have a great week!

A face I’ve seen a lot lately

I personally have a love hate relationship with the shoulder joint. It’s a mysterious area with much interconnection with the rest of the body, yet there are multiple local factors that can make a good shoulder bad. Obviously there are the 4 muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularus), the deltoid, teres major, trapezius….and then all the other muscles that attach from the ribs and neck to the shoulder blade….all of which can be pain generating sources.

Above all else though, at least over the past few months for me…has been the glenohumeral joint (GHJ) capsule. The GHJ capsule overlaps the joint providing an extra measure of stability to an otherwise very mobile joint. A tight capsule is one difficult entity to treat. Before I go on explaining why the joint capsule can suck to treat, let’s go through a basic arthrokinematic example talking about a tight capsule:

A tight anterior capsule will drive the humeral head POSTERIOR too soon with external rotation

A tight posterior capsule will drive the humeral head ANTERIOR too soon with internal rotation

A tight inferior capsule will drive the humeral head SUPERIOR too soon with abduction

A tight superior capsule will drive the humeral head SUPERIOR too soon with abduction (this one goes against the joint arthokinematics we learned in school)

I have had a recent influx of clients with chronic capsule tightness that borderlines on being diagnosed as frozen shoulder…but isn’t because they can still actively raise the arm up over 40-50 degrees in the scapular plane. A tight and fibrosed capsule is hard to treat because as a manual therapist, if can’t move their shoulder without pain, I can’t do a heck of a lot. One client I saw 2 weeks ago was so sore (for 8 months!!) that I couldn’t do PROM into ER or IR without a huge bout of rebound pain into the superior and anterior shoulder joint. In her case, both the anterior and posterior capsule was tight leading into multidirectional glenohumeral joint restriction. After clearing the cervical spine, I did tons of soft tissue work to the posterior capsule, quadrilateral space, pecs, lats, and traps…this helped with pain but unfortunately didn’t drastically change her AROM…she is possibly in the freezing stage of adhesive capsulitis.

Above all else, I feel one of the hardest parts of treating the shoulder has nothing to do with me at all. It has all to do with the patient. I often get fantastic results using manual therapy for some spinal conditions. However, the shoulder requires a lot of active care…meaning the patient can’t be lazy. Corrective and rehabilitative exercise is a MUST for the vast majority of shoulder problems. For athletes, this is great. But for a mother of 3 who works full time and barley has enough time in the day to eat, doing the required home exercise program is…well…hard. This is what they don’t tell you in school…they show you great exercises that get shoulders better…but they don’t tell you how hard it is to get clients to adhere to a graded home exercises program. Sometimes even giving 1 or 2 exercises is all I can do because giving all that is required to create needed mobility and strength in the shoulder is just too much.

So what’s the best way I have found to convince clients to do their exercises? You need to PROVE to them how important they are. Here is how I go about doing that:

1) Many clients with painful shoulders have a large kyphosis or sit in a hunched forward position (desk workers syndrome). This effectively closes off the subacromial space leading to impingement. Have the patient assume their normal poor posture position and tell them to maximally flex their arm. They will have decreased ROM with sooner onset of pain. Then have the client sit erect with scapula back and down and repeat shoulder flexion. This will produce increased ROM and later onset of pain (which hopefully is diminished in the new position). This teaches the patient how important it is to have good posture and strong scapular retractors….this proves to the client how important the exercises are.

2) I also do assisted scapular upward rotation to help clear the acromion and humeral head during arm elevation. If this diminishes or abolishes the shoulder pain I always tell the client that we have to make the muscles that my hands acting as to keep your shoulder feeling this good. Again, I’m proving to them how great they could feel if they put in the work.

A 2009 article from JOSPT did a great job of summarizing the proposed biomechanical mechanisms of scapular kinematic deviations. They are:

1) Inadequate serratus activation: Lesser scapular upward rotation and posterior tilt

2) Excess upper trap activation: Greater clavicular elevation

3) Posterior GHJ soft tissue tightness: Greater scapular anterior tilt and humeral head anterior translation

 4) Thoracic kyphosis or flexed posture: Greater scapular IR and anterior tilt with less upward rotation

(JOSPT Feb 2009: The Association of Scapular Kinematics and Glenohumeral Joint Pathologies)

So what do I do for painful shoulders? Here are some of the usual steps I take for most shoulders problems:

1) Address Thoracic kyphosis: Retraction and extension exercises, thoracic spine manipulation, soft tissue release, posture arch, spikey ball, posture education

 

2) Address scapular stabilizers: Strengthen serratus anterior (wall slides, push up plus, hugs, punches etc), lower traps (Y’s, Overhead pull aparts, chair dips), and rhomboids (rows and active scap squeezing)

 

