Wednesday, June 19, 2019

Elbow Pain, Could the Shoulder be to Blame?

by Julia Glick, PT
As therapists in a clinic located inside of a large tennis club, we are seldom surprised when a number of our patients each year present with lateral epicondylitis – or, as it is more commonly known, tennis elbow. Lateral epicondylitis pain usually occurs over the outside of the elbow where many of the forearm muscles attach, an area that experiences a lot of strain in tennis. However, even those of us who aren’t on the courts every week should be aware of it: it is also common in people who spend a lot of time at the computer or perform lots of gripping during their day. 

Despite the fact that lateral epicondylitis pain feels like it is centered in the elbow, it is important to look at the whole arm. Many people who come to us for tennis elbow have unsuccessfully tried exercises on their own that focus on the wrist and elbow, and are surprised when we turn our attention to the shoulder. Most specifically, the muscles that control shoulder blade position, such as the lower trapezius and serratus anterior, are crucial when treating the elbow, as the position of the whole arm is determined by the orientation of the shoulder blade. 

In fact, several research articles have come out in the past few years that focus on the role weakened shoulder blade stabilizers plays in lateral epicondylitis. Lucado et al. and Day et al. found that people with lateral epicondylitis had significantly weaker lower trapezius and serratus anterior musculature than people without any lateral elbow pain. In a case study performed by Bhatt et al., the research team only treated a woman’s shoulder blade stabilizers and were able to resolve her lateral epicondylitis. Essentially, these studies agree that the muscles that help pull the shoulder blade back and keep it stable also control the position of the arm and elbow: when it comes to prevention of elbow pain, shoulder blade strength and position matters.

Interested in finding some exercises that target the lower trapezius and serratus anterior to help maintain the shoulder blade in its optimal back position? I’ve included some below:

Easier Lower Trapezius
Lie on stomach and roll up a small towel under forehead and place hands on back of head/neck. Squeeze shoulder blades back and down toward opposite pants pocket and lift up elbows. Hold for 5 seconds and perform 5-10 repetitions.







Harder Lower Trapezius (Y)
Lie on stomach and roll up a small towel under forehead. Lift your arms up so they make a “Y” shape. Squeeze your shoulder blades back and down toward opposite pants pocket and lift your arms. Hold for 5 seconds and perform 5-10 repetitions. 











Serratus Anterior Wall Slides
Put your forearms on the wall and push your shoulder blades apart and into the wall. Keep this pressure into the wall and slide your arms up and down. Perform 5-10 repetitions.
















Try these exercises and let us know what you think! If you do have pain that is persistent, please stop by to speak with one of our skilled clinicians, who can help you with your injury.

Resources: 
Bhatt, J., Glaser, R., Chavez, A., & Yung, E. (2013). Middle and Lower Trapezius Strengthening for the Management of Lateral Epicondylalgia: A Case Report. Journal Of Orthopaedic & Sports Physical Therapy43(11), 841-847. doi: 10.2519/jospt.2013.4659

Day, J., Bush, H., Nitz, A., & Uhl, T. (2015). Scapular Muscle Performance in Individuals With Lateral Epicondylalgia. Journal Of Orthopaedic & Sports Physical Therapy45(5), 414-424. doi: 10.2519/jospt.2015.5290

Lucado, A., Kolber, M., Cheng, M., & Echternach, J. (2012). Upper Extremity Strength Characteristics in Female Recreational Tennis Players With and Without Lateral Epicondylalgia. Journal Of Orthopaedic & Sports Physical Therapy42(12), 1025-1031. doi: 10.2519/jospt.2012.4095

Friday, May 3, 2019

Growing Good Body Mechanics in the Garden

by Lauren Sweeney, Office Manager
Of all the places I like to spend time in the late spring and early summer, my garden is one of my favorites. Now that we've braved our last gasp of snow in Chicago (fingers crossed!), I'm ready to uncover my raised beds, turn my compost and get my seedlings started. In all the excitement of getting to grow things, though, it can be easy to forget to be good to our best gardening tools: our bodies. We often don't realize how hard we've worked outside until we're struggling to get out of bed the next morning.

At its core, gardening is no different than any other kind of exercise: it requires movement in multiple planes of motion, and can put strain on the knees and the back. As such, a warmup prior to gardening - a quick walk around the block, some stretches - can help prevent soreness later. As you are gardening, think about how your body is feeling: have you been crouching for a while? Doing a repetitive motion? If you find you're getting sore in one position or during one activity, change your body position or take a break. It can be tempting to plant those last five tomatoes and just be done, but switching to shoveling mulch or taking a water break can give your body the change it needs to get the job done.

