Human Performance and Rehabilitation Centers, Inc.

Knee Pain Explained

Knee pain is something nearly every person experiences at one point or another, usually related to a particular injury or provocative activity, such as lots of kneeling for spring planting in the yard or playing the occasional game of basketball. How do you know the difference between a serious injury versus simple overuse? The causes of knee pain typically fall into one of three categories: traumatic, overuse, and degenerative.

Traumatic is self-explanatory; a fall, collision, twist, or awkward landing can create enough force to damage the structures inside the joint. When this type of damage occurs, the person may experience severe and immediate swelling, severe pain, a loss of ability to move the joint, and an inability to bear weight through the limb; a safe bet is when two of the three exist, the person should seek medical attention from a physician and/or physical therapist immediately. Attempting to “walk it off” is not recommended.

An overuse injury can be a little tougher to recognize. Starting a fitness program or a dramatic change in a person’s activity level (more or less) can provoke this type of pain. So can rapid increases in body weight, such as pregnancy. Adolescents who are going through growth spurts will often have pain in the knees because of changes in the way the muscles and joint function together. The pain may show up immediately or gradually, appearing more and more frequently until it is constant. Swelling may appear but is typically not severe and disappears overnight. Depending on the structure inside the knee that is taking the abuse, surgery may be needed, but many times this is treated quickly and effectively with a short course of rest, stretching and strengthening.

“Degenerative” describes the normal changes our joints experience with aging, specifically thinning of the articular cartilage and the loss of quality in the soft tissue of the joint. Knee pain from degenerative changes generally does not produce swelling and is provoked by remaining in one position for a great deal of time.

Besides pain, a problem within the knee (or any joint) will also cause the muscles around the joint to stop working effectively. Over time this will produce a loss of muscle size as well as a loss of control of the joint. The longer the joint remains untreated, the more severe the muscle atrophy and loss in function will become. Other joints may become painful as a result, particularly the areas above and below the injured joint or the opposite side. Medical treatment should begin before the body learns bad movement patterns.

Unless severe structural damage is present, a course of physical therapy will often be successful in getting rid of pain and restoring a person’s usual activity level. Any physician can refer to physical therapy and in many states no referral is required; in most cases, the therapist can make an accurate assessment of the problem and begin treatment immediately. If the problem is severe enough that a specialist should be involved, the therapist can facilitate the referral and also make recommendations for any diagnostic testing.

Regular Headache or TMD?

It’s been a long day that started with a pounding headache and a rough day at work. A great movie is on TV and the start to a perfect night of relaxation is complete with a warm bag of popcorn. As I settle in and the movie begins, I take the highly anticipated first bite and…OUCH! What was that? The pain is from my mouth but it’s not a normal toothache. The pain in my face and jaw travels up to my temple and ear. My headache has not only returned, but has intensified! I’m experiencing signs and symptoms of temporomandibular disorder (TMD). Can you relate? The National Institute of Dental and Craniofacial Research estimates over 10 million Americans are affected by TMD. This disorder impacts many within our own community and HPRC is here to help inform, educate and treat to restore a healthy and desired lifestyle.

Background: Anatomy and Function

Temporomandibular disorder involves the temporomandibular joint (TMJ) and/or the surrounding musculature. The TMJ is a hinge joint that connects the jaw to the skull, just in front of the ear on both sides of the head. Movement at the TMJ allows for up and down and side to side motions of the jaw for talking, chewing and yawning. The cervical spine and surrounding musculature influence the position and control of the joint.

What Are the Signs and Symptoms of TMD?

Common signs and symptoms are, but not limited to:

  • Pain in the jaw, face, temple region, neck, shoulder and/or ear at rest or during movement
  • Limited jaw motion opening, closing and/or side-to-side
  • A “stuck” or “locking” feeling in the jaw, “clicking” or “popping” when opening and closing the mouth that may or may not be painful
  • Headaches
  • Fatigue in the jaw, head and/or neck region

These symptoms may be temporary, recurring or chronic.

What Causes TMD?

