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.
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 Therapy, 43(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 Therapy, 45(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 Therapy, 42(12), 1025-1031. doi: 10.2519/jospt.2012.4095
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.
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.
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!
Malanga et. al. Mechanisms and efficacy of heat and cold therapies for musculoskelatal injury. Postgrad Med 2015; Early Online 1-9.
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.
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!
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?
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.
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!
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.
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 utilizeavailable 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.