Welcome back to the blog!!
Today we're we're moving up the chain from the knee to the hip. We're discussing femoroacetabular impingement a.k.a. "hip impingement." Anyone familiar with that "pinching" in the front of their hip with a squat, lunge, or while running has likely dealt with a "functional hip impingement" episode. If you have experienced this over a longer period of time, you should be evaluated for hip impingement syndrome.
Hip impingement has gained notice in the sports medicine community specifically over the last 15 years as advancements in diagnostics and surgical procedures has led to increased people going under the knife. This is a syndrome that can be defined in really 2 ways; intra-articular and extra-articular impingement. Extra-articular refers to soft tissue impingement outside the joint, which could be muscular or nervous system in nature. Most commonly though, we are refereing to intra-articular issues which are further classified in to 3 sub-diagnoses; a Pincer Lesion, Cam Lesion or Mixed Lesion. In a Pincer lesion the, there is bony overgrowth of the acetabular rim (the socket) that leads to decreased available motion for femoral head (ball) and increased "pinching" at the top of the joint with flexion. In a Cam Lesion, the overgrowth is on the neck of the femur and leads to an early contact between the acetabulum and head of the femur at end range. Both of these can lead to increased shearing at the joint. They are often diagnosed both clinically with certain special tests as well as with both x-ray and MRI. However, recent studies have show that clinical tests are not as specific as we would like them to be for diagnosis, and imaging does not seem to have a direct correlation between evidence of a Cam or Pincer lesion and the presence of pain.
The amount of information on the internet regarding this condition is endless. Also endless, is the amount of information on how to correct this condition. There are many options from many different medical practitioners including; massage, anti-inflammatory injection, surgery, stretching and strengthening, dry needling, myofascial release, adjusting squat position and form, etc... I'm here to tell you that you really should weigh your options and seek advice from a trusted health care professional to make a decision on your treatment. In many cases, non-operative treatment should be your absolute first choice.
A recent study (https://www.ncbi.nlm.nih.gov/pubmed/30398893) looking at FAI non-operative management in 76 youth athletes showed that 82% of athletes were successfully managed conservatively with rest, physical therapy, and progressive activity introduction.
This is obviously a study with youth, but much of the research also supports non-operative management in the older adult. Cam Impingement does seem to have a increased incidence of steroidal and surgical intervention.
Now, I'm not going to go over the specific exercises that will help you with hip impingement as you should be evaluated by a Physical Therapist to tailor a program directly to your needs or refer you for additional testing if needed, but I will say that structural findings on an imaging technique do not always correlate with pain. Many people function every day with structural hip Pincer and Cam lesions but are asymptomatic and able to squat heavy loads at the gym as well as run long distance races. Healthcare providers need to be very careful diagnosing people on imaging alone, and focus more on individual structural demands and goals for the patient.
Therefore, when looking for a solution to your "squat stopper" hip impingement problem, first seek medical advice from a trusted musculoskeletal expert. You should receive a detailed subjective and clinic evaluation that treats you as an individual with specific needs. Relay your goals to the clinician and then weigh your options based on multiple opinions on what your treatment should be. Remember, conservative treatment should be your first choice when addressing your pain and limitations. Most of the time, a skilled rehab specialist will be able to get you back to doing the things you love, with minimal to no pain all the while avoiding invasive techniques such as surgery if possible.
Well I hope this was educational for everyone. Make sure you check back in next week.
Welcome back everyone!
I'm finally discussing some current research on the diagnosis and treatment of a specific injury. In this week's blog, I'm discussing the current Clinical Practice Guidelines for diagnosing and treating Patellofemoral Pain Syndrome (PFP). So if you have ever had knee pain related to squatting, running, descending stairs etc.. then this should be an informative read for you, providing you some direction in your ability to address your symptoms.
PFP is commonly referred to as "Jumper's or Runner's knee." This condition involves, typically, insidious onset of pain behind or around the knee cap. This is a very common syndrome with an estimated prevalence of 25% up to 50% in the general population over their lifespan and does account for anywhere between 2-7.5% of people presenting for medical care. This syndrome most commonly affects youth athletes between the ages of 12-19 but some studies indicate a higher prevalence in the 50-59 year old age group.