The exact cause of TMD is not clear, but clinicians do believe signs and symptoms arise from problems in the surrounding muscles, the joint itself, stiffness in the cervical spine and poor ergonomics/posture. A rapid onset may occur after an injury, such as a blunt force to the face or whiplash. Other contributing factors include:

  • Grinding/clinching teeth at night
  • Osteoarthritis or rheumatoid arthritis in the TMJ
  • Dislocation of the disc in the TMJ
  • Work, home or emotional stress
  • Recent prolonged and/or high-level dental work
  • Recent cervical injury or surgery
  • Diet (i.e., nuts, ice, tough meats)
  • Overuse/habits (i.e., bubble gum, biting nails, chewing the end of a pen/pencil)

Treatment Options

The most effective treatment for TMD typically involves a collaborative team effort between the patient, a physician or dentist and a physical therapist. As the patient, the following steps may be help in easing symptoms:

  • A soft diet
  • Ice applied outside (ice packs, frozen vegetables) and inside (popsicles, pieces of ice) the jaw
  • Avoid extreme jaw motions that hurt and/or create popping
  • Reduce stress and learn relaxation techniques
  • Keep your teeth slightly apart and jaw relaxed during daily activities

A physician or dentist will evaluate you for TMD, as well as for other possible issues in the teeth, jaw, head and neck. X-rays or an MRI may be performed if found necessary to further examine hard and soft tissues. Medication may be prescribed to help with inflammation. Dentist and oral surgeons can prescribe a helpful tool to reduce the effects of grinding at night called a night guard or splint. These custom made appliances prevent the upper and lower teeth from coming together while sleeping, thus reducing the grinding forces that contribute to TMD.

Physical therapists play a key role in the collaborative effort to get you back to a healthy, desired lifestyle. A licensed PT at HPRC will evaluate and treat all factors contributing to your TMD to reduce symptoms today and to prevent recurrences in the future. Treatments include:

  • Manual techniques (i.e., stretching, mobilizations and manipulation of the TMJ and cervical spine)
  • Exercise instruction (stretching and strengthening of the musculature surrounding the TMJ and cervical spine)
  • Patient education (detailed activity modifications, postural instruction and relaxation techniques)
  • Modalities that help reduce pain and improve tissue health.

Carpal Tunnel Syndrome Explained

Do you wake up at night finding yourself having to shake out your hand because it falls asleep? Do your fingers go numb while you are typing at work? If you answer yes to either or both of these questions, you may have Carpal Tunnel Syndrome.

What is it?

Carpal Tunnel Syndrome is a condition in which the median nerve is compressed as it passes through an opening from the wrist to the hand called the carpal tunnel. It is formed by the carpal bones on the bottom of the wrist and a ligament structure on top (transverse carpal ligament) that runs across the wrist. The Median nerve, is just below this ligament, and provides sensory and motor functions to the thumb, index finger, middle finger and ½ of the ring finger.

Carpal Tunnel Syndrome is a repetitive use injury/Cumulative Trauma Disorder and can begin with numbness and tingling that comes and goes in above specific fingers; however, it can become constant, causing an increase in discomfort in the hand and even forearm. This can be caused from poor positioning while sleeping allowing wrist(s) to stay bent for long periods, using tools that vibrate for long periods of time, poor ergonomics while sitting and typing or even while standing at a work bench with repetitive use of hand(s). Other symptoms include weakness with gripping objects, dropping items with affected hand, swollen feeling in fingers, and/or awakening at night due to discomfort in thumb, index and middle fingers.

If you have these symptoms, It’s important for you to seek medical attention quickly as compression on the nerve will continue and can eventually lead to nerve damage.

How to treat it

Treatment will be based on your age, past medical history and the extent of the syndrome. To begin relieving compression on the nerve at the wrist and prevent wrist motion, wrist splints are beneficial to wear during the time the symptoms are more prevalent. Other treatments can include anti-inflammatory medication, phonophoresis/iontophoresis, median nerve glides, ASTYM (Augmented soft tissue mobilization), changing positions of work station (ergonomics), or surgery to relieve the compression of the nerve in the carpal tunnel.

If your symptoms are not improving with conservative treatment above, a nerve study (EMG) can be ordered to determine the location of the compression and its severity. As a result, this will allow the surgeon to determine if surgical intervention is warranted or to continue with conservative treatment to alleviate the symptoms.