Two hands in brightly-patterned gloves using a trowel to plant a red and yellow flower in the dirt

As most gardening is done on the ground, knees can suffer. If you will be spending a while in a kneeling position, consider knee pads or a gardening pad to reduce pressure. If kneeling is difficult, a bucket or low chair can allow you to plant from a seated position. Gardening using raised beds can help reduce strain as well, as they do not require the gardener to get quite as low to the ground, and when shoveling or raking, be sure to keep knees soft (rather than locked).

Many gardening tasks also require a lot of our core and our backs, so it is important to be mindful of them. When moving heavy materials, such as stone or bags of mulch or soil, be sure to use proper lifting mechanics (bending from the hips, turning feet to move loads rather than twisting or lifting). If something is too difficult to lift alone, use a wheelbarrow or ask someone for help. Try not to overload shovels or trowels, and use a hose for watering instead of lugging around a watering can, especially for hanging plants.

When you are done for the day, finish up with some light stretching. And don't forget to take breaks for food and water! It is easy to misjudge the amount of work we have been doing when we are engaged in a task like gardening. If you do experience a new pain working outside, don't hesitate to stop in our office - we'd be happy to help you get back to enjoying your garden.

Resources:
https://www.moveforwardpt.com/Resources/Detail/gardening
http://www.rehab.msu.edu/wellness/garden.html 

Monday, April 8, 2019

Ice versus Heat: A Hot (or Cold) Topic


by Constance Taras, PT
One of the questions we most commonly field when patients have first sustained an injury is “Should I ice it, or would heat be better?” Both heat and ice are conservative, beneficial modalities, but to better understand the benefits of either, let’s first look at the physiological effects of each:
 









Typically, the more traditional approach is to apply ice to musculoskeletal injuries, but the type of musculoskeletal injury is important. For acute injuries that are swollen, warm, and painful (such as ankle sprains), ice can temporarily numb the area and decrease pain signals from the nerves, therefore decreasing pain. Ice also constricts the surrounding blood vessels so that less fluid and fewer cells arrive at the injured area. While this could theoretically slow down healing to the area as it does restrict the flow of healing mediator cells (leukocytes) to the area, it also means that less swelling is present. Less pressure on all the surrounding structures could mean less pain and improved range of motion.

However, what if we are dealing with a more chronic injury? Chronic injuries often suffer from decreased blood flow to the injured area, and as a result have a harder time healing. Application of heat, therefore, is the more beneficial modality, as it increases the rate that blood and repairing cells reach the injured site to improve the overall healing process. We also tend to recommend heat over ice in the case of a muscle in spasm or a tight muscle: the improved tissue extensibility provided by heat helps to relax shortened and tensed muscles in order to decrease spam and ultimately pain. Heat also allows improved stretching and increased range of motion, whereas ice could cause the muscle to tighten further, decreasing range of motion at a joint.

But an equally important factor to consider is how heat or ice makes you feel! If ice makes your pain worse or vice versa then it may not be the best option for you, even if clinically it makes more sense (unless it is contraindicated by other health conditions, such as diabetes, Raynaud’s disease or hypertension). If you are unsure what is the best modality for you and your specific injury, reach out to a Lakeshore physical therapist to help you build a customized plan!

References:
Malanga et. al. Mechanisms and efficacy of heat and cold therapies for musculoskelatal injury. Postgrad Med 2015; Early Online 1-9.


Tuesday, March 12, 2019

Organization: The Engine of our Practice

by Sally Fansler, PT
As we slowly approach warmer weather in Chicago, many of us are driven toward the traditional "spring cleaning." Here, however, we work to keep things tidy all year round. In my experience, being organized is every bit as important to our employees as being patient, knowledgeable, positive, compassionate, caring and accountable. It is frankly impossible to overstate the value of organization, especially if you are a busy clinician or a physical therapy practice office manager. 

Now, I am a pen-and-paper person at the core so my Office Manager, Lauren, has had to gently nudge me toward the simplicity of digital organization over the years. It has felt like such a success to streamline and digitize many of the day-to-day processes in our physical therapy clinics. Our online patient calendars are synced between both clinics for ease of scheduling and access. Each employee’s schedule is color-coded and clear. Our Google Drive folders are available at a finger’s tap to share research articles, doctor recommendations, or a running program with our patients. And since we already operate within the Google ecosystem, the Google Keep app is the best and appeals to my love of the traditional sticky notes! We create notes and lists, reminders, and check off completed tasks in vivid color. 