Symptoms usually present with no specific injury and can come on slowly overtime. Typically there is worsening of pain with lower-limb loading (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running, especially with hills). There is poor correlation between internal derangement of tissue or cartilage damage and symptoms, and therefore a clinical diagnosis based on a cluster of symptoms associated with pain reports during squatting, descending stairs, and knee flexion positions like prolonged sitting should be used. Your medical provider and rehab specialist should be looking at these things as the best supported way to diagnosis this condition.
Once there is a clear idea that you are dealing with PFP, a tailored strengthening program and symptom management program should be developed based on these well supported treatment approaches. This really should be a staple in all treatment approaches.
Have you ever been told you have flat feet?? Well, it turns out that, flat feet in combination with an increased knee valgus (inward tilt) angle may contribute to symptoms early on.
Therefore, within the first 6 weeks, a pronation controlling foot orthotic may provide relief from symptoms temporarily. Studies also show that over-the-counter orthotics provide just as much support for this condition as do custom orthotics. Talk to your therapist about one that might work for you.
In addition within the first 6 weeks, patellar taping can provide relief for symptoms and can be a very cost effective way to address symptoms early on.
With that that being said, the major focus for individuals with PFP should be gluteal and quadriceps specific strengthening exercises. These should be in both the open chain (resisted knee extension, hip raises, banded stepping etc..) as well as in the closed chain (weighted cross over step ups, progressive resisted squats and lunges etc..). This program should be set over a 6-8 week time frame allowing for true strength gains.
So, If you are someone that is battling anterior knee pain associated with tasks such as running, squatting, descending stairs, or sitting for prolonged periods and are looking for a resolution to your problem, talk to a physical therapist or musculoskeletal healthcare expert today to follow these research supported guidelines to aid in your recovery.
Hope you enjoyed and thanks for reading!
Citation: Willy, Richard Et. al. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2019 Volume:49 Issue:9 Pages:CPG1–CPG95 DOI: 10.2519/jospt.2019.0302
Welcome back to the Blog! Hopefully you have found useful information here in the past, or if this is your first time reading my material, well then, I hope you enjoy!
Today I am discussing 3 ways to optimize your ability to lift and load weight overhead. In addition to helping you lift more in the gym, this also has major implications for maximizing your function as you age. My goal with you reading today is for you to gain a better understanding of how you move with and without weight. So let's get started with the first Key!!
1. How well do you move without weight or load??
One of the most important points. Simply put, Can you move freely and smoothly without restriction when you are not holding weight?. If you can't move smoothly, then you can't load correctly. It's equivalent to attempting squat 150lbs when you can't move from sitting to standing. It's possible to do it once with compensation, but over time it will lead to a disaster. So you first need to understand your movement without load and what you need to do to improve it. A strength and conditioning coach, movement coach, or physical therapist is a great resource here.
2. Identify any limitations and address them with targeted exercises.
I mean how long can you drive a car on a bad tire or without new oil before it breaks down? How far can you ride your bike on plastic parts? So you need to identify and understand your limitations with shoulder Mobility, thoracic Mobility, movement flaws, and/or strictly strength limitations. There are many ways that you can go about doing this. In fact, head to my YouTube channel for more information or see a movement specialist to help you. They'll identify your limitations and restrictions as well as give you some tips on how to correct these. Now, if you've been loading for a long time, and you're like, I'm fine.. I've been doing great. Well that's fine too, but I bet you're wondering; Man, I haven't really ever had anyone look at this. I wonder how much better I could be performing and how many PR's I could break if I was moving optimally? That is another reason why it is important to know your limitations and know what to do to address them.