If you have surgery, what to expect:

Surgery is a scary thought and there are risks involved; however, this surgery is performed using a scope and a small incision and recovery is time is minimized as long as you follow instructions via the doctor and your therapist. If you are non-compliant, the recovery can be long and make you question why you had surgery.

In general, the surgery for CTS is performed under local or regional anesthesia and is an outpatient procedure allowing you to go home the same day after surgery. For endoscopic approach, there is a small incision made at your wrist area, and the tissue that is pressing on the nerve will be cut to decrease the pressure.   After the surgery, a bulky dressing will be used to immobilize your wrist, but your fingers are free allowing you to move them immediately after surgery.

You will follow up in therapy 3-5 days after surgery. The bulky dressing will be removed, incision cleaned and your home exercise program will be initiated. A smaller dressing will be reapplied after therapy for ease of daily dressing changes at home. Approximately 10-12 days from surgery, stitches will be removed either by doctor or therapist and will continue to progress your movement and activities, as tolerated. The length of recovery can vary with each person especially if the nerve has been compressed for a long time, return of your sensation may take longer. Typically, four weeks from surgery, strengthening activities will begin under the supervision of a therapist to ensure you are progressing well without pain or discomfort. Weekly progression of resistance’s/weight limits are issued via your therapist and this methodical succession will return you to your prior level of function pre-Carpal Tunnel symptoms. Full recovery of the nerve is said to be approximately 18 months, but most people’s sensation returns well before that time frame.

Managing Lymphedema

Lymphedema is a condition that has received a lot of attention in recent years. It can result when the lymph nodes are removed or damaged due to cancer treatment. Cancer patients aren’t the only ones who can have lymphedema, which causes swelling in the arms or legs. Individuals suffering from obesity or vascular issues can also experience it. While lymphedema has no cure, it can be managed effectively with physical therapy.

The lymphatic system is a network of organs, nodes and vessels that make and produce fluids necessary to the body’s function. When the lymph nodes are compromised, they fail to remove proteins from the lymphatic fluid, causing an accumulation of fluid and swelling in the limbs. It’s most often an asymmetrical condition, meaning it will only affect one arm or one leg. If the arms or the legs are both affected, one is usually worse than the other.

Many cancer patients will come to us immediately when their lymph nodes have been removed or radiated. But many other patients have suffered from lymphedema for years before they discover exactly what it is and that physical therapy can help.

We use three main techniques for addressing lymphedema: manual lymphatic drainage, multi-layer bandaging and circulation exercises. The duration of therapy will depend on the severity of the case.

  • Manual lymphatic drainage is an incredibly effective technique for pushing fluid out of the areas where it has built up toward the lymph nodes and the center of the body. A therapist should follow specific pathways, or “watersheds,” natural highways that help the fluid reach the lymph nodes and organs where it will be processed and ultimately flushed out of the body as urine.
  • Once manual lymphatic drainage has been performed, multi-layer bandaging helps keep the fluid from returning. Wrapping a leg or arm with bandaging has a compressive effect that helps restrict fluid build-up.
  • Circulation exercises are also an important part of lymphedema management. These are simple movements performed in a sequence that help pump fluid through the lymphatic pathways.

A good therapy program also teaches patients and caregivers to conduct these techniques at home. Once progress is made and independence is gained in therapy, a patient will continue to manage his or her condition, returning to therapy for extra support when the need arises.

Painful Sex… Physical Therapy?

You might find yourself asking why you would see a physical therapist for dyspareunia (pronounced dis-puh-roo-ne-uh) or in layman’s terms, painful sex.  The short answer is because musculoskeletal pain is a significant component of pelvic pain and dyspareunia.  Pelvic Physical Therapy is a specialization in the field of Physical Therapy that treats pelvic pain.

