Conditions Treated

Head

Dizziness and Vertigo
Dizziness and Vertigo Physical Therapy TreatmentDizziness and vertigo (which are terms often used interchangeably) are very common conditions that can significantly impact quality of life and function at any age. Approximately 5.5% of people in the United States or around 15 million people develop symptoms of dizziness each year, with the prevalence increasing with age. In fact, for individuals over 75 years of age, dizziness / vertigo is the most common reason to seek health care. Complaints of dizziness / vertigo may take patients to a variety of practitioners including medical doctors, dentists, and specialists such as ENT’s and neurologists. Very often the first course of treatment is medication. While these can be helpful, they often fall short of identifying and addressing the underlying cause(s) and frequently have undesirable side effects such as drowsiness.

As with most issues, resolution lies in accurately identifying the underlying problem. There can be multiple causes for dizziness and vertigo, and this can complicate clear diagnosis and proper treatment. The therapists at Appalachian Physical Therapy (APT) are trained in differential diagnosis for dizziness / vertigo which is two-fold:

  • Determine the category of dizziness / vertigo, which helps determine treatment:
  • Rule out any serious pathology warranting further testing.
    • Benign Paroxysmal Positional Vertigo – A condition in which the small crystals of the inner ear become dislodged. Identified and treated with fairly simple canalith repositioning techniques.
    • Temporomandibular Dysfunction – The head is a very complex structure full of multiple sensory systems. Problems in the temporomandibular joint, the only synovial joint in the head, can influence multiple senses and also cause dizziness / vertigo.
    • Head Soft Tissues – muscle and fascial dysfunction in the head which can create abnormal tension and disrupt the balance / proprioceptive mechanisms.
    • Cervical (neck) problems – Disturbance in the joints, discs, and soft tissues of the neck has been shown to potentially influence symptoms of dizziness / vertigo.

Once the source of the dizziness / vertigo has been identified, appropriate treatment can then be directed more successfully at the problematic tissue. This may include a variety of interventions including Fascial Manipulation ®, dry needling, joint mobilization, Postural Restoration ®, and more.

Facial Pain and Temporomandibular Joint Dysfunction
26% of all Americans experience facial symptoms at some point in their life. Less than half of these patients seek treatment even though problems often results in absence from work and decreased ability to perform usual activities. Facial and temporomandibular dysfunction may cause a wide variety of symptoms: pain in the head and jaw, headaches, dizziness / vertigo, limited jaw opening, locking of the jaw, clenching, grinding, pain with chewing, and joint popping or other noises. Typically when facial symptoms include the jaw the diagnosis is often TMJ, which stands for temporomandibular joint. However, the more correct term is temporomandibular dysfunction (TMD) as problems typically extend beyond the joint. Muscles, fascia, and ligaments throughout the entire head, face, and neck can become problematic. The temporomandibular joint disc may also dislocate and cause locking of the jaw with it open, closed, or somewhere in between limiting normal movement.

Facial symptoms and TMD may occur as a result of postural abnormalities, trauma, dental issues, problems with the bite (occlusion), and even musculoskeletal issues in the neck, shoulder, or back. Symptoms may also be related to Bell’s palsy, trigeminal neuralgia, fibromyalgia, multiple sclerosis, or neuroma. Studies have demonstrated up to 44% of those with cervicogenic headaches have jaw pain as well.

Treatment is multifaceted since the problem is as well: manual (hands-on) techniques targeting densifications and trigger points in the soft tissues; therapeutic exercise to restore normal range of motion/strength and neuromuscular control; joint mobilization to recapture a dislocated TMJ disc; education as to helpful lifestyle and habit changes. Since the problem may extend beyond the face and area of pain, it is helpful when all involved appreciate that the solution may also.

Headaches
The World Health Organization ranks headaches among the 10 most disabling disorders for males and among the top 5 for females.  Owing to the many different types of headaches that exist, theInternational Headache Society (IHS) has published a clinically useful headache classification system.  This system serves to guide and direct clinical care according to the type of headache a patient is felt to be enduring.  While a headache may be a sign of a life threatening condition, the majority of them are not.  Medications are often the first and sometimes only course of care, prescribed by neurologists as well as other primary care providers.  While these medications can be helpful, many patients still suffer breakthrough residual symptoms, headache “hangover,” and missing out on life.  Some do not find these medications helpful at all.

There is mounting evidence that many headaches have underlying neuromusculoskeletal contributions.  For example, studies show that problems in soft tissues and joints of the head, face, and neck can refer symptoms to the head in a manner that closely resembles many headache patterns.  Some headaches (according to classification) may be entirely amenable to interventions targeting the soft tissues and joints of the face, neck, and head.  These headaches often do not respond favorably to medications typically used for migraine and other severe headaches.  Even in the case of migraine (classified by very specific criteria and not the severity of the headache), attention to the neuromusculoskeletal contributions may reduce the frequency and severity of the migraines, as well as the need for medication.

Neck

Arthritis and Degenerative Joint Disease
Arthritis is very commonly diagnosed and can be somewhat discouraging as the implication is nothing can be done for it. But this is not true! Arthritis one of the most common conditions physical therapists treat, and multiple studies cite the effectiveness of physical therapy in reducing symptoms and improving activity tolerance. While some forms of arthritis are more responsive than others, the majority of cases fit the “wear and tear” or osteoarthritis category.

The actual cause of osteoarthritis is not completely understood, and it is thought to be the result of biochemical (natural substances in our body) and biomechanical (movement) abnormalities. In the neck, this is typically identified on X-ray which shows changes in the spinal facet joints. These changes occur slowly over time, not suddenly or with a trauma (although in some cases a trauma years earlier may have started the process, or a recent trauma may aggravate a silent process). More often people cannot identify an episode triggering the complaints. This lends support to the concept that movement abnormalities left unaddressed will, over time, eventually cause these degenerative changes. Such movement problems may not only be found in the neck, but other segments of the body that influence the neck. Rheumatoid arthritis may also present with pain, limited motion, and positive findings on X-ray but is typically more widespread throughout the body and involves more joint swelling and deformity.

Management of arthritis and degenerative joint disease should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Disc Degeneration and Herniation
Intervertebral discs are situated between the boney vertebrae and serve to provide space and cushioning to the spinal column. Problems with intervertebral discs generally include loss of height or rupture/herniation and are typically identified with X-rays or an MRI. X-rays are capable of imaging only the boney vertebrae, but can provide information on the status of the disc by showing a loss of space between the vertebral levels. An MRI provides more detail as to the actual condition of the disc. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings on imaging. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints (imaging shows greater involvement on one side, but the symptoms are on the other). Studies have shown that disc herniation can be found in up to 76% of symptom-free individuals. Because of this, imaging should not be used as the primary factor in determining treatment.

Management of disc degeneration and herniation should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Post-operative Rehabilitation
Physical therapists are experts at maximizing the restoration of mobility, strength, and function needed to return post-operative patients to their prior level of function or better. Research supports that the majority of patients with neck and arm pain do not require surgery. However, for the portion that do, physical therapy can play a vital role in ensuring the return to activity is appropriate without injury to involved areas.

In most post-operative cases, the neck is not the only area of dysfunction. This is true whether the surgery was in response to sudden trauma involving the neck, or a slower, less obvious process. Identifying and addressing any co-existing movement dysfunctions in other body segments that influence the neck can help to restore normal biomechanics and soft tissue tension throughout. This can significantly reduce the likelihood of recurrent problems in the neck as well as the need for repeated surgery, ongoing use of medication, bracing, and treatment.

Spinal Stenosis
Spinal stenosis is a condition in which the openings in the boney vertebrae become obstructed, narrowing the neural passages. This may occur in the space for the spinal cord (vertebral foramen), or in the holes that the nerve roots pass through (intervertebral foramena). In either case, if narrowing is significant enough it can result in pressure and compression on the spinal cord and/or nerve roots. Stenosis can be a genetic condition, but more often is thought to arise from excess wear and tear on the spine.

In some cases surgery is necessary. However, studies show that up to 20% of Americans have cervical stenosis, and nearly 100% can be treated without surgical intervention. Stenosis is typically identified with X-ray or MRI. It is important to note that findings on imaging do not always correlate with symptoms. Because of this, imaging should not be used as the primary factor in determining treatment.

Management of cervical stenosis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Back/Torso

Disc Degeneraton and Herniation
Intervertebral discs are situated between the boney vertebrae and serve to provide space and cushioning to the spinal column. Problems with intervertebral discs generally include loss of height or rupture/herniation and are typically identified with X-rays or MRIs. X-rays are capable of imaging only the boney vertebrae, but can provide information on the status of the disc by showing a loss of space between the vertebral levels. An MRI provides more detail as to the actual condition of the disc. However, it is important to note that findings on imaging do not always correlate with symptoms. Because of this, imaging should not be used as the primary factor in determining treatment.

 

Management of disc degeneration and herniation should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Costochondritis
Costochondritis is a condition that arises when the cartilage that connects the ribs to the sternum becomes inflamed. There is usually no identifiable injury that gives rise to this condition. Symptoms include chest pain which can mimic a heart attack, therefore this diagnosis should be ruled out. Pain generally begins with sudden onset and resolves in several weeks. Traditional medical treatment generally includes pain management.

 

Costochondritis however may indicate movement dysfunction of the sternal costal joint and the surrounding soft tissue, therefore a thorough physical exam focusing on rib and soft tissue mobility should be performed. Proper identification of causative factors can more rapidly alleviate pain and help prevent further recurrence.

Management of costochondritis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Arthritis and Degenerative Bone Disease
Arthritis is very commonly diagnosed and can be somewhat discouraging as the implication is nothing can be done for it. But this is not true! Arthritis one of the most common conditions physical therapists treat, and multiple studies cite the effectiveness of physical therapy in reducing symptoms and improving activity tolerance. While some forms of arthritis are more responsive than others, the majority of cases fit the “wear and tear” or osteoarthritis category.

 

The actual cause of osteoarthritis is not completely understood, and it is thought to be the result of biochemical (natural substances in our body) and biomechanical (movement) abnormalities. In the low back, this is typically identified on X-ray which shows changes in the spinal facet joints. These changes occur slowly over time, not suddenly or with a trauma (although in some cases a trauma years earlier may have started the process, or a recent trauma may aggravate a silent process). More often people cannot identify an episode triggering the complaints. This lends support to the concept that movement abnormalities left unaddressed will, over time, eventually cause these degenerative changes. Such movement problems may not only be found in the back, but other segments of the body that influence the back. Rheumatoid arthritis may also present with pain, limited motion, and positive findings on X-ray but is typically more widespread throughout the body and involves more joint swelling and deformity.