3. Have a plan with progression of load
How many times have we gone into the gym and just started working out, or just followed the workout for the day that we saw online?? I mean, I'm as guilty of this as anyone, but I do understand the long term importance of progressive load. I think we really need to identify a true strength and conditioning program for us to progress overhead strength. This may look like a standard 8 to 12 week hypertrophy and strength progression. It could be a CrossFit program from your local box or online that you stick to, that you don't deviate from. I think having a plan is ultimately one of the most important things that we need to do with fitness, with nutrition, with our jobs. So having a plan is going to let you optimally load your shoulder and build strength to crush your overhead goals.
So those are the three keys to overhead success and keys to optimizing your overhead shoulder performance which has long term implications with your ability to maintain strength as you age as well as achieve your weightlifting and functional goals!
Hope you enjoyed the blog and check back in soon for our next topic!
What's going on everyone!!
If you've found my blog for the first time, Welcome! If you've read my material before, welcome back and I hope you enjoy. Today, I'm bloggin about optimizing recovery!!
We all know that recovery following high-level intensity exercise or athletic performance is one of the most important things to do to grow as an Competitive Athlete, Olympic lifter, CrossFitter or everyday person looking to excel in the gym or on the field. There's a ton of literature and research out there on how to recover properly, but a lot of it varies, and there's not really any set step by step system to tell you how to recover right. However, there are some very very common and well-supported things that you should be doing, and I'm going to tell you about them right now. These are three things you should be focusing on to optimizing your recovery following a high intensity workout that you can implement today!!!
1. Hydration Recovery. Hydrate and restore your electrolyte balance for the next 48-72 hours. During a long duration >30 minute workout you need carbohydrate and electrolyte replenishment. Following a high intensity workout where you sweat a great deal, you need to be consuming at least half your body weight in ounces for the day. This should be planned out before your workouts for the week. Don't try to play CATCH UP, it doesn't work. Once you start implementing a plan for that hydration recovery it will become a common part of your programming. On a very basic framework, that's hydration and fueling. We all know this, but we don't do it all the time, and I am just as guilty as the next person and continue to work to improve my hydration and nutrition.
2. Muscle and Fascial recovery. Consequently, this involves nervous system recovery as well. Most of us are aware of the two main forms of exercise (energy systems): Aerobic and Anaerobic. Aerobic being longer duration utilizing oxygen to for energy and Anaerobic short-to moderate duration high intensity exercise utilizing lactic acid. Typically with lifting this system is what we are most working with and the by-product of this system (Following our Workouts) leaves us with an acidic environment in the muscle and fascial tissue. In shorter words, this is why we are sore. Generally speaking if you sit around and are lazy following a high intensity workout, the more sore you are and more inhibited your muscle function is. So in combination with hydration, as your flushing fluid in and out, you also need to help assist actively with this. There are now many different modalities out there to help with this such as; pneumatic compression devices, Electronic Stimulation recovery, Massage Guns, Foam Rolling. Not one has been shown to be better than the other, but didactically I have seen some great results from these. I'm not suggesting one over the other but I am here to tell you that you need to be active after a high intensity workout. You need to promote fluid exchange within the muscle, and you need to mobilize that tissue. "Motion is lotion" , and fluid needs to move through your body. Muscle recovery is important so in addition walk, jog, row, or bike I don't care, but you need to recover so that you can perform in the next day or two with your next workout.
Now this next point is something that is not as commonly talked about as the previous two.
3. Mental Recovery. Most of us go to the gym to sort escape from our everyday routine. Maybe from work, from our kids (God Bless them) or from anything else that may be stressing us out. So we get in there, we're in the moment, nothing else is on our brain but throwing that weight around, climbing that rope, or doing a handstand. Sure we might be tired, sore, but mentally we feel clear. We are in the moment, and naturally that feels amazing. The "WORKOUT HIGH." We know that with the changes in our hormones that occur during exercise, it is a stress reliever. Do we appreciate it enough though? I believe, following exercise, we need to mentally reflect what we have accomplished. This is what I love to do with my Mobility class at the end of the week. Think about what you accomplished, not what you didn't accomplish in that session. Think about what your recovery is going to be, and what your goals are for your next workout. Maybe about how this specific training that you're doing is going to lead to other positive outcomes in your life. There's no doubt that if you take the time to mentally appreciate what you have accomplished and see it as something that has presented value to you, you are going to carry that over into the next task or event that you do in your day, the rest of your week, and in the next workout that you do. Overtime that positivity and appreciation is going to accumulate and change you as a person. This is probably the most important point and will have the most impact on your recovery.