Were you aware that you have muscles in the base of your pelvis that are under your control?  These muscles are aptly called the pelvic floor muscles.  The muscles are attached to the front of the pelvis, connect to the tail bone and sacrum at the back of the pelvis and extend outward to reach the side walls of the bony pelvis.  They are the only load bearing horizontal oriented muscles in your body.  Think of a muscular bowl or hammock in the bottom of your pelvis.  Diane Lee PT, prefers to call these muscles a condominium rather than a floor as this gives a more accurate picture of their complex interactive placement with all the connective tissue, organs and nerves of the pelvis.  These muscles serve three main functions:

  1.  Supporting the organs within the pelvis, hence their load bearing function. They support your bladder, rectum, the female  vagina, uterus  and ovaries, and the male prostate.  So they are” always working “at a postural level
  2.  The muscles are sphincteric, in other words they control the opening and closing of the urethra, vagina, and rectum.
  3.  The muscles assist in the sexual response, by providing tone to the vaginal walls, maintaining erection in the female and male  and production of reflexive contractions of the deep muscle during orgasm.   Poor sexual response has been associated with  weak muscles  and poor awareness of muscle.  These same muscles provide stability to the pelvic joints, assisting the increased  demands on the low  back during strenuous tasks.

So what role does the muscle play in pain?  Superficial dyspareunia involves the first layer musculature, those that assist with vaginal tone and erection.  Deep dyspareunia involves the deeper muscles of the pelvis which support the organs and help the low back w stability.  The organs of the pelvis, the muscles and even the skin communicate messages through spinal cord and to each other through nerve tissue.

Muscular tension can be generated through organic cause and by direct injury.  Connective tissue can become restricted secondary to muscular tension and nerve irritation.  Tense/ tight muscles can compress and or stretch nerve tissue.  A pain cycle ensues moving from pain to muscular tension to nerve compression and connective tissue restriction and back to pain.

Muscular pain can be the source of dyspareunia, sometimes seen in postpartum women after injury to the muscle system during birth, or it can be in response to infection or dermatological changes within the tissue to name a few.   Hip pain, because of the proximity of the hip muscles to the pelvic wall can be a contributing factor in dyspareunia.  Low back pain can affect the pelvic floor musculature.

Dyspareunia can be related to hormonal changes in the postpartum breast feeding female or menopausal female, secondarily affecting muscle tissue.  The pain of endometriosis and interstitial cystitis can include musculoskeletal pain. In dyspareunia muscles are generally over working and need to learn to regain their normal length, their ability to relax and return to normal postural levels.  Assessment of dyspareunia includes an evaluation of the low back and pelvic joints, ability of the muscles to contract and especially relax and lengthen and evaluation of the nerve and connective tissue about the pelvis.

Physical therapists treat muscular pain with pressure, gentle stretching techniques and specific relaxation exercises. Mobilization of the spine, pelvic joints and connective tissue are generally a component of the treatment process.  The goal of treatment is to gain awareness and specifically motor control of the muscle to reduce or eliminate the cycle of pain.  Pelvic physical therapy restores the length-tension relationship of the muscles.

Painful sex can be embarrassing to discuss.  A pelvic floor physical therapist will put you at ease.   A pelvic health PT understands the complexities of the pelvic floor, and will help your muscles to regain their normal function.

Signs of a Receptive, Expressive and/or Social Pragmatic Language Disorder

Receptive, expressive and social/pragmatic language are considered critical milestones in a child’s life, but sometimes they are delayed. It’s important that parents and caregivers pay attention to the signs that a child is slowly progressing, not progressing or even regressing in language skills so he or she can receive the proper therapy. Early intervention is essential.

In the early years of life, children should begin to make basic connections between language and their surroundings. For example, a child should observe his/her parents’ mouths when they speak and begin to perform gestural language (e.g., waving). Children should also begin to understand what their parents’ words mean (following commands), form sounds that will eventually become words and pair their own words to become utterances about objects or events. When children have language disorders, they will lack one or more of these basic skills.

When one of our speech-language pathologists begins to work with a patient, a comprehensive evaluation is conducted, which includes assessing language (understanding and use), speech/resonance, voice, fluency, oral motor and swallowing abilities. A thorough plan of care with long-term goals and short-term objectives is developed and therapy is initiated. A big part of success in therapy is working closely with parents and caregivers because the home is an environment rich in opportunities to reinforce language. Home programs can empower the parents and caregivers to be involved in moving the child’s language skills along through play, interaction and socialization.

At HPRC Pediatric Therapy and Pediatric Rehabilitation, our setting is unique in that it offers comprehensive services, including therapy for gross and fine motor skills. If a child exhibits problems in these areas, we have physical and occupational therapists on site to work and collaborate with speech-language pathologists. Together, as a comprehensive team, we can see a child’s development as a complete picture.