Management of arthritis and degenerative joint disease should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Diaphragmatic Retraining
The diaphragm serves many vital roles in the body and is not merely a way to move oxygen into any out of the body. Proper diaphragmatic function is essential for maintaining good posture and promoting normal movement throughout the torso. Suboptimal diaphragm function can lead to a variety of problems throughout the body including neck pain, low back pain, asthma, and limited trunk flexibility, to name a few.

 

Therefore, it is important to examine diaphragmatic function in a variety of medical conditions. Proper function is determined by examining ability to inhale/exhale, by observing rib mechanics throughout the breathing cycle, and by evaluating soft tissue mobility throughout the torso.

Diaphragmatic retraining is achieved by educating patients on faulty breathing mechanics, through the prescription of specific breathing exercises, and by addressing soft tissue restrictions which may be preventing normal mechanics.

Low Back Pain
Low back pain is a very common medical condition affecting 80-90% of the population of the United States at some point during their lives. Back pain is generally broken down into two main classifications: acute and chronic. Acute back pain begins with sudden onset and usually resolves within two to four weeks without significant medical treatment. Chronic back pain occurs when symptoms last longer than four weeks and do not spontaneously resolve.

 

There can be many different causes behind back pain, although back strain is one of the most common causes. Physical therapists receive extensive training to help differentiate between the various causes of back pain in order to determine the most appropriate and effective intervention. Most back pain can be treated through conservative physical therapy intervention and no diagnostic imaging (x-rays, MRI, CT scan) or invasive interventions are necessary.

Management of low back pain should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Spinal Stenosis
Spinal stenosis is a condition in which the openings in the boney vertebrae become obstructed which results in narrowing of the neural passages. This may occur in the space the spinal cord occupies (vertebral foramen), or in the holes that the nerve roots pass through (intervertebral foramena). In either case, if narrowing is significant enough it can result in compression on the spinal cord and/or nerve roots. With foraminal stenosis symptoms generally include numbness/tingling and pain in the lower extremity. Symptoms may worsen with standing/walking and generally ease with sitting or rest. Central canal stenosis generally results in weakness, pain, numbness/tingling in the low back and lower extremities. Stenosis can be a genetic condition, but more often is thought to arise from excess wear and tear on the spine.

 

In some cases surgery is necessary to prevent further damage to neural structures. However, in the majority of cases lumbar stenosis can be treated without surgical intervention. Stenosis is typically identified with X-ray or MRI. It is important to note that findings on imaging do not always correlate with symptoms. Because of this, imaging should not be used as the primary factor in determining treatment.

Management of lumbar stenosis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Spondylosis
Spondylosis is a descriptive term that means degeneration of the spine. This can include osteoarthritis, degenerative disc disease, facet joint arthropathy, and many other diagnoses. Generally spondylosis becomes apparent as we age, although may be due to movement dysfunction throughout the spine and extremities.

 

Management of spondylosis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Spondylolisthesis
Spondylolisthesis is a condition in which a vertebrae shifts forward on the vertebrae below it. It occurs most commonly in the lower lumbar spine just above the sacrum. Symptoms generally include pain, numbness, and or weakness in one or both legs. In some instances no symptoms are present and this condition may be an incidental finding on diagnostic imaging. In extreme cases patients may lose control of their bowels or bladder. Loss of bowel and bladder control is a medical emergency and patients should seek immediate medical care.

 

Spondylolisthesis may be the result of a birth defect, an accident or trauma, repeated hyperextension of the spine, or joint damage due to infection or arthritis. This condition is generally treated conservatively unless it has lead to an unstable fracture which must be treated conservatively.

Management of spondylolisthesis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This approach is especially important with this condition as there may be multiple sources of pain, not just the affected joint. This can make a significant difference in pain and mobility. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Post-Operative Rehabilitation
Physical therapists are experts at maximizing the restoration of mobility, strength, and function needed to return post-operative patients to their prior level of function or better. Research supports that the majority of patients with low back pain do not require surgery. However, for the portion that do, physical therapy can play a vital role in ensuring the return to activity is appropriate without injury to involved areas.

 

In most post-operative cases, the back is not the only area of dysfunction. This is true whether the surgery was in response to sudden trauma involving the neck, or a slower, less obvious process. Identifying and addressing any co-existing movement dysfunctions in other body segments or tissues not addressed through surgery that can influence the back can help to restore normal biomechanics and soft tissue tension throughout. This can significantly reduce the likelihood of recurrent problems in the back as well as the need for repeated surgery, ongoing use of medication, bracing, and treatment.

Elbow / Wrist / Hand

Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition that arises due to the compression of the median nerve. True carpal tunnel syndrome occurs when the nerve is compressed where it passes from the wrist into the hand under the transverse carpal ligament. This condition is though to occur due to overuse of forearm, wrist, and hand muscles. Symptoms generally include weakness, numbness, and tingling, especially in the thumb and index finger. Those affected by this condition may experience worsening of symptoms at night. Patients may report pain with typing at a computer or difficulty grasping small objects during every day activity. Up to 20% of pregnant women may also experience these symptoms, likely due to fluid retention. Precise diagnosis of this condition requires nerve conduction velocity testing.

This condition can be very complex in nature and symptoms may arise from soft tissue restrictions in locations other than the carpal tunnel. The median nerve follows a very complex path as it travels from the neck (cervical spine) to the hand and compression can occur in many different places. Management of carpal tunnel syndrome should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, strength, numbness/tingling, and the ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating carpal tunnel syndrome and its associated complaints by:

 

  1. Addressing all tissues that may be responsible for symptoms. Although the rotator cuff muscles are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with the shoulder including fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Rotator cuff strains and tears that occurred without any provoking incident likely developed due to other contributing factors which resulted in abnormal stress being placed on the shoulder. Postural abnormalities and dysfunctional muscle recruitment can place these muscles in a suboptimal position to work or may result in abnormal stress being placed through these muscles. Our skilled assessment identifies all tissues that need to be targeted in treatment or that warrant referral to another practitioner.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Medial/Lateral Epicondylitis (Golfer’s/Tennis Elbow)
Medial epicondylitis occurs when the common bony attachment of the forearm muscles on the medial epicondyle (inside of the elbow) of the humerus become inflamed. This injury is thought to occur as a result of abnormal stress being placed on the tendons, specifically at their bony attachments. The primary symptoms of this condition are pain and tenderness on the inside or medial aspect of the elbow. There can be many factors contributing to the development of this condition, including overuse, overload, and the initiation of new activities specifically stressing the forearm muscles. This injury is sometimes called golfer’s elbow as this activity can lead to overuse of these forearm muscles.

Similarly, lateral epicondylitis occurs when the common bony attachment of the forearm muscles on the lateral epicondyle (outside of the elbow) become inflamed. Like medial epicondylitis, this injury is believed to be the result of overuse or abnormal stress being placed on the tendons of the forearm muscles that attach to the outside of the elbow. Primary symptoms include pain and tenderness along the outside of the elbow.

Even if this condition is believed to be from repetitive motion or overuse, it is important to undergo a thorough physical therapy examination as therapists may identify deficits in strength, range of motion, flexibility, or faulty biomechanics which may have precipitated or contributed to this condition. Irritation and inflammation of the bone and tendons at their interface indicates excess or abnormal stress is being placed on the involved tissue and to truly eliminate this stress the provoking factors must be properly identified.

Management of medial and lateral epicondylitis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating medial and lateral epicondylitis and its associated complaints by:

 

  1. Addressing all tissues that may be responsible for symptoms. Although tendons and their bony attachments are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with the elbow and forearm including muscle, fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Medial and lateral epicondylitis without any provoking incident likely developed due to other contributing factors resulting in abnormal stress being placed on this tissue. Postural abnormalities and dysfunctional muscle recruitment can contribute to abnormal stress or strain being placed on the tendons and their attachments.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Wrist and hand fractures
Boney fracture may occur in response to trauma, but can also arise from much lower loads applied to bone lacking sufficient density. In either situation, the fracture must be managed appropriately according to the nature and location. Some cases may require surgery with hardware placement to stabilize a joint. When pain and limitations to functional activity persist in the presence of satisfactory bone healing, involvement of soft tissues should be considered. Often soft tissue involvement is overlooked after a trauma involving a fracture, and the bone receives much of the attention. It should be considered that with any trauma severe enough to cause bony fracture, soft tissue injury will be present as well.

Once the acute phase has passed, restoration of normal mobility, strength, and function in the affected region is commenced. This may include addressing habits, sports, and movement abnormalities in the vicinity of the fracture, as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

 

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Pelvis / Hip

Arthritis, Degenerative Joint Disease, & Spondylosis
Arthritis is very commonly diagnosed and can be somewhat discouraging as the implication is nothing can be done for it. But this is not true! Arthritis one of the most common conditions physical therapists treat, and multiple studies cite the effectiveness of physical therapy in reducing symptoms and improving activity tolerance. While some forms of arthritis are more responsive than others, the majority of cases fit the “wear and tear” or osteoarthritis category with degeneration occurring in the joints.

The cause of osteoarthritis is not completely understood, and it is thought to be the result of biochemical (natural substances in our body) and biomechanical (movement) abnormalities. Degenerative changes in the joints occur slowly over time, not suddenly or with a trauma (although in some cases, a trauma years earlier may have started the process or a recent trauma may aggravate a silent process). More often people cannot identify an episode triggering the complaints. This lends support to the concept that movement abnormalities left unaddressed will, over time, eventually promote these degenerative changes. Such movement problems may not only be found in the back, but other segments of the body that influence the back such as the hips and knees. Rheumatoid arthritis may also present with pain, limited motion, and positive findings on X-ray but is typically more widespread throughout the body and involves more joint swelling and deformity.