3) Address soft tissue tightness (BIG ONE!!): Release levator scapula, scalenes, SCM, upper traps, QL space, subscap, pec minor, pec major, lats

 

4) Rotator cuff strengthening: Side lying ER, Isometric ER/IR, scapular plain abduction progressing to ER at various degrees of shoulder abduction, “W” squeezes ( a favourite of mine)

5) Capsular stretching: Door way ER stretch, horizontal adduction and sleeper stretch with PNF contractions being my favourites

Overall, the shoulder is a tough joint to treat because no one exercise or technique works for everyone. It’s a constant trial and error processes that is made easier by a good assessment that takes into account posture, the cervical spine, contractile and non-contractile tissue along with more distal and inter-systemic issues manifesting as shoulder problems. The one thing we as therapists need to remember is that non-acute shoulder dysfunction doesn’t happen overnight…it takes months of misuse before problems arise. Therefore, we shouldn’t expect shoulder problems to disappear instantly. It takes time, focus, and a considered effort on the clients part to get a shoulder healthy.

Do you have any tips for treating painful shoulders? What kinds of techniques do you use?

Have a great day!

Ok, here it is…part 2 of it’s all in the hips. In my last post I discussed the importance of strong gluts for the prevention of knee pain. I explained what the glut muscles do and what happens when they go wrong. Suffice to say, there would be a lot less “pattelofemoral” pain patients in the world if we all worked on strengthening our hips!

Before I begin I want to say that the following exercises are for beginner to intermediate athletes and for those who have knee pain that COULD be attributed to the hips. Like I said in my last entry, there are other factors to knee pain but in any case, there is nothing wrong (or unsafe) about training the hips so I’m confident I wont hurt anyone by giving them some tips and videos. PLEASE note: don’t assume that these exercises will “cure” you of knee pain. I will always always always recommend getting a specific assessment by a trained professional such as a physiotherapist or chiropractor to determine the exact cause of your problem…you knew that was coming lol

Here is a list of exercises I like to give my patients with weak hips that are causing knee and low back pain:

1) The single leg bridge:

This exercise is great for 2 reasons. First and foremost, it strengthens the glut max (butt muscle) on the weight bearing side very well if done correctly. Secondly, this exercise is single leg and as such, the glut medius and minimus are working to control the non weight bearing hip from dropping down to the side. If this exercise is too hard to do..i.e you cant lift up high enough to make your hips level, you can do the double leg bridge…same idea as this, but you use 2 legs to bring your butt up instead of just one.

2) The “telephone” book exercise:

This exercise is tricky and is hard to explain in writing. Basically, you stand on a step (or telephone book lol) with one foot. You drop the other foot that is not on the step down my lowering the hip on that side. You then have to focus on contarcticing the glut med muscle on the weight bearing side to hike up the hip on the non weight bearing side. It’s best to hike the hip up higher then the hip on the weight bearing side for maximal benefit…don’t bent the knee on the weight bearing side much because that is cheating

3) Side lying hip abduction:

This one Is self explanatory…but here are a few key points to know:
a) When raising the leg up, do NOT let the hips roll back. You must try and keep the shoulder, hip and knee parallel. Keep your hand on your hips to sense if they are falling back or not…or do the exercises in front of a mirror if possible.

b) People with weak gluts will cheat in this exercise by using the hip flexor muscle tensor fascia lata (TFL) to raise the leg up instead of using the glut med. You will know this is happening because instead of keeping the leg straight out beside you (or even a little bit extended is best) the leg will come forward…you will flex the hip while abducting the leg because the TFL will do the work for the lazy gluts!

In the video, he uses a plastic band around the ankles to increase resistance. That is a good idea, but poorly executed. The band should ideally be just below the knees for maxiaml effect…having the band around the ankles is a) too hard and b) promotes the use of the TFL over the gluts

4) The Bird Dog:

The dude in this clip actually does a good job of explaining the exercise and common mistakes that are made. Just watch the clip and do what he says 😉
I know the video says this is a killer abs exercise (and it is)…BUT, this exercise is also a great glut max exercise and glut med stabilization exercise. It’s kind of advanced but I thought I’d throw it out there.
To make it easier—Don’t involve the arms. Just extend the legs out one at a time. Hold the leg out in an extended position for 10 seconds, bring it back down, and then do the other leg. This will still target the gluts but won’t do as much for the abs or back..

Do each of these 4 exercises 10 times. That is one set. Do 3-4 sets per day of each. If you develop pain while doing ANY of these exercises, STOP right away!! No need to hurt yourself here haha

As always, feel free to ask any questions you want. There are many more great glut exercises out there (squats, deadlifts etc), but these are the ones I find work well for the majority of people I see. For a personalized exercise program see a trained professional!

Thanks for reading!