Are young female athletes at greater risk for ACL injuries?

Young female athletes are five times more likely to sustain an ACL tear than their male counterparts. This is especially common in explosive multidirectional sports like soccer or basketball. It’s important for girls to learn how to jump and land properly in order to prevent an ACL injury from occurring.

Female athletes from about 14-18 years of age are at greater risk than boys of injuring the anterior cruciate ligament (ACL). This is largely due hormonal changes. An increase in estrogen during puberty causes relaxation of the ligaments and the natural widening of the hips causes changes in biomechanics. A female athlete is likely not conscious of these new structural changes as she continues to snag rebounds or bolt across the soccer field. She may inadvertently land or stop stiff-kneed or in a locked position, and she might have a greater tendency to internally rotate the knee due to weakness of the developing outer hip.

In addition, a female athlete may be accustomed to using only the quadriceps instead of her developing hamstrings to control movements. All of these factors can put the ACL at risk.

It’s important to teach young women early on how to adjust the way they run and jump in competition in order to prevent an ACL tear. A physical therapist can screen an athlete to evaluate body mechanics, potential weakness and faulty movement patterns. Prevention is key. And it’s time well spent since a young athlete who has suffered an ACL tear is 70% more likely to suffer a re-injury.

Here are some strategies:

  • Young athletes should be in shape for the demands of their chosen sport. This includes both cardiovascular capacity and muscular strength. During fatigue or exhaustion, even a small weakness or poor body mechanics can become a bigger problem.
  • A good strengthening program will encourage better hamstring-to-quad strength ratio, which will help reduce reliance on quads only.
  • Good lateral hip strength and hip abduction control will help maintain proper knee position so that a girl doesn’t experience what we call a valgus collapse, or the extra internal rotation of the femur and the knee falling inward.
  • Proper proprioception is key. When the foot hits the ground, the knee should be properly positioned over it. This allows for strong core-hip stability during lunges, running and multidirectional activities.

Physical therapists don’t just treat patients after an injury. They also work with patients to prevent one from occurring.

ACL tears in athletes

“I heard it go ‘pop,’” an athlete says with dread.

That sickening sound and a sudden pain in the knee point to the culprit: an ACL tear. Sports that demand sudden stops and quick lateral movements like football, soccer and basketball are hotbeds for ACL tears. Here’s what an athlete needs to know about recovering from this common sports injury.

About the injury

The anterior cruciate ligament (ACL) is one of four main ligaments in the knee that connect the femur above the knee to the tibia below. Injuries to the ACL can happen to anyone, but they are common among competitive athletes in their late teens to mid- to late twenties. As more young people are participating in sports with higher levels of athleticism, the injury is on the rise. According to the American Academy of Orthopaedic Surgeons, the annual incident rate of ACL injury is about 200,000 with 100,000 ACL reconstructions performed a year.

How it happens       

ACL injuries often occur when an athlete makes a quick stop, plants his or her foot and then changes direction. The abrupt change of speed combined with an abrupt change in direction stresses the ACL, which can tear and make a popping sound. Pain and swelling sets in quickly. Athletes will generally opt for reconstructive surgery of the ligament to maximize their ability to resume competition.

The road to recovery

Orthopedic surgeons thread in a new tendon to replace the torn ACL that is taken from the patient’s hamstring or from a cadaver. A patient will usually be on crutches for the first couple of weeks after surgery. The rehabilitation plan is dependent on the extent of injuries sustained during an ACL tear; it’s not uncommon to also experience damage to the meniscus. Therapy starts with very limited weight-bearing exercises that will slowly increase over time.

Strengthening the quadriceps is the primary goal of first 6 weeks of therapy. This helps provide stability to knee. The physical therapist will then move to short arc exercises, straight leg raises, hip strengthening and some balance exercises.

During the first 6 weeks, the goal is to increase range of motion — helping a patient go from zero to 135 degrees of flexion.