As with many medical offices, all physical patient care charts are gone and replaced by electronic medical records, creating efficient, secure, and compliant documentation that is accessible from anywhere. Innovation and technology changes can make anyone apprehensive, especially for those of us who have become accustomed to doing work in a particular way. However, the new technology benefits are making our daily processes smoother and helping maintain our office productivity as well. 

It is always a work in progress, but once you start to build a trusted organizational system that you use regularly, you can turn a hectic day to an efficient and calm one. It feels great to leave the clinic each day with a clean inbox and a clutter-free desk. With solid systems in place, we can relax and focus on what we do best – patient care.

Friday, February 8, 2019

Treating Back Pain: A Spine of the Times


by Jill Jonda, PT
You’re 34 years old with a 9-5 desk job, but you still regularly go to the gym and play a couple pick-up games of basketball a week. One day you wake up and have nagging, gnawing pain just to the right of your spine in the low back. You wait a couple days and it’s not getting any better: in fact it’s traveling into your right buttock. You think, “But I’m just 34 years old! What’s happening to me?”

Unfortunately, this is a pretty common internal dialogue. According to the NIH, about 8 of 10 adults will experience back pain at some point in their lives. Luckily, physical therapists are equally as used to diagnosing and treating back pain, and the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a well-studied, noninvasive approach for diagnosing and treating pain of a mechanical origin (mechanical pain).  But what is “mechanical pain?” 

Mechanical pain is produced when a stress or force is placed on an anatomic structure and can be aggravated or relieved with greater or less deformation on those tissues. You can demonstrate this easily with just a finger: if you bend your index finger backward to the point of resistance, you’ll experience a strain. Initially, it’s uncomfortable but as you hold it there, pain – the brain’s way of saying to the body, “Stop doing that!” – starts to set in. Once you relieve the stretch on the finger, the pain should subside. The same is true of mechanical pain: many times it completely goes away once the mechanical stress is eliminated.


More often than not, back pain originates from mechanical stress. The spinal column consists of vertebrae and intervertebral discs, which sit between each vertebra. The disc is a very mobile structure consisting of 2 layers – an outer fibrotic layer and an inner gelatinous layer – kind of like a jelly donut. When we flex our spine (bending forward and rounding it), we put greater mechanical stress on the front portion of the disc. The disc becomes displaced backward to the area of least pressure. This generally isn’t a problem, but repeated force on the front portion of the disc can cause the back portion to weaken and start to bulge. The bulge can press on nerve and/or other tissues along the spine, causing pain in areas away from the spine, such as in the buttock or even into the leg (sciatica). Eventually, a bulged disc can lead to a herniation: the jelly center of the disc begins to squish out of the fried dough part, and that’s not ideal for donuts or spines.

As physical therapists, it’s our job to evaluate each of our patients and treat the not only the symptoms but also the cause of their pain, while also preventing similar pain to return in the future. I know my patients think I’m the “posture police,” but for those with pain originating from either the cervical or lumbar spine, I always recommend sitting with good lumbar support in a firm chair to promote a neutral spine. Sitting with slouched posture is bound to produce some sort of mechanical pain, either in the neck or low back, because of the stresses placed on the spine. Also, if sitting is bothersome, stand up and reverse the curvature in your spine by walking around for a few minutes.  Remember, you should see your PT or healthcare provider if your pain isn’t improving. We can help you stand (and sit) corrected!

Resources: 
Treat Your Own Back by Robin McKenzie

Friday, January 11, 2019

Thoracic Outlet Syndrome: A Pressing Matter

by Julia Glick, PT
 If you follow the NBA you have most likely heard that Markelle Fultz, the Philadelphia 76ers’ guard, has thoracic outlet syndrome (TOS). We most commonly hear of athletes from baseball developing this, but rarely basketball – in fact, basketball player Ben Uzoh wasn’t diagnosed until he retired, even though he had previously experienced TOS symptoms. It also took visits to more than 10 clinicians before Fultz was diagnosed with neurogenic TOS. But what does that mean and why was it so hard to diagnose? 
The thoracic outlet is the area between the first rib and collarbone, through which the majority of the nerves and arteries/veins that enter the arm pass. In TOS something in this space narrows and compromises either the nerves or vasculature (arteries/veins). A person with TOS usually has pain, temperature changes, or numbness/tingling at the neck, shoulder, arm, or hand.