Diagnosis often includes imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the joints space or lack of it. MRI may provide even more detail. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings on imaging. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Or the imaging shows similar problems on both sides but only one side is symptomatic. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and joint degeneration, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Management of arthritis and degenerative joint disease should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Bursitis
Bursa are fluid filled sacs found throughout the body, typically near joints. Their purpose is to cushion tendons to decrease friction, and also change the angle of pull a tendon has on a joint to improve efficiency. “Itis” is the suffix used to indicate inflammation, so bursitis refers to inflammation of the bursa. Symptoms may include pain, stiffness, loss of mobility, and tenderness.

Onset may be related to trauma, such as a fall. In this case the inflammation in the bursa can be visible, making diagnosis straightforward. More often, there is no precipitating trauma and bursitis is assumed to be the reason behind a complaint. This seems particularly common when symptoms arise in the hip, and sometimes in the shoulder, elbow, and knee. In these cases diagnosis is typically based on symptoms alone, as there are no clear-cut diagnostic tests for bursitis. Bursa are not visible on X-ray, although calcification in a bursa may be visible. MRI may also detect swelling in bursa. However, since these symptoms (pain, stiffness) also occur with many other musculoskeletal issues, basing diagnosis largely on symptoms is potentially subject to error.

Typical treatment for bursitis may include rest, ice, and anti-inflammatory medication. While this may help following trauma, symptoms in the majority of non-traumatic cases may improve only as long as these measures are sustained and return once stopped. Such a cycle should prompt consideration that either the bursa is not the problem, or that something else is repeatedly irritating the bursa. Most tissues must have an irritant to become symptomatic – they will not spontaneously and primarily become problematic. Removing the source of irritation should not only remove the symptoms, but also keep them from returning.

It has been our experience that differentiating whether the bursa is the problem is not imperative to recovery. What is essential is addressing movement abnormalities that may be irritating multiple tissues, including the bursa. These tissues are simply caught in the middle of a connective tissue tug-of-war. The longer it is sustained, the greater the damage to tissues enduring the application of abnormal tension and force. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to restore normal motion. Experience has also shown us that movement abnormalities outside of the symptomatic region may be playing a part as well. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Dislocation & Subluxation
Dislocation is defined as an event in which joint surfaces are no longer congruent, with movement extending beyond normal anatomical limits. Subluxation is similar but to a lesser degree, almost like the beginning of dislocation. Either can occur in response to trauma. Management begins with relocation of the joint, immobilization to allow healing, pain control measures, and eventually efforts to restore normal strength and mobility as much as possible.

Things get more challenging when dislocation or subluxation recur, or occur initially without a trauma. In such cases the problem is often due to the presence of laxity in the connective tissues that typically restrict joint movement to normal parameters. This may occur in response to repeated episodes of dislocation – almost like over-stretched elastic. In some individuals it may be a reflection of a condition known as hypermobility (see Hypermobility under Other Conditions). Hypermobility is a genetic condition in which there is insufficient collagen in the connective tissues to stabilize joints, allowing them to move too far and sublux or dislocate. Sometimes called Benign Joint Hypermobility Syndrome, it can be anything but benign (meaning of no concern) and involves far more than just the joints.

In the case of recurrent episodes of subluxation or dislocation (in the presence or absence of genetic hypermobility), management is multifaceted. This may involve use of temporary or more permanent extrinsic devices (such as braces) that will assist in limiting excessive joint motion. While this is feasible in some body regions such as the fingers, others (like the hips) do not brace as easily. Once the acute phase is past, restoration of normal mobility as much as possible in the target joint is commenced. While many people assume that strengthening around the joint is primary, this is of limited benefit. Factors contributing to subluxation or dislocation must be addressed in an effort to prevent recurrence. This may include addressing habits, sports, and movement abnormalities in the vicinity of the subluxation or dislocation, as well as throughout the body. This is why we utilize a comprehensive perspective, appreciating how the body works as a total structure. Our approach in rehabilitation is based on our knowledge of biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Femoroacetabular Impingement (FAI)
This is broadly defined as symptoms in the hip thought to be associated with abnormal movement and/or anatomical changes in the hip. Symptoms can include pain in the hip, groin, or low back, along with clicking, locking, and limited mobility. Three types of FAI are recognized:

  1. Cam Deformity – named for the shape of the femoral head and neck resembling a camshaft. It involves an excess of bone along the upper surface of the femoral head. Studies suggest that these deformities are more common in males. It must be appreciated that the body typically manufactures excess bone (like spurs) in areas of abnormal movement or excess stress to serve as a stabilizing counter-force. So the take-home point is that movement abnormality may be the triggering factor.
  2. Pincer Deformity – an excess of growth of the upper lip of the acetabular cup or socket. Studies suggest that these deformities are more common in females. Again, as in the Cam deformity, movement abnormalities may play a dominant role.
  3. Combined Cam and Pincer Deformities – approximately 70% of all FAI fits into this category.

A predisposition to such problems may be genetic in nature. Environmental factors such as habits, repeated movements, sports, or trauma may also play a role. In any case, the potential for connective tissue (muscle, fascia) problems causing movement abnormalities in the hip joint should also be considered.

Diagnosis of subjects with symptoms and mobility deficits in the hip may include X-ray, CT, or MRI. However, a complicating issue is that some of the radiographic findings of FAI have also been described in asymptomatic subjects. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and findings in the hip on imaging, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Factors contributing to FAI must be addressed in an effort to prevent recurrence. Habits, sports, and movement abnormalities in the vicinity of the hip as well as throughout the body may need attention. This is why we utilize a comprehensive perspective, appreciating how the body works as a total structure. Our approach in rehabilitation is based on our knowledge of biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. In the absence of severe signs, a trial of conservative care is reasonable, especially considering that other structures may be influencing symptoms in the hip.

Fracture
Boney fracture may occur in response to trauma, but can also arise from much lower loads applied to bone lacking sufficient density. In either situation, the fracture must be managed appropriately according to the nature and location. Some cases may require surgery, such as a hip pinning or total hip replacement. Pelvic fractures are more typically managed with limiting weight bearing during healing. In either case, when pain and limitations to functional activity persist in the presence of satisfactory bone healing, involvement of soft tissues should be considered. Often soft tissue involvement is overlooked after a trauma involving a fracture, and the bone receives much of the attention. It should be considered that with any trauma severe enough to cause a bone fracture, there will always be soft tissue injury as well.

Once the acute phase is past, restoration of normal mobility as much as possible in the region is commenced. This may include addressing habits, sports, and movement abnormalities in the vicinity of the fracture, as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Groin Strain

The groin refers to the area of the upper, inner thigh. As with soft tissue injury anywhere else, a strain occurs when the fascia and muscles (adductor longus / magnus / brevis, pectineus, gracilis, iliopsoas – see at www.triggerpoints.net; ) of the area are overloaded (demand that exceeds capability). Many people mistakenly relegate this injury to male athletes only. While it does occur more frequently in male athletes, it has nothing to do with male anatomy and can occur in females as well as non-athletes. Sometimes a trauma or high-demand activity can be identified as the causative factor, such as a forceful kick, turning on a planted foot, or a heavy lift. Other times there is no obvious episode and the cause is unidentified. When tissues are already overloaded and “on the edge,” something as simple as getting out of a vehicle may push them into strain. Once injured, they can remain on the edge of injury, an accident waiting to happen again. Symptoms may include pain, a pulling sensation, and aching in the inner thigh with any activity or even at rest. Symptoms may even extend into the pelvic floor region, causing discomfort and problems in the pelvic floor and urogenital region. Imaging (X-ray, MRI) is typically not warranted initially unless there is a strong suspicion of fracture or tissue rupture.

Treatment has two basic levels: 1) Manage the acute symptoms, and 2) Address mobility problems that may have resulted from the injury or been the pre-existing, predisposing factor behind the injury. This may include addressing habits, sports, and movement abnormalities in the vicinity of the strain as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Labral Tears

The labrum is the ring of cartilage lining a joint surface. Found in the hip and shoulder, it provides additional depth and stability to these relatively unstable joints. Problems arise when the labrum is torn, which can occur for a variety of reasons. In a small portion of cases it is present at birth. Sometimes a trauma or high-demand activity can be identified as the causative factor, such as (for the hip) a forceful kick, turning on a planted foot, or a squat. The majority of the time the cause is either unknown or attributed to degeneration. In these cases, biomechanical (movement) problems are likely the cause (see Impingement). Faulty biomechanics (movement patterns) perpetuated over time can gradually wear on the labrum until it tears – like a car with the tires out of alignment. These biomechanical problems may go undetected for an extended period until they progress to the point of causing symptoms: hip pain, aching, locking, and popping with activity or movement. The presence of any or all of these symptoms, however, does not conclusively mean the labrum is torn. Many people mistakenly relegate this injury to athletes only. While it does occur in athletes, it can present in the non-athletic population as well.

Management often begins with imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the cartilage by displaying joint space or lack of it. MRI provides more detail as to the actual condition of the labrum. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings in the joint and labrum. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and the labral tear, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to resolve movement abnormalities. Experience has also shown us that movement abnormalities outside of the hip region may be playing a part as well. In other words, the labrum may tear due to dysfunctional soft tissues and abnormal movement in the back or knee. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. In the absence of severe signs, a trial of conservative care is reasonable, especially considering that other structures may be influencing symptoms more than the labrum.