So, focus on these 3 things so that you can CRUSH your recovery, which is going to lead to dominating your PRs, your competition's, and your games. Make a plan for the upcoming week and reap the benefits!!
Welcome to my first official blog post. This is an exciting day for me as I am two months in to the start of my own performance based, out of network, physical therapy practice (RecoverRx Physical Therapy). Many people often ask me what is performance based physical therapy? Is this specific to athletes or open to everyone? Also, another popular question but more appropriate for a whole additional blog, “Do you take my Insurance?”
These are indeed great questions, and there are many more where they came from. If I were to define performance based physical therapy, I would combine a couple different definitions from some of my colleagues and mentors in the field, Danny Matta and Mike Reinhold, among others. Performance based physical therapy is physical therapy provided to athletes of all age ranges and high performance individuals alike in a performance based gym or clinic setting, mixing traditional physical therapy assessment and intervention with progressive strengthening and mobility protocols to reduce pain and optimize performance. Therefore, we must talk about “performance.”
Performance is a term that seems to have a connotation with athletes only, but can and should be associated with performance in any aspect of our lives. Whether that be with your 1 rep max back squat, ability to hike 10 miles, play soccer on the weekends, or simply be able to throw a baseball with your son. All these different activities have a different meaning for every individual, but I think we can all agree that we should all be able to perform at an optimal level in any passion of ours. I believe most people have that vision of what their optimal performance looks like even if it is a mirror image of themselves in their 20s or of them modeling their fitness idols now. We should never dismiss this or any vision as unattainable.
Throughout my years as a performance based physical therapist, I have realized that if this vision turns in to a mindset shift, then pain or physical limitations cannot stop you from achieving your vision of optimal performance. I have seen patients climb Mt. Kilimanjaro 6 months after ACL reconstruction, Clean and Jerk 185 lbs. following rotator cuff surgery, and run a marathon following 2 years of pain and not running. The key to their success was a mindset shift away from what their limitations are to what they could achieve.
“Nothing can stop the man with the right mental attitude from achieving his goal; nothing on earth can help the man with the wrong mental attitude.” – Thomas Jefferson
This is where Performance Based Physical Therapy helps people along their path to high performance. Being able to rehab in an environment focused on their performance goals allows people to keep their vision alive. Assessing peoples’ functional movement patterns i.e. hip hinge, squat, lunge, overhead shoulder position etc.. as well as assessing for mobility, flexibility, and strength impairments lays the ground work for developing a performance based approach to rehab. Also, allowing people to have input in to their recovery and presenting a progressive program gives people the accountability they need to stay in it for the long run.
I think a main frustration among many traditional physical therapists is the lack of compliance by patients as well as lack of grit needed to achieve the long term goals of self-sustained pain management and self-optimization. With Performance Based Physical Therapy, there is constant communication with the patient to give them the small changes in their programming over the long haul to achieve their goals. They develop the grit they need to see it out to the end. And that’s what it takes, a little “Vision, Mindset, and Grit” (Shout out to Scott Burrows book) to “Recover, Rebuild, and Redefine” yourself.
Thanks for Reading!
Luke Greenwell, PT, DPT, CSMT, CSCS
Dr. Luke Greenwell is a Performance Based Physical Therapist with an extensive background in treating the injured athlete. He is passionate about returning people to the sports & activities they love. He has post-doctorate certifications in Manual Spine Therapy and Functional Dry Needling. He is also a NSCA Certified Strength and Conditioning Specialist. He has extensive experience in Dartfish video gait/running analysis, concussion rehab, & functional movement screening & correction. He is the owner of CrossFit based RecoverRx Physical Therapy