Part of what makes it so difficult to diagnose is that there are no standard diagnostic criteria for TOS. There are also several presentations: neurogenic, vascular, and non-specific. With neurogenic TOS, the brachial plexus (nerves that pass through the thoracic outlet) are compressed and will usually cause pain and/or weakness. Features of vascular TOS tend to look more like coldness and numbness, as the arteries and veins are compressed. Regardless of presentation, these symptoms are often difficult to reproduce because they can change based on the position of the head, neck, shoulders and arms.

There are no specific causes for TOS, which often makes it even harder to diagnose. Past trauma or overuse, such as in overhead sports, could possibly increase the likelihood of developing TOS. Anatomically, someone is more at risk if they have an extra upper rib or have any type of tightness of fascia or muscle that decrease the amount of space of the thoracic outlet.

Presently, there are several treatment options for TOS: physical therapy, injection, and first rib removal surgery. In physical therapy, the goals are to restore full range of motion of the shoulder and neck, decrease any restrictions that are impinging on the nerves as they pass through the thoracic outlet, decreasing pain, and improving strength. Fultz has been attending physical therapy, and his agent has reported improvements: they hope he will return in the 2018-2019 season. Here’s hoping for a full recovery for Fultz! 

References: 
Baumann, M. (2018, December 4). What baseball can tell us about Markelle Fultz’s latest diagnosis. https://www.theringer.com/nba/2018/12/4/18126446/markelle-fultz-thoracic-outlet-syndrome 

Bell, S. (2018, December 10). What is thoracic outlet syndrome, and what does it mean for Markelle Fultz? http://www.espn.com/nba/story/_/id/25455660/what-thoracic-outlet-syndrome-does-mean-markelle-fultz

Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD007218. DOI: 10.1002/14651858.CD007218.pub

Retrieved from: https://twitter.com/wojespn/status/1070074789409153024  

Retrieved from: https://twitter.com/ESPNNBA/status/1077668580706209792

Smith, J. (2018, December 4). Sixers announce Markelle Fultz out indefinitely, reveal plan for injury. https://sixerswire.usatoday.com/2018/12/04/sixers-markelle-fultz-out-indefinitely-shoulder-injury/ 

Wojnarowski, A. (2018, December 5). 76ers’ Markelle Fultz has thoracic outlet syndrome, to miss 3-6 weeks. http://www.espn.com/nba/story/_/id/25453907/markelle-fultz-philadelphia-76ers-expected-miss-3-6-weeks-shoulder-rehabilitation

Friday, December 7, 2018

The Home Stretch

by James Bansberg, PT
Some of the most common advice we receive when we complain about a newly discovered ache or pain is to just “stretch it out.” But what does that even mean? How long do I hold it? When should I do it? Do I just throw my leg up on a table for a couple of seconds and beg the pain to go away?

Most of what we know about stretching is either a myth or based heavily on outdated science. Worse yet, when speaking to various health professionals, their recommended duration for stretching can vary greatly, which can be confusing and sometimes discouraging for their clients. Luckily, a 2018 study by Thomas et. al has helped answer some of these questions. The study focused on most effective form of stretching for improving range of motion, as well ideal stretch duration and frequency.

Despite its vilification in recent media, the researchers found that static stretching was more effective than other forms of stretching for improving range of motion long term. This doesn’t mean that static stretching should be the only form of stretching utilized in a regular workout program, however. Other studies have discovered the benefits of other forms such as dynamic and ballistic stretching, especially prior to activity.

As for duration, there’s good news for the more impatient types: a 30-60 seconds hold was as beneficial as other, longer durations (60-120 seconds and over 120 seconds). Consistency, however, was key: the research showed stretching more than 5 times a week was more effective than 2-3. Interestingly, 7 days of stretching per week did not yield better results than 5 days, making the sweet spot between 5-7 days per week.

The final portion of the study looked at optimal time spent per week stretching to maximize mobility changes. Surprisingly, a minimum of 5 minutes was required for significant changes, with the ideal time being anywhere between 5-10 minutes.

Ultimately, some stretching is better than no stretching, and recent studies have found benefits to other forms of stretching as well as foam rolling. However, even stretching has a proper dosage, so it is important we utilize available evidence to guide our decision-making so that we are able to reap the greatest benefit. 

References: 
Thomas E., Bianco A., Paoli A., Palma A. The Relation between Stretching Typology and Stretching Duration: The Effects on Range of Motion. Int. J. Sports Med. 2018;39:243–254. doi: 10.1055/s-0044-101146.