Pelvic / Abdominal Pain and Dysfunction - Women
Millions of Americans are suffering from pelvic floor dysfunction. Yet, for most, the disease goes unidentified and untreated. Statistics say that 1 out of every 5 Americans (of every age) suffer from some type of pelvic floor dysfunction at some time in their life. Over 25 million Americans suffer from urinary incontinence alone or involuntary loss of urine. This is not just a “women’s” disorder: men and children can have pelvic floor dysfunction as well.” (http://www.beyondbasicsphysicaltherapy.com )

Adolescents and women have special needs related to changes in their body as they mature such as puberty, pregnancy, hormonal fluctuations, and menopause. These events, even when occurring normally and without complication, can contribute to the development of pain and dysfunction in the pelvic, hip, and abdominal regions. Unfortunately, many are embarrassed to discuss these and simply live with or around them. Others may pursue mainstream interventions that yield less than satisfactory results, undesirable side effects, and/or ongoing care. These conditions may include:

  • Coccydynia
  • Core Instability / Insufficient Pelvic Floor Support
  • Cysts
  • Bladder (Urinary Tract) Issues – Incontinence (stress, urge, functional, mixed), frequency, retention, recurrent infections, kidney stones, interstitial cystitis, painful bladder syndrome
  • Bowel (Fecal) Incontinence – accidental bowel leakage
  • Dysmenorrhea – menstrual cycle abnormalities (excessive bleeding, cramping, frequency, duration)
  • Dyspareunia – difficult or painful intercourse
  • Endometriosis
  • Gastrointestinal Disturbances – constipation, diarrhea, flatus (gas), bloating, food intolerance/allergy, irritable bowel syndrome (IBS), reflux, heartburn.
  • Hernia
  • Pre/post-partum Problems
  • Post-Surgical Pain – laparoscopic, caesarian, episiotomy, epidural
  • Prolapse – cystocele, rectocele, enterocele
  • Vulvar Vestibulitis, Vulvodynia
  • Yeast Infection – Recurrent

The network of muscles, ligaments, fascia, and skin in the pelvic and abdominal regions serves as a complex support structure that holds organs and nerves in place. When this supportive soft tissue environment becomes compromised, symptoms can present as arising from the organ itself – even when the organ is fine. This may explain why tests and procedures may determine that the organs is clear, even in the presence of symptoms. In the absence of organ dysfunction, soft tissues must be considered as a potential source for problems. Overload to these supportive soft tissues can arise from a variety of sources such as pregnancy, hormonal fluctuations, everyday activities (even prolonged sitting), sports, surgical procedures, and trauma. Previous musculoskeletal problems in the trunk and extremities may also play a role in exacerbating pelvic and abdominal conditions. For example, hip or back problems often play a role in pelvic dysfunction. (As a matter of fact, when neck, back, knee, shoulder, or other problems do not respond to appropriate care, the pelvic and abdominal support soft tissues should be considered as a potential source.) Some diagnoses, such as urinary incontinence, are commonly thought to be inevitably associated with age and pregnancy. While these life events certainly can stress the pelvic structures, this does not justify these problems occurring in younger women who have never been pregnant! Additionally, there is a growing body of literature associating the frequency of urinary incontinence in elderly women with higher risk of falling. This takes urinary incontinence far beyond an embarrassing inconvenience to a potentially life changing event. Interstitial cystitis is another good example. The literature provides very little clarity as to the underlying pathology driving this problem, as most tests are negative. Repeated antibiotics are typically utilized, often with no lasting resolution. This diagnosis is one that lends strong support to the concept that the soft tissue support environment of the bladder is the problem – not the bladder itself.

Surgical procedures can be necessary and helpful. But sometimes surgery is not an option, or an individual may understandably prefer to pursue other interventions. Surgery is not always successful at fully alleviating symptoms. Sometimes symptoms respond well initially but later return. The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. The same could be said for medications, which typically have undesirable side effects. In the absence of severe signs, a trial of conservative care is typically reasonable, warranted, and preferred over surgery and medication.

The therapists in our practice are specially trained to identify and address the source(s) of these problems. Our emphasis is on restoring the normal soft tissue support environment to the organs. This allows us to perform interventions both with and without utilizing internal techniques through or too the pelvic floor (currently internal techniques are through our North Carolina office only). We embrace a comprehensive perspective, appreciating how the body works as a total structure. Our approach is often as follows:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing. (However, in the presence of internal dysfunction movement tests may be less informative.)
  • Identify by palpation which soft tissues are contributing to the problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ® (trunk, extremities, and internal dysfunction including visceral manipulation), Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Our knowledge of biomechanics drives our efforts to maximize normal motion. While somewhat unconventional and non-traditional in terms of women’s health physical therapy (or any PT for that matter), the results we accomplish speak for themselves.

Pelvic / Abdominal Pain and Dysfunction - Men
Millions of Americans are suffering from pelvic floor dysfunction. Yet, for most, the disease goes unidentified and untreated. Statistics say that 1 out of every 5 Americans (of every age) suffer from some type of pelvic floor dysfunction at some time in their life. Over 25 million Americans suffer from urinary incontinence alone or involuntary loss of urine. This is not just a “women’s” disorder: men and children can have pelvic floor dysfunction as well.” (http://www.beyondbasicsphysicaltherapy.com )

Men, like women, are subject to pain and dysfunction affecting the pelvic and abdominal regions. Unfortunately, many are embarrassed to discuss these and simply live with or around them. Others may pursue mainstream interventions that yield less than satisfactory results, undesirable side effects, and/or ongoing care. These conditions may include:

  • Coccydynia
  • Core Instability
  • Cysts
  • Bladder (Urinary Tract) Issues – frequency, difficulty initiating, weak urine stream, dribbling, retention, recurrent infections, kidney stones, interstitial cystitis, painful bladder syndrome
  • Bowel (Fecal) Incontinence – accidental bowel leakage
  • Dyspareunia – difficult or painful intercourse
  • Erectile Dysfunction
  • Gastrointestinal Disturbances – constipation, diarrhea, flatus (gas), bloating, food intolerance/allergy, irritable bowel syndrome (IBS), reflux, heartburn.
  • Hernia
  • Post-Surgical Pain
  • Prolapse
  • Prostatitis, Benign Prostatic Hyperplasia

The network of muscles, ligaments, fascia, and skin in the pelvic and abdominal regions serves as a complex support structure that holds organs and nerves in place. When this supportive soft tissue environment becomes compromised, symptoms can present as arising from the organ itself – even when the organ is fine. This may explain why tests and procedures may determine that the organs is clear, even in the presence of symptoms. In the absence of organ dysfunction, soft tissues must be considered as a potential source for problems. Overload to these supportive soft tissues can arise from a variety of sources such as everyday activities (even prolonged sitting), sports, surgical procedures, and trauma. Previous musculoskeletal problems in the trunk and extremities may also play a role in exacerbating pelvic and abdominal conditions. For example, hip or back problems often play a role in pelvic dysfunction. (As a matter of fact, when neck, back, knee, shoulder, or other problems do not respond to appropriate care, the pelvic and abdominal support soft tissues should be considered as a potential source.) Some diagnoses, such as prostatitis or urinary tract problems are commonly thought to be inevitably associated with aging. While life events certainly can stress the pelvic structures, this does not justify these problems (such as hernia or erectile dysfunction) occurring in young men. Interstitial cystitis is good example. The literature provides very little clarity as to the underlying pathology driving this problem, as most tests are negative. Repeated antibiotics are typically utilized, often with no lasting resolution. This diagnosis is one that lends strong support to the concept that the soft tissue support environment of the prostate and bladder may be the problem – not the prostate or bladder itself.

Surgical procedures can be necessary and helpful. But sometimes surgery is not an option, or an individual may understandably prefer to pursue other interventions. Surgery is not always successful at fully alleviating symptoms. Sometimes symptoms respond well initially but later return. The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. The same could be said for medications, which typically have undesirable side effects. In the absence of severe signs, a trial of conservative care is typically reasonable, warranted, and preferred over surgery and medication.

The therapists in our practice are specially trained to identify and address the source(s) of these problems. Our emphasis is on restoring the normal soft tissue support environment to the organs. This allows us to perform interventions both with and without utilizing internal techniques through or too the pelvic floor (currently internal techniques are through our North Carolina office only). We embrace a comprehensive perspective, appreciating how the body works as a total structure. Our approach is often as follows:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing. (However, in the presence of internal dysfunction movement tests may be less informative.)
  • Identify by palpation which soft tissues are contributing to the problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ® (trunk, extremities, and internal dysfunction including visceral manipulation), Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Our knowledge of biomechanics drives our efforts to maximize normal motion. While somewhat unconventional and non-traditional in terms of pelvic health physical therapy (or any PT for that matter), the results we accomplish speak for themselves.

Pelvic / Abdominal Pain and Dysfunction – Children
Millions of Americans are suffering from pelvic floor dysfunction. Yet, for most, the disease goes unidentified and untreated. Statistics say that 1 out of every 5 Americans (of every age) suffer from some type of pelvic floor dysfunction at some time in their life. Over 25 million Americans suffer from urinary incontinence alone or involuntary loss of urine. This is not just a “women’s” disorder: men and children can have pelvic floor dysfunction as well.” (http://www.beyondbasicsphysicaltherapy.com )

Children’s physical complaints sometimes have their basis in manipulation (so do adult’s, for that matter!). Yet when they persist or demonstrate clear evidence of a problem, it is unfair to relegate them to the field of “growing pains.” It’s also hard to ignore the numbers of children consulting health care providers for gastrointestinal issues such as irritable bowel syndrome, constipation, gas, encopresis, as well as bedwetting, etc. These issues are not only physically problematic for children, but can erode their fragile, developing self-confidence. They also place an additional burden and heartbreak on parents who are trying to sort out the legitimacy of complaints, coordinate and finance medical care, and coordinate life around their children’s problems. Sometimes children and parents are too embarrassed to discuss these issues. Others may pursue mainstream interventions that yield less than satisfactory results, undesirable side effects, and/or ongoing care. These conditions may include:

  • Coccydynia
  • Core Instability / Insufficient Pelvic Floor Support
  • Cysts
  • Bladder (Urinary Tract) Issues – Incontinence (bedwetting, stress, urge, functional, mixed), frequency, retention, recurrent infections, kidney stones, interstitial cystitis, painful bladder syndrome
  • Bowel (Fecal) Incontinence – accidental bowel leakage, encopresis
  • Gastrointestinal Disturbances – constipation, diarrhea, flatus (gas), bloating, food intolerance/allergy, irritable bowel syndrome (IBS), reflux, heartburn.
  • Hernia
  • Post-Surgical Pain – appendectomy
  • Yeast Infection – Recurrent

The network of muscles, ligaments, fascia, and skin in the pelvic and abdominal regions serves as a complex support structure that holds organs and nerves in place. When this supportive soft tissue environment becomes compromised, symptoms can present as arising from the organ itself – even when the organ is fine. This may explain why tests and procedures may determine that the organs is clear, even in the presence of symptoms. In the absence of organ dysfunction, soft tissues must be considered as a potential source for problems. Overload to these supportive soft tissues can arise from a variety of sources such as hormonal fluctuations, everyday activities (even prolonged sitting), sports, surgical procedures, and trauma. Previous musculoskeletal problems in the trunk and extremities may also play a role in exacerbating pelvic and abdominal conditions. For example, hip or back problems often play a role in pelvic dysfunction. (As a matter of fact, when neck, back, knee, shoulder, or other problems do not respond to appropriate care, the pelvic and abdominal support soft tissues should be considered as a potential source – forget about growing pains!)