At the 8 to 12-week mark, the healing process is well underway with the reconstructed tendon tightening down as it should. Balance and biomechanics become key therapy priorities. Patients also progress into plyometric training, working their way up to light jogging and mild ladder drills at about the 10-week juncture. After 12-16 weeks, patients get into heavier plyometrics with the intention of soon getting back into their chosen sport. The therapist observes movement and watches for any signs of instability or imbalance.

Listen to your PT

Throughout therapy, it’s critical that a patient stick to the prescribed home exercise program to supplement therapy sessions. It’s also important a patient understand that the adage “no pain, no gain” does not apply to ACL recovery.  Take it slow and allow the ligament to fully heal in place. Patience goes a long way in preventing future injury.

Ankle Sprain: Here’s how to treat this common injury

Ankle sprains can happen to anyone. Sure, athletes who spend a lot of time running and jumping are vulnerable, but everyday individuals can experience ankle sprains while carrying out routine activities. Stepping off a curb incorrectly, stumbling while doing yard work, or other occasions when you unexpectedly meet uneven terrain can result in an ankle sprain. The good news is that this injury rarely requires surgery. Patients can recover quickly with the right treatment.

What usually happens when you sprain your ankle is that the ankle rolls inward, tearing the anterior talofibular ligament. Physical therapists classify ankle sprains in one of three categories depending on the level of trauma the ligament sustains.

A Grade 1 sprain is a mild sprain that will heal on its own. You can walk it off, and it exhibits little to no swelling. Ice and rest are recommended to ensure a full recovery, which tends to occur within a week.

A Grade 2 sprain usually exhibits bruising as well as swelling immediately after the injury takes place. A Grade 3 sprain presents a higher degree of swelling and bruising and results in difficulty walking. A physical therapist can determine the extent of the injury through a routine examination of the ankle.

The treatment for a Grade 2 or 3 ankle sprain is first to decrease the swelling through what we call “PRICE,” an acronym that stands for Protect, Rest, Ice, Compression and Elevation. Once the swelling subsides, we focus on restoring movement to the ankle through manual therapy to the ankle joint. We also have patients perform specific isolated exercises that build flexibility. A common exercise is to have patients “draw” the alphabet with the big toe of the affected foot while sitting in a resting position.

As we see improvement in the movement of the ankle, we focus on restoring strength to the area by exercising the surrounding musculature. We also work to restore balance – a very important function of the ankle. Think about it. Your ankles are constantly working to help your body adjust to uneven surfaces as you move throughout the day. We work to restore this sense of balance by having patients perform proprioceptive exercises, or exercises that help the body understand where it is in relation to its environment.

Generally, patients can make a full recovery from an ankle sprain within two to four weeks.

Sit Up Straight: How Workplace Posture Impacts Health

For a growing number of professionals, the cumulative effects of working behind a desk can take their toll. Years of pecking away at a computer and talking on the phone can lead to a variety of issues, including headaches, stiffness, and pain in the shoulders, middle back and neck. There’s hope, though. These issues can be effectively addressed through physical therapy and by making adjustments to your everyday posture.

We see patients routinely who experience pain that we can link directly to the way they sit at work. The modern world has created all sorts of demands that don’t square with our bodies’ natural movements. We are not designed to perch in uncomfortable chairs six to eight hours a day, and as the years go by, our body rebels by expressing pain. Physical therapists address these issues by using interventions that can effectively remove stiffness. We also help patients strengthen muscles in the upper back to provide additional support to the neck and shoulders. And, we make specific recommendations for postural adjustments so that pain does not return.

Improving the way you sit at a desk goes a long way. Here are some recommendations:

  • Your feet should touch the floor completely. For people under 5’5”, this can be a challenge as most desks are made for taller people. Use a box or stool if needed.
  • You should be able to place your forearm on your desk or your elbows on arm rests while typing at a keyboard.
  • Your knees should be at a 90-degree angle when you sit, making sure your knees are in line with your hips.
  • Don’t crane your neck to talk on the phone. Use a headset.
  • Ideally, your computer screen should be at eye level.

One of the most important issues to remember is that the body doesn’t like being stagnant. Set a timer and take a “micro-break” every 20 minutes. I can hear the work-a-haulics groaning, but this doesn’t have to take long – a mere 10-15 seconds is all that’s required to stand up and stretch. It’s a simple strategy that goes a long way in protecting your health and warding off pain.