Surgical procedures can be necessary and helpful. But sometimes surgery is not an option, or an individual may understandably prefer to pursue other interventions. Surgery is not always successful at fully alleviating symptoms. Sometimes symptoms respond well initially but later return. The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. The same could be said for medications, which typically have undesirable side effects. In the absence of severe signs, a trial of conservative care is typically reasonable, warranted, and preferred over surgery and medication.

The therapists in our practice are specially trained to identify and address the source(s) of these problems. Our emphasis is on restoring the normal soft tissue support environment to the organs. This allows us to perform interventions without utilizing internal techniques through or too the pelvic floor. We embrace a comprehensive perspective, appreciating how the body works as a total structure. Our approach is often as follows:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing. (However, in the presence of internal dysfunction movement tests may be less informative.)
  • Identify by external palpation which soft tissues are contributing to the problems.
  • Address these with manual techniques such as Fascial Manipulation ® (trunk, extremities, and internal dysfunction including visceral manipulation), Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Our knowledge of biomechanics drives our efforts to maximize normal coordinated movement and function to all the system: urogenital, gastrointestinal, nervous, and musculoskeletal. This then allows for normal growth and development, and may in turn, even prevent many problems considered typical for adults.

Piriformis Syndrome
The piriformis is one of several muscles in the buttock region which participates in hip rotation (turning out or in). While not very large in size, its importance is attributed to its proximity to the sciatic nerve. Anatomical variations in people cite the sciatic nerve as passing in front of, behind, or through the piriformis muscle. Regardless of which arrangement a person possesses, this close relationship between muscle and nerve creates potential problems. If the piriformis muscle becomes irritated, swollen, injured, or in spasm it could compress on the sciatic nerve and cause pain, numbness, tingling, and even weakness in the back, hip, and leg. These are also symptoms attributed to sciatica.

As with soft tissue injury anywhere else, a strain occurs when the fascia and muscles (see at www.triggerpoints.net; ) of the area are overloaded (demand that exceeds capability). Sometimes a trauma or high-demand activity can be identified as the causative factor, such as a fall, twisting, or heavy lifting. Hypermobility and sacroiliac joint problems can also play a part in piriformis syndrome. Other times there is no obvious episode and the cause is unidentified. When tissues are already overloaded and “on the edge,” something as simple as getting out of a vehicle or prolonged sitting may push them into strain. Pregnancy may also further overload tissues. Once injured, they can remain on the edge of injury, an accident waiting to happen again. Imaging (X-ray, MRI) is typically not warranted initially unless there is a strong suspicion of fracture or tissue rupture. There are no diagnostic tests to absolutely rule piriformis syndrome in/out, and it is a diagnosis based largely on symptoms.

Treatment has two basic levels: 1) Manage the acute symptoms, and 2) Address mobility problems that may have resulted from the injury or been the pre-existing, predisposing factor behind the injury. This may include addressing habits, sports, and movement abnormalities in the vicinity of the strain as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Post-operative Rehabilitation
The irreversible nature of surgery as well as variable outcomes associated with it justifies careful consideration. Research supports that the majority of patients with pelvic and hip pain do not require surgery. However, for the portion that do, physical therapy should play a vital role in pain management as well as restoration of mobility, strength, and function needed to return post-operative patients to activity.

It must be considered that while surgery addresses tissues that have been damaged (hip joint) it does not resolve the underlying cause of the problem. Joints do not degenerate without some driving factor. Very often biomechanical (movement) abnormalities arising from the soft tissues that dictate movement are to blame. When these tissues are dysfunctional and disrupt normal movement, joints are simply caught in the middle of an anatomical tug-of –war. The sustained stress and torsion applied to them eventually wears them out. If these issues are not resolved then the destructive stresses and forces will continue and potentially cause future problems.

Our approach in rehabilitation reflects this appreciation for biomechanics, and drives our efforts to resolve movement abnormalities. Our experience has also shown us that movement abnormalities outside of the surgical region may be playing a part as well. In other words, the hip may wear out because of dysfunctional soft tissues and abnormal movement in the back or knee. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Sciatica
The sciatic nerve begins in the lower back region as the nerve roots coming off the spinal cord at the 4th and 5th lumbar levels, as well as the first 3 sacral nerve roots. As these nerve roots enter the buttock region they merge to form the sciatic nerve, which is the largest nerve in the body. It continues down the back of the leg providing motor and sensory innervation. Sciatica is the term used to imply irritation of this nerve. It is commonly the diagnosis rendered when someone experiences leg pain. A straight leg raise test is often utilized to confirm this diagnosis, which involves raising the leg while keeping the knee straight. While this may stretch the sciatic nerve, it does not exclusively isolate it from multiple other structures that are also tensioned with this maneuver. There are no specific diagnostic tests for sciatica, making it a diagnosis based purely on symptomology. X-ray and MRI do not provide information about the nerve, although they can yield some insight into lower back problems. Often when imaging does present with findings in the low back and a patient presents with leg pain, the information is extrapolated and a diagnosis of sciatica is often applied. Treatment often includes anti-inflammatories such as steroids, injections, rest, and possibly lumbar traction.

Yet this diagnostic and treatment model has its flaws.

  1. The sciatic nerve is not the only structure that can cause lower extremity symptoms. For instance, the referred symptom pattern of the gluteus minimus muscle in the buttock has a pattern down the back of the leg very similar to what is commonly attributed to sciatica (www.triggerpoints.net). This is also true of the hamstring musculature.
  2. Nerves do not typically become inflamed or symptomatic without some kind of irritant. Trauma, fascial restrictions, pelvic dysfunction, and excessive sitting are just some examples of potential irritants. The nerve is simply responding to its environment and situation.
  3. Imaging of the lower back does not give definitive information as to the cause of lower extremity symptoms. Some internet sources cite a lumbar herniated disc as causing sciatica 90% of the time. While this could potentially occur, it has been our experience in practice that this is a gross overestimation, and represents a commonly perpetuated myth about back and leg symptoms. The improvement we accomplish in abolishing leg pain without ever changing the findings on imaging demands skepticism of this hypothetical relationship. Certainly they often occur simultaneously, but this does not prove cause and effect. Rather, it supports a global approach to the body appreciating that movement dysfunctions in one segment can irritate structures in multiple other regions.
  4. Medications and injections may calm down the irritated nerve, but do nothing to identify and address the causative factors. This is why the problem so often improves but returns, often not fully resolving.

Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Sacroiliac Joint (SIJ) Dysfunction
The SIJ is the articulation between the sacrum and the pelvis. While it does not have much range of motion, the mere fact that it is not fused indicates that it is meant to move. Pain located between the low back and buttock is often attributed to the SIJ. Problems are thought to arise when this joint becomes incorrectly positioned and/or inflamed. While there are multiple clinical examination tests that can be done to theoretically stress the joint and identify problems, the reality is they are not very specific or reliable. Imaging (X-ray, MRI) may demonstrate arthritic changes here, but it is important to note that findings on imaging do not always correlate with symptoms. Just because an image shows a flaw does not confirm that this flaw is the source of pain. Because of this, imaging should not be used as the primary factor in determining treatment.

Traditional treatment interventions include measures to address inflammation in the joint (medications, injections, ice, etc.), mobilization/manipulation to reposition, and measures to stretch and stabilize (bracing, exercise). While these approaches may provide some relief, it has been our experience that they take longer to accomplish improvement (if any), and that problems have a tendency to return. Perhaps this is because none of these traditional measures address the cause of the problem. It makes sense to consider that while the joint may be painful, popping, or mal-positioned, it is often the soft tissues dictating joint movement that are causing the problem.

Management of SIJ problems should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even when X-ray and MRI findings don’t change, or never showed a significant problem. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems. Sometimes bracing may be helpful temporarily, such as during pregnancy.

Shoulder

Bursitis
Bursa sacs are a type of soft tissue that are located throughout our body and act to decrease friction and to dissipate force. Bursitis generally develops in the shoulder as a result of overuse or repetitive overhead motion. This condition occurs commonly in throwing or pitching athletes as well as swimmers. Autoimmune disease such as diabetes, rheumatoid arthritis, thyroid dysfunction, or history of stroke may also predispose an individual to develop this condition. Symptoms include difficulty reaching overhead or behind the back as well as pain with everyday tasks such as pushing or pulling a door. Even if this condition is believed to be from repetitive motion or overuse, it is important to undergo a thorough physical therapy examination as therapists may identify deficits in strength, range of motion, flexibility, or faulty biomechanics which may have led to this condition. Irritation and inflammation of a bursa sac generally indicates excess or abnormal stress is being placed on the involved tissue and to truly eliminate this stress the provoking factors must be properly identified.

Management of bursitis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating bursitis and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Although bursa sacs are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with the shoulder including muscle, fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Shoulder bursitis without any provoking incident likely developed due to other contributing factors resulting in abnormal stress being placed on this tissue. Postural abnormalities and dysfunctional muscle recruitment can contribute to abnormal stress or friction being placed on the bursa.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Frozen Shoulder/Adhesive Capsulitis
Frozen shoulder is a condition with unknown cause, which results in pain and loss of mobility of the shoulder. Women and those with autoimmune diseases, such as diabetes, thyroid dysfunction or those with a history of a stroke are at an increased risk to develop this condition. In addition, those patients with a history of rotator cuff tear or total shoulder replacement with resulting loss of range of motion may develop frozen shoulder. If left untreated, it generally takes about 2 years to resolve spontaneously. With treatment, this time frame can be significantly shortened. This condition is complex, and many factors in addition to the shoulder joint play a role.

Due to its complex nature and unknown cause, management of adhesive capsulitis should include a variety of physical interventions. Therapy should focus on identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, capsular mobility, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating adhesive capsulitis and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Although the joint is usually the source of pain with this condition, it is important to determine the involvement of any other structures associated with the shoulder joint including muscle, fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Postural abnormalities and dysfunctional muscle recruitment can in abnormal stress or friction being placed on the bursa.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Impingement Syndrome and Rotator Cuff Tendonitis
Shoulder impingement and rotator cuff tendonitis are the two most common causes of shoulder pain and disability. This condition is thought to occur when the space between the humeral head (upper arm bone) and the top of the shoulder joint is decreased, resulting in pinching or compression of the rotator cuff musculature or soft tissue of the shoulder joint. Symptoms include increasing difficulty reaching overhead or behind the back, pain or difficulty with dressing/undressing, and limitation with overhead throwing. Many times it is difficult to identify an activity or injury that may have provoked this condition. For this reason, even though this condition can be quickly diagnosed with clinical testing, it is more difficult to determine the underlying cause as many factors can contribute to this condition. Therefore, it is important to undergo a thorough physical therapy examination to determine the factor or factors contributing to shoulder impingement so they can be properly addressed. Many times improper mechanics of the shoulder (glenohumeral) and neighboring joints including those of those associated with the neck and the rib cage can contribute to this condition.

Management of impingement and rotator cuff tendonitis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for resolving impingement syndrome and its associated complaints by:

  1. Addressing other tissues in addition to the joints that may be responsible for symptoms. Joints are certainly not the only structure that can provoke symptoms: fascia and muscles can generate pronounced pain, stiffness, and even referred symptoms farther down the arm including numbness, tingling, and aching. Our skilled assessment identifies all tissues that need to be targeted in treatment.
  2. Addressing any contributing factors. Shoulder impingement without any provoking incident likely developed due to other contributing factors resulting in abnormal stress on the involved shoulder. Postural abnormalities and dysfunctional muscle recruitment can place this joint in a suboptimal position to work or may result in abnormal stress being placed through the joint.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Rotator Cuff Strains and Tears
The rotator cuff is made up of 4 muscles which stabilize the humeral head (upper arm bone) in the shoulder joint. Injuries to the rotator cuff commonly occur in athletes and those performing repetitive overhead movements, such as pitchers and swimmers. Older adults may experience an injury to the rotator cuff as a result of a fall or even from a minor trauma, such as lifting an everyday object. Symptoms of a rotator cuff strain or tear include shoulder and arm pain, weakness, difficulty performing activities requiring reaching with the affected arm. Proper diagnosis can be made from a thorough physical therapy examination. Diagnostic imaging including x-rays and MRI’s are not always needed to make a definitive diagnosis and to direct treatment. Treatment is more dependent on the degree of tearing. For partial tears, nonsurgical treatment including physical therapy can be effective. For full thickness tears, surgical repair followed by post-operative rehabilitation may be more appropriate. Whether or not surgery is indicated, a physical therapist is vital to the recovery process. For non-traumatic rotator cuff tears, faulty biomechanics in the torso or other areas of the body may lead to a tear of these muscles. Your therapist can work determine the cause of the symptoms and tailor the intervention to this area as well the area you are currently having pain in. Treatment not only works to address the associated symptoms, but the initial cause of the injury in order to prevent further damage.

Management of rotator cuff strains and tears should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating rotator cuff strains and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Although the rotator cuff muscles are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with the shoulder including fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Rotator cuff strains and tears that occurred without any provoking incident likely developed due to other contributing factors which resulted in abnormal stress being placed on the shoulder. Postural abnormalities and dysfunctional muscle recruitment can place these muscles in a suboptimal position to work or may result in abnormal stress being placed through these muscles. Our skilled assessment identifies all tissues that need to be targeted in treatment or that warrant referral to another practitioner.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Sprains
Physical therapists have experience treating sprains and strains throughout the body. These may develop quickly through traumatic onset, or may develop slowly through prolonged overload. Often soft tissue structures are at fault, and non-invasive manual techniques are effective in resolving the resulting pain and dysfunction. Sprains may also develop due to postural compensations that place abnormal stress on a muscle, and your therapist is trained to recognize these and prescribe therapeutic exercise to improve the ability of the body to handle everyday activity and the forces that are placed on it.
Tendonitis
A tendon is a type of soft tissue that functions to connect muscle to it’s bony attachment, and dysfunction in a joint or muscle can cause inflammation to occur here. This can result in pain, decreased range of motion, and decreased strength. Pain may also radiate down the arm to the elbow. Movements such as buckling a seat belt or brushing one’s hair may become very painful. Often times, this develops due to overuse, muscular imbalances, or range of motion deficits. Some studies have shown that tendinitis results from decreased blood flow to the area, which interferes with the normal healing process. Blood flow can be restored by resolving trigger points in muscle and allow healing to take place. This can be done through dry needling, a very safe and effective treatment option. When a tendonitis develops, the issue has likely been ongoing for quite some time, resulting in dysfunction in other areas of the body, such as the torso or cervical and thoracic spine. Your therapist will also identify these impairments, and treat these compensations as well.
Upper Extremity Radiculopathy
The cervical spine consists of seven vertebrae, which are separated by an intervertebral disc. Between these vertebrae are nerve roots, which exit the spine and function to supply strength and sensation to our arms and hands. Radiculopathy in the arms and hands often occurs as a result of compression of a nerve in the cervical spine. This condition may occur as a result of fascial restrictions, disc herniation, arthritis, or a history of manual labor. Symptoms of this condition may include radiating pain from the neck into the shoulder blade, arm, and hand. Additionally, patients may report weakness and difficulty performing fine motor tasks such as using a key to open a door or turning the lid of a jar. Most commonly, this occurs in patients in their 50s and can often be resolved with conservative care including physical therapy. Therapists can also treat concomitant symptoms that occur with cervical spine dysfunction, such as headaches, shoulder pain, and vertigo/dizziness. Symptoms such as these require treatment to prevent further loss of function in the body.

Management of upper extremity radiculopathy should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating upper extremity radiculopathy and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Due to the radiation of symptoms it may be difficult to accurately identify the structure or structures causing the pain or symptoms. It is therefore important to undergo a thorough examination exploring multiple structures throughout the head, neck, shoulder, arm, and torso to determine which structures require treatment for symptom resolution.
  2. Addressing any contributing factors. Upper extremity radiculopathy that occurs without any provoking incident likely developed due to other contributing factors resulting in abnormal stress being placed on this tissue. Postural abnormalities and dysfunctional muscle recruitment can contribute to abnormal stress or friction being placed on the torso, shoulder, arm, and cervical spine.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.

Knee

Arthritis, Degenerative Joint Disease
Arthritis is very commonly diagnosed and can be somewhat discouraging as the implication is nothing can be done for it. But this is not true! Arthritis one of the most common conditions physical therapists treat, and multiple studies cite the effectiveness of physical therapy in reducing symptoms and improving activity tolerance. While some forms of arthritis are more responsive than others, the majority of cases fit the “wear and tear” or osteoarthritis category with degeneration occurring in the joints.

The cause of osteoarthritis is not completely understood, and it is thought to be the result of biochemical (natural substances in our body) and biomechanical (movement) abnormalities. Degenerative changes in the joints occur slowly over time, not suddenly or with a trauma (although in some cases, a trauma years earlier may have started the process or a recent trauma may aggravate a silent process). More often people cannot identify an episode triggering the complaints. This lends support to the concept that movement abnormalities left unaddressed will, over time, eventually promote these degenerative changes. Such movement problems may not only be found in the back, but other segments of the body that influence the back such as the hips and knees. Rheumatoid arthritis may also present with pain, limited motion, and positive findings on X-ray but is typically more widespread throughout the body and involves more joint swelling and deformity.

Diagnosis often includes imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the joints space or lack of it. MRI may provide even more detail. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings on imaging. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Or the imaging shows similar problems on both sides but only one side is symptomatic. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and joint degeneration, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Management of arthritis and degenerative joint disease should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Bursitis
Bursa are fluid filled sacs found throughout the body, typically near joints. Their purpose is to cushion tendons to decrease friction, and also change the angle of pull a tendon has on a joint to improve efficiency. “Itis” is the suffix used to indicate inflammation, so bursitis refers to inflammation of the bursa. Symptoms may include pain, stiffness, loss of mobility, and tenderness.

Onset may be related to trauma, such as a fall. In this case the inflammation in the bursa can be visible, making diagnosis straightforward. More often, there is no precipitating trauma and bursitis is assumed to be the reason behind a complaint. This seems particularly common when symptoms arise in the hip, and sometimes in the shoulder, elbow, and knee. In these cases diagnosis is typically based on symptoms alone, as there are no clear-cut diagnostic tests for bursitis. Bursa are not visible on X-ray, although calcification in a bursa may be visible. MRI may also detect swelling in bursa. However, since these symptoms (pain, stiffness) also occur with many other musculoskeletal issues, basing diagnosis largely on symptoms is potentially subject to error.

Typical treatment for bursitis may include rest, ice, and anti-inflammatory medication. While this may help following trauma, symptoms in the majority of non-traumatic cases may improve only as long as these measures are sustained and return once stopped. Such a cycle should prompt consideration that either the bursa is not the problem, or that something else is repeatedly irritating the bursa. Most tissues must have an irritant to become symptomatic – they will not spontaneously and primarily become problematic. Removing the source of irritation should not only remove the symptoms, but also keep them from returning.

It has been our experience that differentiating whether the bursa is the problem is not imperative to recovery. What is essential is addressing movement abnormalities that may be irritating multiple tissues, including the bursa. These tissues are simply caught in the middle of a connective tissue tug-of-war. The longer it is sustained, the greater the damage to tissues enduring the application of abnormal tension and force. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to restore normal motion. Experience has also shown us that movement abnormalities outside of the symptomatic region may be playing a part as well. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Dislocation & Subluxation
Dislocation is defined as an event in which joint surfaces are no longer congruent, with movement extending beyond normal anatomical limits. Subluxation is similar but to a lesser degree, almost like the beginning of dislocation. Either can occur in response to trauma. Management begins with relocation of the joint or patella, immobilization to allow healing, pain control measures, and eventually efforts to restore normal strength and mobility as much as possible.

Things get more challenging when dislocation or subluxation recur, or occur initially without a trauma. In such cases the problem is often due to the presence of laxity in the connective tissues that typically restrict joint movement to normal parameters. This may occur in response to repeated episodes of dislocation – almost like over-stretched elastic. In some individuals it may be a reflection of a condition known as hypermobility (see Hypermobility under Other Conditions). Hypermobility is a genetic condition in which there is insufficient collagen in the connective tissues to stabilize joints, allowing them to move too far and sublux or dislocate. Sometimes called Benign Joint Hypermobility Syndrome, it can be anything but benign (meaning of no concern) and involves far more than just the joints.

In the case of recurrent episodes of subluxation or dislocation (in the presence or absence of genetic hypermobility), management is multifaceted. This may involve use of temporary or more permanent extrinsic devices (such as braces) that will assist in limiting excessive joint motion. While this is feasible in some body regions such as the fingers, others (like the hips and knees) do not brace as easily and on an ongoing basis. Once the acute phase is past, restoration of normal mobility as much as possible in the target joint is commenced. While many people assume that strengthening around the joint is primary, this is of limited benefit. Factors contributing to subluxation or dislocation must be addressed in an effort to prevent recurrence. This may include addressing habits, sports, and movement abnormalities in the vicinity of the subluxation or dislocation, as well as throughout the body.

This is why we utilize a comprehensive perspective, appreciating how the body works as a total structure. Our approach in rehabilitation is based on our knowledge of biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Fracture
Boney fracture may occur in response to trauma, but can also arise from much lower loads applied to bone lacking sufficient density. In either situation, the fracture must be managed appropriately according to the nature and location. Some cases may require surgery, such as with hardware or joint replacement. When pain and limitations to functional activity persist in the presence of satisfactory bone healing, involvement of soft tissues should be considered. Often soft tissue involvement is overlooked after a trauma involving a fracture, and the bone receives much of the attention. It should be considered that with any trauma severe enough to cause a bone fracture, there will always be soft tissue injury as well.

Once the acute phase is past, restoration of normal mobility, strength, and function as much as possible in the region is commenced. This may include addressing habits, sports, and movement abnormalities in the vicinity of the fracture, as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Joint Replacement
Arthritis and the presence of “bone on bone” in the knee joint are frequently cited as necessitating joint replacement (for further discussion on this see Arthritis/DJD above). When partial or total joint replacement is pursued, rehabilitation is vital to restoring mobility and function. This typically includes measures to control swelling and pain, maximize lower extremity range of motion, improve strength/neuromuscular control, restore balance/proprioception, and ultimately return people to their prior level of function or better. Traditional measures may include exercise, soft tissue stretching, scar tissue and joint mobilization, balance/proprioceptive retraining, and strengthening. We have also found that more progressive interventions such as Fascial Manipulation®, dry needling, and Postural Restoration® techniques may advance patients even further in their recovery when appropriately utilized. We also utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion not just in the post-operative knee, but globally.
Meniscal Tear
Meniscus are the peanut-shaped rings of cartilage found inside the knee joint, providing additional depth and stability. Problems arise when the meniscus tear, which occurs for a variety of reasons. Sometimes a trauma or high-demand activity can be identified as the causative factor, such as a blow to the knee, turning on a planted foot, or slipping / falling. But many times there is no known trauma and the cause is unknown. In these cases, biomechanical (movement) problems are likely the cause. Faulty biomechanics perpetuated over time can gradually wear on the meniscus until it tears – like a car with the tires out of alignment. These biomechanical problems may go undetected for an extended period until they progress to the point of causing symptoms: knee pain, aching, swelling, limited flexion (bending) or extension (straightening), locking, and popping with walking, sports, or even at rest. The presence of any or all of these symptoms, however, does not conclusively mean the meniscus is torn.

Management often begins with imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the cartilage by displaying joint space or lack of it. MRI provides more detail as to the actual condition of the labrum. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings in the joint and meniscus. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and the meniscal tear, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to resolve movement abnormalities. Experience has also shown us that movement abnormalities outside of the knee may be playing a part as well. In other words, the meniscus may tear due to dysfunctional soft tissues and abnormal movement in the hip or ankle. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

The irreversible nature of surgery as well as variable outcomes associated with it justify careful consideration. In the absence of severe signs, a trial of conservative care is reasonable, especially considering that other structures may be influencing symptoms more than the meniscus.

Muscle Strain / Tear
As with soft tissue injury anywhere, a strain occurs when the fascia and muscles (typically the hamstrings and quadriceps – see at www.triggerpoints.net; ) are overloaded (demand that exceeds capability). Sometimes a trauma or high-demand activity can be identified as the causative factor, such as a forceful kick, turning on a planted foot, heavy lift, or fall. Other times there is no obvious episode and the cause is unidentified. When tissues are already overloaded and “on the edge,” something as simple as getting out of a vehicle may push them into strain. Once injured, they can remain on the edge of injury, an accident waiting to happen again. Symptoms may include pain, loss of flexibility, a pulling sensation, and aching in the thigh with any activity or even at rest. In more severe cases significant bruising may be present, and there may be a palpable or visible divot in the muscle. Imaging (X-ray, MRI) is typically not warranted initially unless there is a strong suspicion of fracture or tissue rupture requiring surgery.

Treatment has two basic levels: 1) Manage the acute symptoms, and 2) Address mobility problems that may have resulted from the injury or been the pre-existing, predisposing factor behind the injury. This may include addressing habits, sports, and movement abnormalities in the vicinity of the strain as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

Foot and Ankle

Arthritis, Degenerative Joint Disease (DJD)
Arthritis is very commonly diagnosed and can be somewhat discouraging as the implication is nothing can be done for it. But this is not true! Arthritis is one of the most common conditions physical therapists treat, and multiple studies cite the effectiveness of physical therapy in reducing symptoms and improving activity tolerance. While some forms of arthritis are more responsive than others, the majority of cases fit the “wear and tear” or osteoarthritis category with degeneration occurring in the joints.

 

The cause of osteoarthritis is not completely understood, and it is thought to be the result of biochemical (natural substances in our body) and biomechanical (movement) abnormalities. Degenerative changes in the joints occur slowly over time, not suddenly or with a trauma (although in some cases, a trauma years earlier may have started the process or a recent trauma may aggravate a silent process). More often people cannot identify an episode triggering the complaints. This lends support to the concept that movement abnormalities left unaddressed will, over time, eventually promote these degenerative changes. Such movement problems may not only be found in the back, but other segments of the body that influence the back such as the hips and knees. Rheumatoid arthritis may also present with pain, limited motion, and positive findings on X-ray but is typically more widespread throughout the body and involves more joint swelling and deformity.

Diagnosis often includes imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the joints space or lack of it. MRI may provide even more detail. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings on imaging. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Or the imaging shows similar problems on both sides but only one side is symptomatic. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and joint degeneration, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Management of arthritis and degenerative joint disease should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain and mobility – even though the findings on imaging don’t change. The irreversible nature of surgery, as well as the variable outcomes associated with it justifies careful consideration. In the absence of severe findings, a trial of conservative care is reasonable especially considering that other structures may be influencing symptoms more than the joint. Our approach in physical therapy is straightforward:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Achilles Tendonitis / Rupture
Achilles tendonitis occurs when the tendon becomes inflamed due to overuse or as the result of abnormal stress being placed on this tissue. Symptoms of this condition include pain and tenderness in the tendon, which is worsened by attempting to bend the foot towards the shin. Ruptures of the Achilles tendon occur when the tendon actually tears. This condition may be the result of a forceful trauma to the foot and ankle or may be the result of chronic Achilles tendonitis. Many times it is difficult to identify an activity or injury that may have resulted in Achilles tendonitis. Therefore, it is important to undergo a thorough physical therapy examination to determine the factor or factors contributing to this condition so they can be properly addressed. Many times improper mechanics of the ankle and neighboring joints including the hip can contribute to this condition.

 

Management of Achilles tendonitis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity. Achilles tendon rupture is generally managed through surgical intervention or immobilization followed by similar treatment for Achilles tendonitis.

Our approach with physical therapy can be very helpful for resolving Achilles tendonitis/ruptures and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Although the calf and Achilles tendon are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with this condition including fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Achilles tendonitis or ruptures that occurred without any provoking incident likely developed due to other contributing factors, which resulted in abnormal stress being placed on this tissue. Postural abnormalities and dysfunctional muscle recruitment can place these muscles in a suboptimal position to work or may result in abnormal stress being placed through these muscles. Our skilled assessment identifies all tissues that need to be targeted in treatment or that warrant referral to another practitioner.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Bursitis
Bursa sacs are a type of soft tissue that are located throughout our body and act to decrease friction and to dissipate force. Bursitis generally develops in the foot or ankle as a result of overuse or repetitive motion. This condition occurs commonly with running, jumping, or exercising on uneven ground. Autoimmune disease such as diabetes, rheumatoid arthritis, thyroid dysfunction, or history of stroke may also predispose an individual to develop this condition. Symptoms include pain and tenderness in the back of the ankle, especially when running uphill. Even if this condition is believed to be from repetitive motion or overuse, it is important to undergo a thorough physical therapy examination as therapists may identify deficits in strength, range of motion, flexibility, or faulty biomechanics which may have led to this condition. Irritation and inflammation of a bursa sac generally indicates excess or abnormal stress is being placed on the involved tissue and to truly eliminate this stress the provoking factors must be properly identified.

 

Management of bursitis should include identifying and addressing muscular/fascial imbalances, movement abnormalities, muscle weaknesses, and faulty postures/habits. This can make a significant difference in pain, range of motion, and ability to use the affected extremity.

Our approach with physical therapy can be very helpful for treating bursitis and its associated complaints by:

  1. Addressing all tissues that may be responsible for symptoms. Although bursa sacs are generally the source of pain with this condition, it is important to determine the involvement of any other structures associated with the ankle including muscle, fascia, ligaments, tendons, and cartilage.
  2. Addressing any contributing factors. Ankle bursitis without any provoking incident likely developed due to other contributing factors resulting in abnormal stress being placed on this tissue. Postural abnormalities and dysfunctional muscle recruitment can contribute to abnormal stress or friction being placed on the bursa.
  3. Reducing or preventing surgery, medication, bracing, and ongoing treatment. Skillfully addressing sources of pain and causative factors as noted above can play a significant role in resolving complaints and limiting ongoing problems and treatment.
Cartilage Tear
Found inside most joints, cartilage serves to cushion and provide additional depth and stability. Problems arise when the cartilage tears, which can occur for a variety of reasons. Sometimes a trauma or high-demand activity can be identified as the causative factor, such as turning on a planted foot, or slipping / falling. But many times there is no known trauma and the cause is unknown. In these cases, biomechanical (movement) problems are likely the cause. Faulty biomechanics perpetuated over time can gradually wear on the cartilage until it tears – like a car with tires that are out of alignment. These biomechanical problems may go undetected for an extended period until they progress to the point of causing symptoms: foot/ankle pain, aching, swelling, limited mobility, locking, and popping with walking, sports, or even at rest. The presence of any or all of these symptoms, however, does not conclusively mean the cartilage is torn.

 

Management often begins with imaging such as X-ray or MRI. X-ray is capable of imaging only the boney structures, but can provide some insight as to the status of the cartilage by displaying joint space or lack of it. MRI provides more detail as to the actual condition of the cartilage. However, it is important to note that findings on imaging do not always correlate with symptoms. For example, people with relatively minor symptoms may present with significant findings in the joint and cartilage. The reverse may also occur: someone with severe symptoms may demonstrate minimal or no findings on imaging. Sometimes the findings do not correlate with the patient’s complaints: imaging shows greater involvement on one side, but the symptoms are worse on the other. Multiple studies conclude that due to the poor correlation between imaging and symptoms, findings must be interpreted in conjunction with the patient’s full clinical presentation. Overemphasizing the role of imaging in determining patient management has been shown to lead to inappropriate/failed treatment including surgery, as well increased expense and poor outcomes. Symptoms may be related to other sources, and the cartilage tear, while telling a story of a joint under stress, may be an incidental finding. Because of this imaging should not be used as the primary factor in determining treatment.

Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to resolve movement abnormalities. Experience has also shown us that movement abnormalities outside of the foot and ankle may be playing a part as well. In other words, the cartilage may tear due to dysfunctional soft tissues and abnormal movement in the hip or knee. Because of this, we utilize a comprehensive approach that appreciates how the body works as a total structure:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.

The irreversible nature of surgery as well as its mixed outcomes justifies careful consideration. In the absence of severe signs, a trial of conservative care is reasonable, especially considering that other structures may be influencing symptoms more than the meniscus.

Dislocation & Subluxation
Dislocation is defined as an event in which joint surfaces are no longer congruent, with movement extending beyond normal anatomical limits. Subluxation is similar but to a lesser degree, almost like the beginning of dislocation. Either can occur in response to trauma. Management begins with relocation of the joint, immobilization to allow healing, pain control measures, and eventually efforts to restore normal strength and mobility as much as possible.

 

Things get more challenging when dislocation or subluxation recur, or occur initially without a trauma. In such cases the problem is often due to the presence of laxity in the connective tissues that typically restrict joint movement to normal parameters. This may occur in response to repeated episodes of dislocation – almost like over-stretched elastic. In some individuals it may be a reflection of a condition known as hypermobility (see Hypermobility under Other Conditions). Hypermobility is a genetic condition in which there is insufficient collagen in the connective tissues to stabilize joints, allowing them to move too far and sublux or dislocate. Sometimes called Benign Joint Hypermobility Syndrome, it can be anything but benign (meaning of no concern) and involves far more than just the joints.

In the case of recurrent episodes of subluxation or dislocation (in the presence or absence of genetic hypermobility), management is multifaceted. This may involve use of temporary or more permanent extrinsic devices (such as braces) that will assist in limiting excessive joint motion. While this is feasible in some body regions such as the fingers, others (like the knees and ankles) do not brace as easily and on an ongoing basis. Once the acute phase is past, restoration of normal mobility as much as possible in the target joint is commenced. While many people assume that strengthening around the joint is primary, this is of limited benefit. Factors contributing to subluxation or dislocation must be addressed in an effort to prevent recurrence. This may include addressing habits, sports, and movement abnormalities in the vicinity of the subluxation or dislocation, as well as throughout the body.

This is why we utilize a comprehensive perspective, appreciating how the body works as a total structure. Our approach in rehabilitation is based on our knowledge of biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement tests and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Fracture
Boney fracture may occur in response to trauma, but can also arise from much lower loads applied to bone lacking sufficient density. In either situation, the fracture must be managed appropriately according to the nature and location. Some cases may require surgery, such as with hardware or joint replacement. When pain and limitations to functional activity persist in the presence of satisfactory bone healing, involvement of soft tissues should be considered. Often soft tissue involvement is overlooked after a trauma involving a fracture, and the bone receives much of the attention. It should be considered that with any trauma severe enough to cause a bone fracture, there will always be soft tissue injury as well.

 

Once the acute phase is past, restoration of normal mobility, strength, and function as much as possible in the region is commenced. This may include addressing habits, sports, and movement abnormalities in the vicinity of the fracture, as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Joint Replacement

Arthritis and the presence of “bone on bone” in a joint are frequently cited as necessitating joint replacement (for further discussion on this see Arthritis/DJD above). When partial or total joint replacement is pursued, rehabilitation is vital to restoring mobility and function. This typically includes measures to control swelling and pain, maximize lower extremity range of motion, improve strength/neuromuscular control, restore balance/proprioception, and ultimately return people to their prior level of function or better. Traditional measures may include exercise, soft tissue stretching, scar tissue and joint mobilization, balance/proprioceptive retraining, and strengthening. We have also found that more progressive interventions such as Fascial Manipulation®, dry needling, and Postural Restoration® techniques may advance patients even further in their recovery when appropriately utilized. We also utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion not just in the post-operative foot and ankle, but globally.
Muscle Strain / Tear
As with soft tissue injury anywhere, a strain occurs when the fascia and muscles of the foot and ankle are overloaded and demand exceeds capability. Sometimes a trauma or high-demand activity can be identified as the causative factor, such as a forceful kick, turning on a planted foot, heavy lift, or fall. Other times there is no obvious episode and the cause is unidentified. When tissues are already overloaded and “on the edge,” something as simple as getting out of a vehicle may push them into strain. Once injured, they can remain on the edge of injury, an accident waiting to happen again. Symptoms may include pain, loss of flexibility, a pulling sensation, and aching in the effected muscle with any activity or even at rest. In more severe cases significant bruising may be present, and there may be a palpable or visible divot in the muscle. Imaging (X-ray, MRI) is typically not warranted initially unless there is a strong suspicion of fracture or tissue rupture requiring surgery.

 

Treatment has two basic levels: 1) Manage the acute symptoms, and 2) Address mobility problems that may have resulted from the injury or been the pre-existing, predisposing factor behind the injury. This may include addressing habits, sports, and movement abnormalities in the vicinity of the strain as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Plantar Fasciitis
Plantar fasciitis occurs when the plantar fascia, a thick connective tissue located on the bottom of the foot, becomes inflamed. This condition may arise form a traumatic injury or may be the result of chronic overloading of these tissues. Symptoms generally include pain in the bottom of the foot, which may be present close to the heel or throughout the entire length of the bottom of the foot. Pain is generally worse when first putting weight on the foot in the morning or when initially standing after sitting for extended periods. If this condition arises due to a traumatic episode, initial treatment may include management of the acute symptoms. In the absence of a single traumatic episode a thorough patient history of clinical examination needs to be performed to determine the factors contributing to this condition.

 

In traumatic injuries, once the acute phase has passed, they can be managed similarly to plantar fasciitis that begins with out an obvious cause. Treatment will generally include restoration of normal mobility, strength, and function as much as possible. Interventions may focus on addressing habits, sports, and movement abnormalities in the foot and ankle, as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion:

  • Assess the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identify by palpation which soft tissues and joints are contributing to the movement problems.
  • Address these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassess with movement and palpation to determine response to treatment.
  • Educate as to causative factors and correction so as to reduce the likelihood of future problems.
Sprain
Ankle sprains are one of the most common injuries to this region of the body. Sprains generally occur as a result of a trauma to the foot and ankle resulting in twisting and turning. The most common ankle sprain is an inversion ankle sprain, where the foot is forced inward toward the opposite leg. With this injury the ligaments of the lateral aspect (outside) of the ankle are commonly stressed and may even tear to some degree. Sprains are generally graded from I (small tearing) to III (complete rupture of the involved ligaments) Diagnostic imaging including x-rays and MRI’s are generally not necessary to rule out a fracture or to determine the degree of tearing. Proper diagnosis can be made through a thorough clinical examination.

 

Depending on the degree of tearing, sprains may be treated differently. With complete tearing, a period of immobilization may be required to allow the ligaments to heal before rehabilitation may begin. With more minor injuries, treatment will generally include restoration normal mobility, strength, and function as much as possible. Other modalities may be utilized to help with management of pain. A thorough biomechanical assessment is generally also utilized to minimize excess strain on the foot/ankle and supporting ligaments. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion by:

  • Assessing the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identifying by palpation which soft tissues and joints are contributing to the movement problems.
  • Addressing identified dysfunction with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassessing movement and palpation to ensure proper treatment response.
  • Educating as to causative factors and correction so as to reduce the likelihood of future problems.
Shin Splints (Medial Tibial Stress Syndrome)
Medial tibial stress syndrome also known as shin splints is a condition that occurs when the connective tissue that unites the muscles of the lower leg to the tibia become inflamed. This pathology generally occurs due to repetitive stress to this region of the body. It is more common in runners and is most frequently caused by training errors including rapid increase in mileage, improper shoe wear, or running on hard surfaces. This condition may also occur due to biomechanical movement dysfunction throughout the torso and legs. Symptoms generally include pain in the shin. When this condition first develops symptoms may be present at the beginning of an activity and decrease throughout the performance of the activity. In more chronic presentations symptoms may be present throughout activities and may prompt a change in activity level. In many cases the underlying cause to the development of this syndrome may not be immediately apparent, as biomechanics in the foot and ankle may appear normal. For this reason, it is critical to perform a more global examination of gait and examine movement throughout the trunk, hips, and pelvis.

 

Treatment of medial tibial stress syndrome will generally include restoration of normal mobility, strength, and function as much as possible. Interventions may focus on addressing habits, sports, and movement abnormalities in the foot, ankle, and lower leg as well as throughout the body. This is why we utilize a comprehensive perspective, respecting how the body works as a total structure. Our approach in rehabilitation reflects an appreciation for biomechanics, and drives our efforts to maximize normal motion by:

  • Assessing the trunk and extremities for faulty movement patterns and restrictions with mobility testing.
  • Identifying by palpation, which soft tissues and joints are contributing to the movement problems.
  • Addressing these with manual techniques such as dry needling, Fascial Manipulation ®, Postural Restoration ®, and exercise.
  • Reassessing with movement and palpation to determine treatment response.
  • Educating as to causative factors and correcting them so as to reduce the likelihood of future problems.
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